MODELS: HOW UNDERLYING DIFFERENCES AFFECT
Ludwig Benner, .Jr.
of Southern California, USA
our efforts to discover and correct workplace safety and health problems, we
often wait too long and then fix the wrong problems. The reasons: inadequate
intellectual concepts of the phenomenon of accidental harm lead to use of
inappropriate investigation and analysis tools, which misdirect the search for
data that define our safety and health problems and their solutions. Borrowed
technology from other disciplines is inadequate for future safety improvement
tasks. This paper explores underlying accident concepts and investigative
practices) how they affect workplace safety, and what is happening to overcome
some intellectual shortcomings.
illustrate this issue, differing conceptual models of the accident phenomenon
currently driving safety problem identification in
U. S. government agencies were examined. From this examination, criteria for
judging the merit of alternative accident models in occupational safety and
health programs were defined. The criteria were then used to rate each model.
The models’ impact on the investigative methodologies resulting were
examined next, and criteria for judging the methodologies were defined.
Applications of the highest—rated models and methodology were then
compared with existing practice to determine what improvements might be
expected. Based on the findings, further development and applications efforts
1982 an estimated 11,100 fatal and 1,900,000 disabling injuries in workplaces
were experienced in the United States(1). In 1970, amid much fanfare, national
legislation was adopted in the U.S. to stop this carnage in workplaces, and
much action has been taken. Yet since then, almost 2% of our working population
suffers serious workplace injury each
For each of these workers, the safety control system failed. Why did it fail?
SAFETY PROBLEM DISCOVERY AND DEFINITION ISSUES
evidence that points to the reason is accumulating from my inquiries into a
wide range of safety matters. This evidence indicates that these failings flow
from intellectual shortcomings in the safety problem discovery and definition
processes, rather than from other origins. Each new examination of that process
I undertake seems to add greater weight to that conclusion. With each new
inquiry, specific intellectual inadequacies seem to become clearer. Apparently
my concern is shared by others.(2,31,32) My work indicates that this matter
deserves urgent attention. It is gratifying to be able to discuss the issue at
this seminar, and I thank the sponsors for this opportunity.
information in this paper reflects observations in many inquiries into this
safety problem definition and response issue. The inquiries were conducted both
as an employee of the National Transportation Safety Board in accident
investigations, and during personal research in support of my teaching
activities. The issue was examined from many individuals’ perspectives.
For example, it was examined from the workers viewpoint. An early inquiry
related to defining tasks facing emergency response workers dealing with
hazardous materials.(3) In emergency situations, what techniques should they
use to identify and define the danger?(4) How are these workers expected to
interpret emergency response instructions(5) How does one define and measure
their effectiveness in accident emergencies(6)?
of intellectual confusion from paper)
1: MEANING OF “CAUSE” IN ACCIDENT INVESTIGATION
l. What do you mean by the word “cause” as you use it in accident
which leads to an outcome or result.
primary underlying reason for an act or event.
that takes the actions of an object or being and is the reason for the second
word used to show the relationship of an action to an individual or thing;
means made or associated with a happening; it is responsible for the happening .
effort by individuals or groups to achieve a desired end.
event which leads to the resultant occurrence of another event.
influence that determine a particular outcome.
event or combination of events that determine the outcome of a
condition that leads to an occurrence.
that results in an effect or another phenomenon.
state, situation, occurrence, event which leads to, is primarily conducive to a
second state, situation, etc.(etc) which is partially responsible for a second
occurrence, event (etc).
reason for a studied occurrence.
determination of what happened.
event, state, action or reason that leads to a fact.
root source by which a resultant event can be explained.
cause is-the event or set of events producing the accident. l believe cause is
the same as factors.
reason that an event occurred; the driving force or motivation.
that brings about an effort or result.
event, circumstance or condition or any combination of these that brings about
or helps bring about a result. (Webster and l agree)
sum effect of various factors which, in combination, precipitate the occurrence
of an event.
accident, except for 2% that are classified as acts of nature, is caused by the
unsafe behavior of an individual, or an unsafe mechanical or environmental
condition, or both. The investigator must identify and describe the causes, as
failure to do so negates the entire investigation effort.
reason for the state of things.
producing an effect or result; a person or thing acting voluntarily or
involuntarily as the agent that brings about an effect or result.
reason for an event to occur.
as those singularly or in combination, that bring about a result (usually a
known result); an entity that is the agent of bringing something about .
be an action of a person; can be a failure on the part of a mechanism.
item that allows or drives the event to occur.
factor must be logically related — traceable to the result. Must be a
factor without which the result, the, accident, would not have occurred, or
would not have the same way with the same outcome.
event(s) which deviated from the usual or accepted operating procedures.
event which if changed would have interrupted the chain of events and prevented
starts an imbalance in a balanced system.
that if not present or active would have stopped or
stopped (or altered) the outcome of a sequence.
summary of what happened; let management pick out what they believe to be the
or conditions most closely associated with the injurious event which make the
injurious event irreversible.
events, situations or circumstances which lead to an accident or permit the
accident to occur.
off—normal action or event without which the accident would or could not
which directly contributes to an event called an accident.
energy input that produces or contributes to the energy of the accident.
that helps tell me “why” and accident occurred.
which triggers an action or that which is a motivating force in the
factor which, when it is present alone or in the proper combination with other
such factors, results in the occurrence of the accident.
of the verifiable circumstances contributing to the accident; the source of
such being human, environmental, mechanical or whatever.
event that produces a 2nd event.
factor which led to or formed the conditions necessary for the accident to
events and factors which together brought on the accident.
factors which contributed to or the deficiency in the system to control the
flow of energy or prevention of accidents.
events and factors that combined to result in an accident; these may range from
general systemic oversights to specific events immediately preceding the
failure or failures that led to or created the accident.
chain—of-events or things that occurred that permitted an incident to
or condition sufficient to produce an unwanted result.
cause in a cause-effect relationship.
condition which effects an event with either wanted or unwanted results.
group or system actions, conditions, deficiencies, failures, changes, errors
and responses which contribute to the initiation of potential or accident losses.
Benner, Jr. Univ. of Southern California 05-19-83
groups: Replies/populations:5/5: l5/l6: 15/15: 19/25: total=54/61
nouns counted = 88 in 53 replies