12750813-risk management & accident-causation.ppt

risk management & accident-causation

1. Protect the Force Through Risk Management
ACAC11
ACCIDENT
CAUSATION

2. Protect the Force Through Risk Management
ACAC22
Early Man

3. Protect the Force Through Risk Management
ACAC33
Factory managers reasoned that
workers were hurt because —
ACCIDENT
PEOPLE PROBLEM
Industrial Revolution
Number is Up
People ErrorCarelessness
Act of God
Cost of doing
Business

4. Protect the Force Through Risk Management
ACAC44
“Industrial Accident Prevention”
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich.
Domino Theory
Social
Environment
and Ancestry
Fault of the
Person
(Carelessness)
Unsafe Act
or
Condition
Accident Injury
MISTAKES OF PEOPLE

5. Protect the Force Through Risk Management
ACAC55
Heinrich’s Theorems
INJURY - caused by accidents.
ACCIDENTS - caused by an unsafe act –
injured person or an unsafe condition –
work place.
UNSAFE ACTS/CONDITIONS - caused by
careless persons or poorly designed or
improperly maintained equipment.
FAULT OF PERSONS - created by social
environment or acquired by ancestry.
SOCIAL ENVIRONMENT/ANCESTRY - where
and how a person was raised and educated.

6. Protect the Force Through Risk Management
ACAC66
Heinrich’s Theory
Corrective Action Sequence
(The three “E”s)

Engineering

Education

Enforcement

7. Protect the Force Through Risk Management
ACAC77
Modern
Causation
Model
OPERATING
ERROR
RESULT:
-No damage
or injury
-Many fatalities
-Major damage
MISHAP
(POSSIBLE)

8. Protect the Force Through Risk Management
ACAC88
How accidents are caused &
how to correct those causes.
Parallels Heinrich's to a point.
Injury is called RESULT, indicating it could
involve damage as well as personal injury
and the result can range from no damage
to the very severe.
The word MISHAP is used rather than Accident
to avoid the popular misunderstanding that an
accident necessarily involves injury or damage.
Finally, the term OPERATING ERROR is used
instead of Unsafe Act & Unsafe condition.
Modern Causation

9. Protect the Force Through Risk Management
ACAC99
Operating Errors:
Being in an unsafe position
Stacking supplies in unstable
stacks
Poor housekeeping
Removing a guard
Examples

10. Protect the Force Through Risk Management
ACAC1010

Revolutionized accident
prevention

A weakness in the
design or operation of
a system or program
Systems Defect

11. Protect the Force Through Risk Management
ACAC1111
Examples
Systems defects include:
Improper assignment of responsibility
Improper climate of motivation
Inadequate training and education
Inadequate equipment and supplies
Improper procedures for the selection &
assignment of personnel
Improper allocation of funds

12. Protect the Force Through Risk Management
ACAC1212
Modern
Causation
Model
OPERATING
ERRORS
RESULT:
-No damage
or injury
-Many
fatalities
-Major damage
MISHAP
(POSSIBLE)
SYSTEM
DEFECTS
Operating Errors occur because
people make mistakes,
but more importantly,
they occur because of
SYSTEM DEFECTS

13. Protect the Force Through Risk Management
ACAC1313
System defects occur because of
Managers design the Systems
Modern Causation Model
OPERATING
ERRORS
RESULT:
-No damage
or injury
-Many
fatalities
-Major damage
MISHAP
(POSSIBLE)
SYSTEM
DEFECTS
COMMAND
ERROR
MANAGEMENT / COMMAND ERROR

14. Protect the Force Through Risk Management
ACAC1414
A defect in some aspect of the
safety program that allows an
avoidable error to exist.
Ineffective Information Collection
Weak Causation Analysis
Poor Countermeasures
Inadequate Implementation Procedures
Inadequate Control
Safety Program Defect

15. Protect the Force Through Risk Management
ACAC1515
SAFETY
MANAGEMENT
ERROR
A weakness in the knowledge or
motivation of the safety manager
that permits a preventable defect
in the safety program to exist.
Safety Management Error

16. Protect the Force Through Risk Management
ACAC1616
Modern Causation Model
SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT
COMMAND
ERROR
SYSTEM
DEFECT
OPERATING
ERROR
MISHAP
RESULTS

17. Protect the Force Through Risk Management
ACAC1717

Initial studies show for each disabling injury,
there were 29 minor injuries and 300 close
calls/no injury.

