Advanced Accident Investigation
Advanced Accident Investigation
Advanced Accident Investigation
1
Definitions and Theories
Sources:
Harvey F. Thomas, Ph.D., CSP, CHMM
Industrial Safety and Health, David Goetsch, Merrill
Publishers, pgs. 29-39
2
Learning Objectives
Know the definitions attendant to
safety and health management
Know the basic theories of accident
causation
3
What is Safety
Multi-faceted
Multi-discipline
http://www.colored-diamonds.com/page7.htm
5
Safety & Health Discipline
Interactions
Industrial
Environmental Operations Medical
Hygiene
Facilities
Test and
Legal Training
6 evaluation
What does safety mean?
Definition of Terms
“Safety is the prevention of accidents and the
mitigation of personal injury or property
damage which may result from accidents.”
Mroz
the incident…..” Kecelakaan adalah aliran energi yang berpotensi berbahaya atau
kondisi lingkungan yang diawali dengan perencanaan atau operasi pengawasan atau kelalaian, sehingga kondisi atau
tindakan yang memicu insiden i
8
Then what is safety relative to an
accident?
“Safety is a condition or state of being
resulting from the modification of
human behavior, and/or design of the
physical environment to reduce the
possibility of hazards, thereby reducing
accidents.” Keselamatan adalah suatu kondisi atau keadaan yang dihasilkan dari modifikasi
perilaku manusia, dan / atau desain lingkungan fisik untuk mengurangi kemungkinan bahaya, sehingga mengurangi
kecelakaan. "
Strasser et al.
9
Incident vs. Accident
Accidental triad
1. When an unwanted energy flow occurs
or a hostile environmental condition
develops.
2. Barriers or controls << than adequate.
3. Persons or objects are in the energy
path or exposed to the environmental
condition…Ketika aliran energi yang tidak diinginkan terjadi atau kondisi lingkungan yang berkembang.
4. Hambatan atau kontrol << dari cukup.
5. Orang atau benda berada di jalur energi atau terkena kondisi lingkunga
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Definition of terms
Approaches to Use of Barriers.
1. Barriers on the energy source.
2. Barriers on the targets (person or objects).
3. Barriers between the energy flow and the
targets.
4. Separation of the flow and targets by time
or space.
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Definition of Terms
Incident – an incident is not an accident--
there have been no losses. The worst that
has happened is a near miss. No persons
or objects were in the energy flow.
14
“That occurrence in
a sequence of
events which
usually produces
unintended injury,
death, or property
damage”.
17
Components of risk –
probability and severity
Highest
Risk
Ri
sk
18
Definition of Terms continued…
Loss control – accident prevention achieved through complete
safety and health hazard control program. pencegahan kecelakaan dicapai melalui
.
19
Definition of Terms continued…
Accident prevention-elimination of factors
and conditions that pose hazard and risk.
20
Definition of Terms
Injury – damage or harm to body as result
of violence, infection or other source.
Illness – environmental stress resulting in
abnormal physiological condition.
Acute illness – immediate effects
Chronic illness – long term
effects.
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Why do accidents happen?
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Theories of Accident Causation
Major theories presented include:
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Accident/Incident Theory of
Accident Causation.
Epidemiological Theory of
Accident Causation.
Combination Theory of Accident
Causation.
24
Why do Employees get Hurt on the
JOB?
Accident Prone?(rawan)
Carelessness?
25
Equipment Failure?
Hazardous Work?
26
Theories of Accident Causation
Single Factor Theory
27
10% by unsafe conditions.
2% unavoidable.
28
Theories of Accident Causation
Heinrick’s Axioms of Industrial Safety
diragukan lagi
Kebenaran yang perlu
29
Theories of Accident Causation
Heinrich’s Axioms
Most accidents due to unsafe behavior by people. Kebanyakan kecelakaan karena perilaku yang tidak aman
30
Unsafe act by person or condition not
always accident ending.
31
Theories of Accident Causation
Select corrective actions by identifying cause.
32
Theories of Accident Causation
Management assume responsibility
for safety.
33
Heinrich’s Domino Theory
Three Phases
Pre-Contact Phase
Contact Phase
Post-Contact Phase
34
Heinrich’s Domino Theory
Theory has two central points:
36
Human Factors Theory of Accidents
Chain of events caused by human error.
Overload.
Inappropriate activities.
37
Overload
Inappropriate Inappropriate
Human errors factor
activities response
39
Accident/Incident Theory
Overload
Ergonomic Traps
Decision to Err
Human Error
System Failure
40
Petersen’s Accident/Incident Theory
Human Error
Systems failure
Accident
•Responsibility
•Training
Injury/damage
•Policy
41
•Inspection
Epidemiological
Theory
Predisposition Situational
Characteristics Characteristics
•Perceptions •Risk
assessment by
•Environmental individuals
Factors
•Peer pressure
•Susceptibility of
people •Priorities of the
supervisor
•Attitude
Make Decisions
Environment
Task to be Performed
43
System Theory of Causation
Feedback Loop
Weigh Make
risks decision
Persons
MachinePersons
Task to be
Environment performed
Interaction
Collect
44 information Stress factors???
System Theory of Causation
Firenzie recommendation factors
before beginning collecting,
weighing,and making decisions.
Job requirements.
45
Loss if task is attempted but
fails.
46
Energy-Related Accident Causation
Theory
Accidents can be prevented by controlling
the energy involved or changing the
structures that cause the damage.
47
Energy-Related Accident Causation
Theory
Limit the Energy
48
Prevent the Release of the Energy
49
Energy-Related Accident Causation
Theory
Place a Barrier on the Energy Source.
50
Raise the Injury or Damage Threshold.
Rehabilitate.
51
Combination Theory
Often cause of accident
cannot be explained by one
theory.
52
Behavioral Scientists
McGregor
Herzberg
Likert
Argyris
Blake and Mouton
Skinner
53
Theories of Accident Causation
Summary
54
Theories of Accident Causation
55
Theories of Accident Causation
Epidemiological theory-models for
epidemiological factors and disease
good for epidemiological factors and
accident.
Systems theory views accident
situation as combination of person,
machine and environment.
56
• Combination theory claims that no
one model/theory can explain all
accident.
57
Questions????
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