Accident Causation Why Do We Have Accidents? Updated 1 July 2014

Accident Accident CausationCausation

Why Do We Have Accidents?Why Do We Have Accidents?

Updated 1 July 2014

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERCausation HistoryCausation History

Early man – Accidents were the result Early man – Accidents were the result of Bad Spiritsof Bad Spirits

Civilized man - Injured person was at Civilized man - Injured person was at fault due to stupidity fault due to stupidity

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERCausation HistoryCausation History

Industrial revolution – carelessness Industrial revolution – carelessness caused accidents. caused accidents. • Natural side effect of productionNatural side effect of production• Cost of doing businessCost of doing business• Human nature – people will always be Human nature – people will always be

carelesscareless

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERCausation HistoryCausation History The court systemThe court system

• Upheld the view of individual responsibility Upheld the view of individual responsibility • Injured worker had to sueInjured worker had to sue• Employer had to be found completely to blameEmployer had to be found completely to blame

Public opinion Public opinion • Rose against rose against the "worker alone-Rose against rose against the "worker alone-

is-to-blame" theory. is-to-blame" theory. • Courts became more responsive to workers' Courts became more responsive to workers'

claims. claims. • By 1908 State legislatures implemented an By 1908 State legislatures implemented an

employer's liability law.employer's liability law.

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERCausation HistoryCausation History

Employers take noticeEmployers take notice• Financial responsibility for an injured Financial responsibility for an injured

worker worker • More cost effective to prevent More cost effective to prevent

accidents. accidents. • Only theory remained personal Only theory remained personal

carelessness carelessness • Safety program success was hit and Safety program success was hit and

missmiss

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERIndustrial RevolutionIndustrial Revolution

Natural Side Effect of

Production

Natural Side Effect of

Production“Acts of God”“Acts of God”

ACCIDENTS

Number Is Up ApproachNumber Is

Up ApproachPeople ErrorsPeople Errors

CarelessnessCarelessness

Employers Rationale for Accidents

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERHeinrich’s TheoryHeinrich’s Theory

Scientific ApproachScientific Approach Heinrich’s model to accident Heinrich’s model to accident

causation has been the basic causation has been the basic approach in accident prevention and approach in accident prevention and has been used mostly by safety has been used mostly by safety societies and professional people societies and professional people since its publication in since its publication in 19321932. This . This was the was the first scientific approach.first scientific approach.

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Heinrich’s AccidentHeinrich’s AccidentCausation ModelCausation Model

Injury

Accident

Unsafe ActOr

UnsafeCondition

Fault of the Person

Social Environment& Ancestry

Mistakes of People

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERAccident CausationAccident Causation

SocialEnvironmentAnd Ancestry

Fault of thePerson

(Carelessness)

Unsafe ActOr

ConditionAccident Injury

1932 - First Scientific Approach To Accident Prevention – H.W. Heinrich

“Industrial Accident Prevention”

Mistakes of People

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Three “E’s” ofThree “E’s” ofAccident PreventionAccident Prevention

EngineeringEngineering

EducationEducation

EnforcementEnforcement

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERBeyond EngineeringBeyond Engineering

InstructionInstruction

PersuasionPersuasion

DisciplineDiscipline

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation Model

Parallels Heinrich’s theoryParallels Heinrich’s theory ““InjuryInjury” becomes “” becomes “ResultResult””

• Varies from no damage to very severeVaries from no damage to very severe ““AccidentAccident” becomes “” becomes “MishapMishap””

• Injury not requiredInjury not required ““Unsafe Act or Unsafe ConditionUnsafe Act or Unsafe Condition” ”

becomes “becomes “Operating ErrorOperating Error””• Act and condition captured as error Act and condition captured as error

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation ModelModern Causation ModelModern Causation Model

OPERATINGERROR

MISHAP

No damage or injury

RESULTS

Major damageOr fatalities

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation ModelModern Causation ModelModern Causation Model

OPERATINGERROR

MISHAP RESULTS

Disrupted Disrupted OperationOperation

No damage or injury

RESULTS

Major damageOr fatalities

No damage or injury

RESULTS

Major damageOr fatalities

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation ModelModern Causation ModelModern Causation Model

OPERATINGERROR MISHAPMISHAP RESULTS

EventEvent

No damage or injury

RESULTS

Major damageOr fatalities

Disrupted Disrupted OperationOperation

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation ModelModern Causation ModelModern Causation Model

OPERATINGOPERATINGERRORERROR

OPERATINGOPERATINGERRORERROR

MISHAP RESULTS

Injury or Injury or damagedamageEventEvent

Failure to Failure to properly properly operate or operate or maintainmaintainfacilities or facilities or equipment equipment

No damage or injury

RESULTS

Major damageOr fatalities

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation ModelModern Causation ModelModern Causation ModelModern Causation Model

