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Accident/Incident Prevention Techniques, Second Edition – 2nd Edition ( 2011 )

Similar records in OSTI. GOV collections:. Second edition. Full Record Other Related Research. Abstract A fundamental element in a comprehensive, modern safety program is the thorough investigation of accidents and incidents. Publication Date: Research Org. Furthermore, these two dimensions can vary independently; that is, causes can be important because they occur very close in time to the accident and therefore they reveal something about the time of the accident, or they can be important because they are a prime cause underlying the accident, or both.

By examining both the temporal and causal importance of factors involved in the wider circumstances as well as the immediate circumstances of the accident, analysis focuses on why the accident happened, rather than just describing how it happened. Second, accidents are generally agreed to be multicausal.

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Human, technical and environmental components in the work system can interact in critical ways. Traditionally, accident analysis frameworks have been limited in terms of the range of categories defined. This, in turn, limits the nature of the information obtained and so limits the range of options highlighted for preventive action. When the wider circumstances of the accident are taken into consideration, the model has to deal with an even more extensive range of factors.

Human factors are likely to interact with other human factors and also with non-human factors. The patterns of occurrences, co-occurrences and inter-relationships of the wide range of possible different elements within the causal network provides the most complete and therefore most informative picture of accident genesis.

Third, these two considerations, the nature of the event and the nature of its contribution to the accident, interact. Although multiple causes are always present, they are not equivalent in role. Accurate knowledge of the role of factors is the essential key to understanding why an accident happens and how to prevent it from recurring. For example, immediate environmental causes of accidents may have their impact because of earlier behavioural factors in the form of standard operating procedures. Similarly, pre-existing aspects of work systems may provide the context in which routine errors committed during skill-based behaviour can precipitate an accident with harmful consequences.

Normally these routine errors would have benign consequences. Effective prevention would be best served if it were targeted towards the latent underlying causes, rather than the immediately precipitating factors. This level of understanding of the causal network and how it influences outcome is possible only if all types of factors are included for consideration, their relative timing is examined and their relative importance is determined.

Despite the potential for an almost infinite variety in the ways that human action can directly contribute to accidents, relatively few patterns of causal pathways account for the majority of accident causation. In particular, the range of underlying latent conditions which set the scene for later human and other factors to have their effect are limited predominantly to a small number of aspects of work systems. Feyer and Williamson reported that only four patterns of factors accounted for the causes of approximately two-thirds of all occupational fatalities in Australia over a 3-year period.

Not surprisingly, almost all of these involved human factors at some point. The nature of human involvement varies as to type and timing and as to its importance in terms of causing the accident Williamson and Feyer Most commonly, human factors in the form of a limited range of pre-existing, flawed work systems create the underlying prime causes of the fatal accidents.

Accident/incident investigation manual. Second edition (Technical Report) |

These combine with later lapses during skilled performance or with hazards in environmental conditions to precipitate the accident. These patterns illustrate the layered role typical of the involvement of human factors in accident genesis. To be of use in preventive strategy formulation, however, the challenge is not to simply describe the various ways in which the human element is involved but rather to identify where and how it may be possible to intervene most effectively.

This is possible only if the model used has the capacity to describe accurately and comprehensively the complex network of interrelated factors involved in accident causation, including the nature of the factors, their relative timing and their relative importance. Give me a ladder that is twice as stable, and I will climb it twice as high. Consider the following scenario: A cigarette is invented that causes half the frequency of smoking-related deaths per cigarette smoked as compared to present-day cigarettes, but in all other ways it is indistinguishable.

Does this constitute progress? Thus, although the death rate per cigarette smoked is cut in half, the death risk due to smoking remains the same per smoker. As a consequence, the smoking-related death rate in the population increases. However, as people are willing to take no more risks with their health and lives than they see fit in exchange for the satisfaction of other desires, they will cut down on other, less appealing, unsafe or unhealthy habits. The end result is that the lifestyle-dependent death rate remains essentially the same. The above scenario illustrates the following basic premises of risk homeostasis theory RHT Wilde ; :.

The first is the notion that people have a target level of risk —that is, the level of risk they accept, tolerate, prefer, desire or choose.

The target level of risk depends on perceived benefits and disadvantages of safe and unsafe behaviour alternatives, and it determines the degree to which they will expose themselves to safety and health hazards. The second premise is that the actual frequency of lifestyle-dependent death, disease and injury is maintained over time through a closed-loop, self-regulating control process. Thus, fluctuations in the degree of caution people apply in their behaviour determine the ups and downs in the loss to their health and safety.

different Accident/Incident Prevention Techniques, Second Edition

Moreover, the ups and downs in the amount of actual lifestyle-dependent loss determine the fluctuations in the amount of caution people exercise in their behaviour. Among the many psychological contributions to the literature on occupational accidents and disease, traffic accidents and lifestyle-dependent ill health, only a relatively few deal with motivational factors in the causation and the prevention of these problems. Most of the publications deal with variables such as permanent or semi-permanent traits e. It may be reasoned, however, that all variables other than motivational ones i.

