Occupational Accidents Review

8/8/2019 Occupational Accidents Review

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NeetiNeeti

Contact: [email protected]: [email protected]

Review of Approaches and Theories of Review of Approaches and Theories of Occupational AccidentsOccupational Accidents



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Outline different approaches, recent changes and shifts in accidentsOutline different approaches, recent changes and shifts in accidentsinvestigations,investigations,

Review definitions and classifications of unsafe acts at workplace,Review definitions and classifications of unsafe acts at workplace,

Understand various Theoretical perspectives /assumptions to studyUnderstand various Theoretical perspectives /assumptions to studycausal links between factors and deviations from expectedcausal links between factors and deviations from expectedperformances.performances.

Review on Cognitive and Social theories effecting humanReview on Cognitive and Social theories effecting humancapabilities and intention to perform learned task,capabilities and intention to perform learned task,

ObjectivesObjectives



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ILO Global Estimates in 1999, for the year 1998-ILO Global Estimates in 1999, for the year 1998-

• 264 million non fatal accidents, resulting at least 3 days absence from work264 million non fatal accidents, resulting at least 3 days absence from work• Everyday some 970 people die because of occupational accidentsEveryday some 970 people die because of occupational accidents• 345,500 fatal accidents345,500 fatal accidents• Accidents, grossly under reported in India, even so 23 injuries per 1000 factoryAccidents, grossly under reported in India, even so 23 injuries per 1000 factory

workers were officially reported.workers were officially reported.

Recent Estimates (ILO & WHO), 2005, for the year 2001-Recent Estimates (ILO & WHO), 2005, for the year 2001-

• Work related accidents and Illness on rise due to rapid IndustrializationWork related accidents and Illness on rise due to rapid Industrialization• 268 million non fatal accidents268 million non fatal accidents• 351,500 fatal accidents351,500 fatal accidents• Work place accident and illness responsible for the loss of 4% of the world’sWork place accident and illness responsible for the loss of 4% of the world’s

GDP in compensation and absence.GDP in compensation and absence.• Accident rates rising in ASIA and LATIN AMERICAAccident rates rising in ASIA and LATIN AMERICA• In Construction Industry highest number of accidents, about one death in everyIn Construction Industry highest number of accidents, about one death in every

10 minutes.10 minutes.• Age group- 15 to 24 years and 60 above, prone for accidentsAge group- 15 to 24 years and 60 above, prone for accidents

Facts: Occupational AccidentsFacts: Occupational Accidents



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Stage 1: Technical PeriodStage 1: Technical Period

Stage 2: Human Error PeriodStage 2: Human Error Period

Stage 3: Socio Technical PeriodStage 3: Socio Technical Period

Stage 4: Organizational Culture PeriodStage 4: Organizational Culture Period

Changes in Accident CausationChanges in Accident Causation

(Weigmann and Shappell, 2001)(Weigmann and Shappell, 2001)



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The Person Approach-The Person Approach- Focus on people at sharp end,Focus on people at sharp end, unsafe acts arise primarily from aberrant mental processesunsafe acts arise primarily from aberrant mental processes Countermeasures- reduce unwanted variability in human behavior.Countermeasures- reduce unwanted variability in human behavior. Limitation: Isolates unsafe acts from system context.Limitation: Isolates unsafe acts from system context.

The System Approach-The System Approach- Focus on upstream systemic factors,Focus on upstream systemic factors, Errors are consequences rather than causes, originating from workplace andErrors are consequences rather than causes, originating from workplace and

organizational processes (ex. Poor design, policies and external factors etc),organizational processes (ex. Poor design, policies and external factors etc), Countermeasures- Change conditions under which human works, buildCountermeasures- Change conditions under which human works, build

defenses, barriers and safeguards.defenses, barriers and safeguards. Limitation; Fails to consider Individual Variability.Limitation; Fails to consider Individual Variability.

Approaches to study Human Error Approaches to study Human Error



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Error-Error-

any member of a set of human actions that exceeds some limit of acceptabilityany member of a set of human actions that exceeds some limit of acceptability(Swain and Guttmann, 1983),(Swain and Guttmann, 1983),

any human action or inaction that exceeds the tolerances defined by the systemany human action or inaction that exceeds the tolerances defined by the systemwith which the human interacts (Lorenzo, 1990),with which the human interacts (Lorenzo, 1990),

the failure to achieve an intended outcome beyond the influence of randomthe failure to achieve an intended outcome beyond the influence of random

occurrence (Reason, 1990),occurrence (Reason, 1990),

a necessary outcome to allow humans to explore and understand systemsa necessary outcome to allow humans to explore and understand systems(Rasmussen, 1990; Reason, 1990) and derivative of operators' social experience(Rasmussen, 1990; Reason, 1990) and derivative of operators' social experienceof responsibility and values (Taylor, 1987).of responsibility and values (Taylor, 1987).