SYSTEMDEFECTSYSTEMDEFECT

OPERATINGERROR

MISHAP RESULTS

Single Most Important Single Most Important Addition to New ModelAddition to New Model

System DefectSystem Defect

No damage or injury

RESULTS

Major damageOr fatalities

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERSystem DefectsSystem Defects

Weaknesses in the way the system is Weaknesses in the way the system is designed or operateddesigned or operated• Improper assignment of responsibilitiesImproper assignment of responsibilities• Improper climate of motivationImproper climate of motivation• Inadequate training and educationInadequate training and education• Inadequate or improper equipment or Inadequate or improper equipment or

suppliessupplies• Poor personnel selection for jobPoor personnel selection for job• Inadequate fundingInadequate funding

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation Model Modern Causation Model Modern Causation Model Modern Causation Model

OPERATINGERROR

MISHAP RESULTS

No damage or injury

RESULTS

Major damageOr fatalities

COMMAND/MANAGEMENT

ERROR

COMMAND/MANAGEMENT

ERROR

SYSTEMDEFECT

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERManagement ErrorManagement Error

ManagersManagers

• Design systemsDesign systems

• Create proceduresCreate procedures

• Enforce disciplineEnforce discipline

• Provide trainingProvide training

Why does the manager fail to identifyWhy does the manager fail to identify system defects or take action?system defects or take action?

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation Model Modern Causation Model Modern Causation Model Modern Causation Model

OPERATINGERROR

MISHAP RESULTS

No damage or injury

RESULTS

Major damageOr fatalities

SAFETYPROGRAM

DEFECT

SAFETYPROGRAM

DEFECT

COMMAND/MANAGEMENT

ERROR

SYSTEMDEFECT

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERSafety Program DefectSafety Program Defect

Ineffective information collectionIneffective information collection

Weak causation analysisWeak causation analysis

Poor countermeasuresPoor countermeasures

Inadequate controlsInadequate controls

Inadequate programsInadequate programs

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation Model Modern Causation Model Modern Causation Model Modern Causation Model

SAFETYPROGRAM

DEFECT

COMMAND/MANAGEMENT

ERROR

SYSTEMDEFECT

OPERATINGERROR

MISHAP RESULTS

No damage or injury

RESULTS

Major damageOr fatalities

SAFETYSAFETYMANAGEMENTMANAGEMENT

ERRORERROR

SAFETYSAFETYMANAGEMENTMANAGEMENT

ERRORERROR

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Safety Management Safety Management ErrorError

KnowledgeKnowledge

MotivationMotivation

IntegrationIntegration

RelevanceRelevance

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERAccidents & Near MissesAccidents & Near Misses

1

29

300

1

59

600

Heinrich’s InitialResearch

RecentStudies

Serious

Minor

Near Miss

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

There are seven avenues through which There are seven avenues through which we can initiate countermeasures. None we can initiate countermeasures. None of these areas overlap. They are:of these areas overlap. They are:

Safety management errorSafety management error Safety program defectSafety program defect Management / Command errorManagement / Command error System defectSystem defect Operating errorOperating error MishapMishap ResultResult

Seven AvenuesSeven Avenues

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERModern Causation Model Modern Causation Model Modern Causation Model Modern Causation Model

SAFETYPROGRAM

DEFECT

SAFETYPROGRAM

DEFECT

COMMAND/MANAGEMENT

ERROR

COMMAND/MANAGEMENT

ERROR

SYSTEMDEFECTSYSTEMDEFECT

OPERATINGERROR

OPERATINGERROR MISHAPMISHAP RESULTS

No damage or injury

RESULTS

Major damageOr fatalities

No damage or injury

RESULTS

Major damageOr fatalities

SAFETYSAFETYMANAGEMENTMANAGEMENT

ERRORERROR

SAFETYSAFETYMANAGEMENTMANAGEMENT

ERRORERROR

7

65

4321

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

SAFETYMANAGEMENT

ERROR

TRAININGEDUCATIONMOTIVATIONTASK DESIGN

1

2 3 4 5 6 7

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

SAFETYPROGRAM

DEFECT

REVISE INFORMATIONCOLLECTIONANALYSISIMPLEMENTATION

2

3 4 5 6 71

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

TRAININGEDUCATIONMOTIVATIONTASK DESIGNDISCIPLINESUPPORT

3

4 5 6 71 2COMMAND/

MANAGEMENTERROR

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

SYSTEMDEFECT

DESIGN REVISION VIA-- - SOP- REGULATIONS- POLICY LETTERS- STATEMENTS

4

5 6 71 2 3

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

OPERATINGERROR

ENGINEERINGSAFETY DEVICESWARNING DEVICESTRAININGMOTIVATION

5

6 71 2 3 4

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

MISHAP

PROTECTIVE EQUIPMENTBARRIERSSEPARATION

6

71 2 3 4 5

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Seven AvenuesSeven AvenuesPotential CountermeasuresPotential Countermeasures