Some, though, may well have a favourable effect upon the accident rate per unit of productivity or per unit distance of mobility. When applied, for instance, to road traffic, RHT posits that the traffic accident rate per time unit of road-user exposure is the output of a closed-loop control process in which the target level of risk operates as the unique controlling variable.

Thus, in contrast with temporary fluctuations, time-averaged accident risk is viewed as independent of factors such as the physical features of the vehicle and road environment and of operator skills. Instead, it ultimately depends on the level of accident risk accepted by the road-user population in exchange for the perceived benefits received from motor-vehicle mobility in general like driving a lot , and from specific risky acts associated with that mobility in particular like driving well in excess of the average speed.

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Thus, it is reasoned that at any moment of time, vehicle operators, equipped with their perceptual skills, perceive a certain level of accident risk and they compare this with the amount of accident risk they are willing to accept. The level of the latter is determined by the pattern of trade-offs between expected costs and benefits associated with the available alternatives for action. Thus, the target level of risk is that level of risk at which the overall utility of manner and amount of mobility is thought to maximize.

The expected costs and benefits are a function of economic, cultural and person-related variables, and their long-term, short-term and momentary fluctuations. These control the target level of risk at any specific moment of time. Whenever road users perceive a discrepancy between target risk and experienced risk in one direction or the other, they will attempt to restore the balance through some behavioural adjustment.

However, any action taken carries a certain likelihood of accident risk. The sum total of all actions taken by the road users in a jurisdiction in a given time period like 1 year , produce the frequency and severity of the traffic accidents in that jurisdiction. It is hypothesized that this accident rate has an influence through feedback upon the level of accident risk perceived by the survivors and thus upon their subsequent actions and subsequent accidents, and so forth.

Thus, as long as the target level of risk remains unchanged, accident toll and behavioural caution determine each other in a circular causal chain. This homeostatic process, in which the accident rate is both consequence and cause of changes in operator behaviour, is modelled in figure 1.

The self-correcting nature of the homeostatic mechanism can be recognized in the closed loop that runs from box e to box b , to box c , to box d , and then back to box e. It may take some time for people to become aware of a change in the accident rate the feedback may be delayed, and this is symbolized by f.

Note that box a is located outside the closed loop, meaning that interventions that lower that target level of risk can bring about a lasting reduction in the accident rate box e. Figure 1. The process described herein can be further and quite clearly explained by another example of homeostatic regulation: the thermostatic control of the temperature in a house. The set temperature comparable to box a on the thermostat is at any point in time being compared with the actual temperature box b. Whenever there is a difference between the two, there is a need for adjustment box c , which triggers an adjustment action i.


As a result, the air that is distributed through the house becomes colder via air conditioning or warmer via heating—box e , as desired. After some time symbolized by f the air at the new temperature reaches the point set on the thermostat and gives rise to a new temperature reading, which is compared with the set-point temperature box a , and so on. The house temperature will show major fluctuations if the thermometer is not very sensitive. Note, however, that these deficiencies will not alter the time-averaged temperature in the house. Note too that the desired temperature analogous to box a in figure 1 is the only factor outside the closed loop.

Resetting the thermostat to a new target temperature will produce durable changes in the time-averaged temperature. Just as a person chooses a target level of risk on the basis of the perceived benefits and costs of safe and risky behaviour alternatives, so is the target temperature selected in consideration of the pattern of expected costs and benefits of higher or lower temperatures e.

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A lasting discrepancy between target risk and actual risk can occur only in the case of consistent over- or under-estimation of risk, just as a thermometer that produces a temperature reading that is consistently too high or too low will cause real temperature to deviate systematically from target temperature. It may be deduced from the model described above that the introduction of any accident countermeasure that does not alter the target level of risk is followed by road users making an estimate of its intrinsic effect upon safety—that is, the change in accident rate that would occur if operator behaviour did not change in response to the new countermeasure.

This estimate will enter into the comparison between perceived and accepted level of risk and thus influence subsequent adjustment behaviour. If the initial estimates are incorrect on average, a disturbance in the accident rate will occur, but only temporarily, because of the correcting effect due to the feedback process. This phenomenon has been discussed in an OECD report.

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This report mentions numerous examples, as follows:. Taxicabs in Germany equipped with anti-lock brake systems were not involved in fewer accidents than taxis without these brakes, and they were driven in a more careless manner. Increases in lane width of two-lane highways in New South Wales in Australia have been found to be associated with higher driving speeds: a speed increase by 3.