Recent studies indicate for each serious result
there are 59 minor and 600 near-misses.
INITIAL STUDIES
RECENT STUDIES
Near-Miss Relationship
1SERIOUS
MINOR
CLOSE CALL
29
300
1SERIOUS
MINOR
CLOSE CALL
59
600

18. Protect the Force Through Risk Management
ACAC1818
There are seven avenues through which
we can initiate countermeasures. None
of these areas overlap. They are:
 Safety management error
 Safety program defect
 Management / Command error
 System defect
 Operating error
 Mishap
 Result
Seven Avenues

19. Protect the Force Through Risk Management
ACAC1919
Seven Avenues
Potential countermeasures for each modern
causation approach include:
SAFETY
MANAGEMENT
ERROR
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
1
234567

20. Protect the Force Through Risk Management
ACAC2020
Seven Avenues
Potential countermeasures for each modern
causation approach include:
SAFETY
PROGRAM
DEFECT
REVISE INFORMATION
COLLECTION
ANALYSIS
IMPLEMENTATION
2
345671

21. Protect the Force Through Risk Management
ACAC2121
Seven Avenues
Potential countermeasures for each modern
causation approach include:
COMMAND
ERROR
TRAINING
EDUCATION
MOTIVATION
TASK DESIGN
3
456712

22. Protect the Force Through Risk Management
ACAC2222
Seven Avenues
Potential countermeasures for each modern
causation approach include:
SYSTEM
DEFECT
DESIGN REVISION VIA--
- SOP
- REGULATIONS
- POLICY LETTERS
- STATEMENTS
4
567123

23. Protect the Force Through Risk Management
ACAC2323
Seven Avenues
Potential countermeasures for each modern
causation approach include:
OPERATING
ERROR
ENGINEERING
TRAINING
MOTIVATION
5
671234

24. Protect the Force Through Risk Management
ACAC2424
Seven Avenues
Potential countermeasures for each modern
causation approach include:
MISHAP
PROTECTIVE EQUIPMENT
BARRIERS
SEPARATION
6
712345

25. Protect the Force Through Risk Management
ACAC2525
Seven Avenues
Potential countermeasures for each modern
causation approach include:
RESULT
CONTAINMENT
FIREFIGHTING
RESCUE
EVACUATION
FIRST AID
7
123456

26. Protect the Force Through Risk Management
ACAC2626
A system is simply a group of interrelated parts
which, when working together as they were
designed to do, accomplish a goal. Using this
analogy, an installation or organization can be
viewed as a system.

The elements of the Army Systems Model are:
Task
Person
Training
Environment
Materiel
Army Systems Model

27. Protect the Force Through Risk Management
ACAC2727
TASK
Army Systems Model
•Communication Control
•Arrangement
•Demands on soldiers
•Time aspects

28. Protect the Force Through Risk Management
ACAC2828
PERSON
Army Systems Model
Selection
•Mentally
•Physically
•Emotionally
•Qualified
Motivation
•Positive
•Negative
•Retention

29. Protect the Force Through Risk Management
ACAC2929
Army Systems Model
TRAINING
Types
•Initial
•Update
•Remedial
Targets
•Operator
•Supervisor
•Management
Considerations
•Quality/Quantity

30. Protect the Force Through Risk Management
ACAC3030
Army Systems Model
ENVIRONMENT
•Noise
•Weather
•Facilities
•Lighting
•Ventilation

31. Protect the Force Through Risk Management
ACAC3131
Army Systems Model
MATERIEL
•Supplies
•Equipment
•Machine Design
•Maintenance

32. Protect the Force Through Risk Management
Army Systems Model
SAFETY
MANAGEMENT
ERROR
SAFETY
PROGRAM
DEFECT
RESULT
MISHAP
OPERATING
ERROR
SYSTEM
DEFECT
COMMAND
ERROR
Army Systems
Model
•Task
•Training
•Environment
•Materiel
•Person

33. Protect the Force Through Risk Management
ACAC3333

34. Protect the Force Through Risk Management
ACAC3434
Protect the Force Through Risk Management