Rankin (2004) “An error Rankin (2004) “An error is a human action (behavior) that unintentionally departsis a human action (behavior) that unintentionally departs

from the expected action (behavior)”.from the expected action (behavior)”.

Violation-Violation- Violations as deviations from operating procedures, recommended practices,Violations as deviations from operating procedures, recommended practices,

rules or standards that are deliberate.rules or standards that are deliberate.

Rankin (2004) “A violation is a human action (behavior) that intentionally departsRankin (2004) “A violation is a human action (behavior) that intentionally departsfrom the expected action (behavior)”.from the expected action (behavior)”.

Error and Violations: DefinitionError and Violations: Definition



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ClassificationsClassifications

Errors According to Hinckey(1997)Errors According to Hinckey(1997)Name or Type Method/ Classification Authors Example classifications

Human Reliability Assessments / HumanError Probabilities Classifications

Swain Error of omission, error of commission (selection errors, sequence errors, time errors, and qualitative errors)

Performance Shaping Factors (PSF) Swain, Meister Inadequate lighting in the work area, inadequate training or skill, Poor verbal communication

Ergonomic Method Alexander Errors during the perception stage, errors during the decision-

making process, errors during the action process

Psychological Classifications Norman, Salvendy Slips in the formation of intention, from faulty activation of schemas, from faulty triggering of active schemas

Stress Based Classifications Altman Work load, occupational change, problems of occupational frustration, occupational stress like noise, lighting

Task Based Classification Dhillon Design error, operator error, fabrication error, maintenanceerror

Classification of Human Performance inIndustry

Harris and Chaney Planning, designing and developing, producing, distributing

Behavior Based Classification Berliner Perceptual processes, mediational processes, communication processes, motor processes

Mistake-Proofing Classification Nikkan Kogyo Shimbum Forgetful ness, errors due to misunderstanding, errors in

identification, errors made by amateurs



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Reason(1990): Behavioral, Contextual and Conceptual-Reason(1990): Behavioral, Contextual and Conceptual-

Skill Based ErrorsSkill Based Errors• SlipsSlips - failures in carrying out the actions of a task- failures in carrying out the actions of a task• LapsesLapses of memory cause to forget to carry out an action.of memory cause to forget to carry out an action.

MistakesMistakes are a more complex type of error of doing the wrong thing believing it to be right.are a more complex type of error of doing the wrong thing believing it to be right.

• Rule-based mistakesRule-based mistakes - performance based on remembered rules and procedures.- performance based on remembered rules and procedures.• Knowledge-based mistakesKnowledge-based mistakes -operator has to resort to an expert judgment unsupported by rules-operator has to resort to an expert judgment unsupported by rules

and procedures.and procedures.

Violations (Lawton, 1998)-Violations (Lawton, 1998)-

• Erroneous Violations-Erroneous Violations- Unwitting deviations from expected action, Caused by excessive timeUnwitting deviations from expected action, Caused by excessive timepressure or work load and inexperience and lack of understanding of rules, not motivated to savepressure or work load and inexperience and lack of understanding of rules, not motivated to savetime.time.

• Exceptional Violations-Exceptional Violations- Extremely risky, occurs when unusual circumstances call for an unusualExtremely risky, occurs when unusual circumstances call for an unusualresponse requiring knowledge base processing for solution.response requiring knowledge base processing for solution.

• Situational Violations-Situational Violations- Motivated by the desire to keep the job going in adverse conditions,Motivated by the desire to keep the job going in adverse conditions,result of factors in employees immediate work environment.result of factors in employees immediate work environment.

• Routine Violations-Routine Violations- Occur when a shortcut between two points presents itself and is taken onOccur when a shortcut between two points presents itself and is taken on

regular basis, usually go unpunished, often have benign effects, promoted by the belief that riskregular basis, usually go unpunished, often have benign effects, promoted by the belief that riskassociated with behavior is offset by the skill.associated with behavior is offset by the skill.

Cont….Cont….





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Information Processing ModelsInformation Processing Models

Rasmussen’s Skill-Rule-Knowledge FrameworkRasmussen’s Skill-Rule-Knowledge Framework1. Skill Based Behavior (SBB)1. Skill Based Behavior (SBB)

-- smooth, automated and highly integrated, takes place without conscious control or attention, generally smooth, automated and highly integrated, takes place without conscious control or attention, generally at routine tasks.at routine tasks.

- - Performance is governed by unconsciousPerformance is governed by unconscious mental schemasmental schemas

- Errors in connections with lack of attention at tasks.- Errors in connections with lack of attention at tasks.

