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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