More on near misses and unsafe acts that result in no consequence- remember this is from the 1930s and 40s “It needs but little thought for the average person to conclude that the no-injury accident ratio herein expressed is not exaggerated. How many drivers of automobiles would care to assert that they had never had […]
Lots of talk about SIF (Serious Injuries & Fatalities) these days. It even has a new acronym some of you may have seen being used… STKY (Stuff [or Sh_t] That Kills You). Leave it to the safety profession to package this risk management approach into a “program” that can be marketed and sold as another
Heinrich wrote this in 1941. So many want to decry his belief that unsafe acts play a significant role in accidents. In my earlier posts, I shared his position that unsafe acts are a reflection on management and not so much on the worker who carried out the unsafe act. In this quote from his
“Very few unsafe acts will result in damage or injury. In a highly protected system, the probability that the consequences of an isolated action will penetrate the various layers of defense is vanishingly small. Several causal factors are required to create a ‘trajectory of opportunity’ through these multiple defenses. Many of the causal contributions will
We hear it all the time… “yes of course we have a safety management system.” Then we ask one simple question, “can we see your OSH auditing plan for the year/3-years/5-years?” The most common response we get is “OSHA does not require us to conduct overall workplace audits.” That is true and it is also
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
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.
“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