- SBB rely on- SBB rely on signalssignals- With deliberate practice and experience, performance becomes automatized - With deliberate practice and experience, performance becomes automatized

- Skill based errors are highest at work.- Skill based errors are highest at work.

2.2. Rule Based Behavior (RBB)Rule Based Behavior (RBB)

-- requires conscious effort to recall and follow stored rules.requires conscious effort to recall and follow stored rules.

-- rely onrely on signssigns for indication of stimulusfor indication of stimulus

- applicable to tackle familiar problems in which solutions are governed by stored rules- applicable to tackle familiar problems in which solutions are governed by stored rules

- Errors at this level- application of bad rules, misapplication of good rules.- Errors at this level- application of bad rules, misapplication of good rules.

3. Knowledge Based Behavior (KBB)-3. Knowledge Based Behavior (KBB)-

-- controlled by highest level of processing hierarchy controlled by highest level of processing hierarchy

- nature of information at this level - nature of information at this level symbolssymbols

-- stored knowledge helps to execute unfamiliar, complex tasks, requiring -interpretation, diagnosis and stored knowledge helps to execute unfamiliar, complex tasks, requiring -interpretation, diagnosis and some level of decision making for performance.some level of decision making for performance.

TheoriesTheories



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Reason’s General Error Modeling System (GEMS)Reason’s General Error Modeling System (GEMS) The Automatic SubsystemThe Automatic Subsystem - enormous pool of schemata to activate- enormous pool of schemata to activate

- no limitation of either number or duration of retention- no limitation of either number or duration of retention

- Two core mechanism in selection of schemata to be activated - Two core mechanism in selection of schemata to be activated

Pattern Matching Pattern Matching && Frequency Gambling Frequency Gambling

- Strong but wrong errors – slips and Lapses (attention problem)- Strong but wrong errors – slips and Lapses (attention problem)-Types of selective attention deficit- divided attention, distraction-Types of selective attention deficit- divided attention, distraction

The Attentional /Controlled SubsystemThe Attentional /Controlled Subsystem

-- powerful logical capabilities powerful logical capabilities

- limited, sequential, slow, effortful, and difficult to sustain- limited, sequential, slow, effortful, and difficult to sustain- rule and knowledge based errors (problem solving failure)- rule and knowledge based errors (problem solving failure)

--knowledge based errors- faults in interpretation and causal thinking knowledge based errors- faults in interpretation and causal thinking

or incomplete knowledge.or incomplete knowledge.

Cont….Cont….



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Norman and Shallice’s attention to action ModelNorman and Shallice’s attention to action Model

Two challenges for error based theories (Reason, 1990)-Two challenges for error based theories (Reason, 1990)-• specify control system that allows for the relative autonomy of wellspecify control system that allows for the relative autonomy of well

established learned programs,established learned programs,

• Acknowledgment that actions doesn’t always go according to plansAcknowledgment that actions doesn’t always go according to plans

Control StructuresControl Structures• horizontal- habitual activitieshorizontal- habitual activities

• vertical threads- higher level attention processesvertical threads- higher level attention processes

Human Fallibility-Human Fallibility-

arise from natural tendency to minimize ‘cognitive strain’ and toarise from natural tendency to minimize ‘cognitive strain’ and to

‘over utilize’ stored knowledge structures, heuristics, shortcuts‘over utilize’ stored knowledge structures, heuristics, shortcutsthat simplify complex informational problems.that simplify complex informational problems.

Cont….Cont….



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SHEL ModelSHEL Model

(Hawkins, 1975)(Hawkins, 1975)



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Reason (1990, 1993)Reason (1990, 1993)

Swiss Cheese ModelSwiss Cheese Model



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Theory of Planned Behavior (Icek Ajzen, 1988)Theory of Planned Behavior (Icek Ajzen, 1988)

Attitude toward behavior Attitude toward behavior Subjective normsSubjective norms

Perceived Behavior ControlPerceived Behavior Control

Process of Accident CausationProcess of Accident Causation

Common trend of classification of factors (Brown, Wills &Common trend of classification of factors (Brown, Wills &Prussia, 2000)Prussia, 2000)

• Person as CausePerson as Cause• System as CauseSystem as Cause• System Person Sequence as CauseSystem Person Sequence as Cause

IntentionIntention Behavior Behavior



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Review of FactorsReview of Factors

Person as CausePerson as Cause:: Errors as product of wayward Mental Processes , Attitude andErrors as product of wayward Mental Processes , Attitude and

BehaviorsBehaviors

Accident proneness- few people, unitary trait, general characteristics, as innate and unAccident proneness- few people, unitary trait, general characteristics, as innate and unmodifiable characteristics, as explanatory conceptmodifiable characteristics, as explanatory concept

