In his 1990 paper, The contribution of latent human failures to the breakdown of complex systems Jame Reason presented us with three classifications of organizations. As usual, his work and results were spot on! The three (3) categories are: Pathological organizations Calculative organizations Generative organizations When we read these descriptions, as well as what Westrum…...
As the “safety culture” debate rages on, I came across this 2019 research paper that I found to be spot on. Of course, those are my biases shining through as I believe all organizations have a culture; in fact, they will have multiple cultures. So I am not one who subscribes to the idea that…...
At 3:00 p.m. on August 18, 2022, an employee entered an empty liquid propane gas (LPG) tank for servicing at an industrial equipment wholesaler facility. Earlier in the day, the employee approached a supervisor and stated that he wanted to enter the tank to spray a penetrating oil product on an internal valve to loosen…...
There are many concepts related to the science and practice of human factors. However, from a practical standpoint, having a unified view of what we should be concerned about is most helpful when considering aviation maintenance human factors. An excellent way to gain this understanding is by using a model. For over a decade, “PEAR”…...
The HFACS model was designed to be a classification tool rather than a predictive tool. However, since its initial development, there has been a lot of interest on whether it can also be used as a predictive tool. That is, can it be used to inform us about which factors in preconditions for unsafe acts,…...
I posted an article today @ SAFTENG explaining his accident pyramid model and discussing some of his Domino model. This quote is his own words trying to use the lottery to explain his pyramid model. I think it is a very fitting analogy. “The machine is dangerous as man makes it so. It is the…...
Another article defending the work of H. W. Heinrich, Assistant Superintendent Engineering and Inspection Division, The Travelers Insurance Company. I feel the need to explain how many have misstated Heinrich’s Accident Pyramid in this article. His Accident Pyramid is probably his most famous piece of work and by far what most attribute to his work. …...
First, let’s DEFINE what we mean when we use the term “remotely operated shutoff valve.” I have come to love the UK’s HSE definition, which is: A valve DESIGNED, INSTALLED, and MAINTAINED for the primary purpose of achieving rapid isolation of plant items containing hazardous materials in the event of a failure of the primary…...
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“Proximate Causes and Subcauses (Personal).— In connection with the unsafe acts of persons (which are the direct causes of the majority of accidents) the immediately preceding subcauses are of great value in determining the most practical remedy. For example, it is not always enough to know merely that a machine operator oiled his machine while…...
H. W. Heinrich, Assistant Superintendent Engineering and Inspection Division, The Travelers Insurance Company is best known as the “Father of Industrial Safety”. Much of what he developed in the 1920s-1950s can still be applied today. He was a true pioneer in our profession, but it seems there are some in the profession today that want…...
Heinrich’s take on unsafe acts and the “vital significance” of what drove that behavior. He clearly believed that unsafe acts were a reflection of MANAGEMENT and not solely the worker. “Proximate Causes and Subcauses (Personal).— In connection with the unsafe acts of persons (which are the direct causes of the majority of accidents) the immediately…...