RESULT

CONTAINMENTFIREFIGHTINGRESCUEEVACUATIONFIRST AID

7

1 2 3 4 5 6

Systems Model

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

ConclusionConclusion

The Army approach to accident The Army approach to accident causation allows us to:causation allows us to:

1.1. Look beyond the individualLook beyond the individual2.2. ID the systemic defectID the systemic defect3.3. Use the information to develop Use the information to develop

controls & prevent accidentscontrols & prevent accidents

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERArmy Systems ModelArmy Systems Model

SAFETYMANAGEMENT

ERROR

SAFETYPROGRAM

DEFECT

RESULT

MISHAP

OPERATINGERROR

SYSTEMDEFECT

COMMANDERROR

Army SystemsArmy SystemsModelModel

• Task• Person• Training• Environment• Materiel

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

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

Army Systems ModelArmy Systems Model

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

The elements of the Army The elements of the Army Systems Model are:Systems Model are:

TaskTask PersonPerson TrainingTraining EnvironmentEnvironment MaterielMateriel

Army Systems ModelArmy Systems Model

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

TASKTASK

Army Systems ModelArmy Systems Model

• Communication Control

• Arrangement

• Demands on soldiers

• Time aspects

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

PERSONPERSON

Army Systems ModelArmy Systems Model

Selection

• Mentally

• Physically

• Emotionally

• Qualified

Motivation

• Positive

• Negative

• Retention

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERArmy Systems ModelArmy Systems Model

TRAININGTRAINING

Types• Initial• Update• Remedial

Targets• Operator• Supervisor• Management

Considerations• Quality/Quantity

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERArmy Systems ModelArmy Systems Model

ENVIRONMENTENVIRONMENT

• Noise• Weather• Facilities• Lighting• Ventilation

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERArmy Systems ModelArmy Systems Model

MATERIELMATERIEL

• Supplies• Equipment• Machine Design• Maintenance

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

WhatHappened ?

(cause Factors)

•Human Mistakes/Errors

•Materiel Failure

•Environmental Factors

Why Did itHappened ?

(System Inadequacies/Roo

t Cause)

•Leader

•Training

•STDS / Procedures

•Support

•Individual

What to do About it ?

(Recommendations)

•Fixes

•Remedial Measures

•Countermeasures

DA PAM 385-40

3 W’s Approach to Information Collection, Analysis and Recommendations

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

1

RECENT STUDIES

SERIOUS

MINOR

NEAR MISS

59

600

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

How to analyze the Near MissHow to analyze the Near Miss

1.1. Identify the systemic defectIdentify the systemic defect

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

SYSTEM

DEFECT

Army System Model

TaskTrainingEnvironmentMaterial

Person

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

How to analyze the Near MissHow to analyze the Near Miss

1.1. Identify the systemic defectIdentify the systemic defect

2.2. Identify cause factors:Identify cause factors:

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

WhatHappened ?

(cause Factors)

•Human Mistakes/Errors

•Materiel Failure

•Environmental Factors

Why Did itHappened ?

(System Inadequacies/Roo

t Cause)

•Leader

•Training

•STDS / Procedures

•Support

•Individual

What to do About it ?

(Recommendations)

•Fixes

•Remedial Measures

•Countermeasures

Cause FactorsCause Factors

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

WhatHappened ?

(Cause Factors)

•Human Mistakes/Errors

•Materiel Failure

•Environmental Factors

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

How to analyze the Near MissHow to analyze the Near Miss

1.1. Identify the systemic defectIdentify the systemic defect

2.2. Identify cause factors:Identify cause factors:• Human, Materiel, EnvironmentalHuman, Materiel, Environmental

If human –If human –• Identify the system inadequacies, the root causeIdentify the system inadequacies, the root cause• Leader, Training, Standards, Support, IndividualLeader, Training, Standards, Support, Individual

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

WhatHappened ?

(cause Factors)

•Human Mistakes/Errors

•Materiel Failure

•Environmental Factors

Why Did itHappened ?

(System Inadequacies/Roo

t Cause)

•Leader

•Training

•STDS / Procedures

•Support

•Individual

What to do About it ?

(Recommendations)

•Fixes

•Remedial Measures

•Countermeasures

System InadequaciesSystem Inadequacies

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Why Did itHappened ?

(System Inadequacies/Root Cause)

1. Leader

2. Training

3. STDS / Procedures

4. Support

5. Individual

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER

Near Miss - SummaryNear Miss - Summary

1.1. Identify the systemic defectIdentify the systemic defect

2.2. Identify cause factors:Identify cause factors:• Human, Materiel, EnvironmentalHuman, Materiel, Environmental

If human –If human –• Identify the system inadequacies and root causeIdentify the system inadequacies and root cause• Leader, Training, Standards, Support, IndividualLeader, Training, Standards, Support, Individual

U.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTERU.S. ARMY COMBAT READINESS CENTER