Accident Involvement- psychological phenomenon closely associated with accidents, not aAccident Involvement- psychological phenomenon closely associated with accidents, not astable phenomenon measured through temporary statesstable phenomenon measured through temporary states

Researchers Findings

Goodenough (1976) Field dependent people were more involved in accidents

Kahneman, Ben-Ishai and Lotan (1973) People with more experience in life events

Valerie and Cooper (1991)Valerie and Cooper (1991) Type A Behavior, neuroticism, introverts, ambivertsType A Behavior, neuroticism, introverts, ambiverts

Lajunen (2001), Cellar et al(2002) & Clarke and RoberstonLajunen (2001), Cellar et al(2002) & Clarke and Roberston(2005)(2005)

Agreeableness and ConscientiousnessAgreeableness and Conscientiousness

Cheyne et al(2006)Cheyne et al(2006) In ability to sustain attentionIn ability to sustain attention

Siu et al (2002)Siu et al (2002) Accidents rate not related to Age, Occupational Injuries wereAccidents rate not related to Age, Occupational Injuries were

related to age in curvilinear manner related to age in curvilinear manner

Kolich et al (1999)Kolich et al (1999) Non work Stressors (Family, financial and social etc) affectNon work Stressors (Family, financial and social etc) affectindividual’s information processing capabilities at workindividual’s information processing capabilities at work

Brehmer (1994)Brehmer (1994) Experience and Deliberate practice sets the task free fromExperience and Deliberate practice sets the task free fromconscious processingconscious processing

Elander (1993)Elander (1993) Hazard Perception LatencyHazard Perception Latency

Clarke (2006)Clarke (2006) Safety Perception, Agreeableness had greater predictive ValiditySafety Perception, Agreeableness had greater predictive Validity



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Cont….Cont….

System As Cause-System As Cause- Errors often depend on latent factors originating mainly formErrors often depend on latent factors originating mainly form

work place design and functions.work place design and functions.


Deming (1986), Norman(1988) & SedwickDeming (1986), Norman(1988) & Sedwick(1993), Deming, Latzako and Saunders (1995)(1993), Deming, Latzako and Saunders (1995)

Errors have roots in their system designErrors have roots in their system design

Gardner et al(1999)Gardner et al(1999) Poor Machine Designs, poor man-machinePoor Machine Designs, poor man-machineinterfaceinterface

Baberg (2001)Baberg (2001) Technology use in system, automationTechnology use in system, automation

System-Person Sequence Factors-System-Person Sequence Factors- Errors as product of Organizational, Social,Errors as product of Organizational, Social,

Technical and Operator's evaluation and reaction toward these interacting factors.Technical and Operator's evaluation and reaction toward these interacting factors.

• Safety Culture-Safety Culture- IAEA(1986), Attawood et al (2006)IAEA(1986), Attawood et al (2006)

• Safety Climate-Safety Climate- Wallace et al (2006) – management-employee relations andWallace et al (2006) – management-employee relations and

Organizational Support (antecedents of safety climate), Griffin & Neal (2000), Zohar Organizational Support (antecedents of safety climate), Griffin & Neal (2000), Zohar

(2002), Cox &Cox (1991) and Barlin et al (2002)(2002), Cox &Cox (1991) and Barlin et al (2002)



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……


Chyene, Tomas, Cox andChyene, Tomas, Cox and

Oliver (1999)Oliver (1999)

Employee’s attitude toward management, managers as keyEmployee’s attitude toward management, managers as key

groupgroupHurst(1998)Hurst(1998) Hardware-people-corporate; people (nature of error) ,Hardware-people-corporate; people (nature of error) ,

corporate influence accident process through items- safetycorporate influence accident process through items- safetyculture, training, management processes.culture, training, management processes.

Rundmo(1996)Rundmo(1996) Risk perception-psychological strain-risk behavior Risk perception-psychological strain-risk behavior

Haslam et al (2005)Haslam et al (2005) Organizational preference- safety vs workloadsOrganizational preference- safety vs workloads

Inaccurate perception or risk, ‘won’t happen to me’ attitudeInaccurate perception or risk, ‘won’t happen to me’ attitude

Mullen(2004)Mullen(2004) Safety climate, pressure to perform, Perceived risk OptimisticSafety climate, pressure to perform, Perceived risk OptimisticBias, One’s Self Image, Group Behavior Bias, One’s Self Image, Group Behavior



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Reason(1990)Reason(1990) Factors differently associated with categories of unsafeFactors differently associated with categories of unsafe

acts,Violations decrease with age, men report more violation, lapsesacts,Violations decrease with age, men report more violation, lapsesmore frequent in women, skill related to violationmore frequent in women, skill related to violation

Parker et al (1995), LawtonParker et al (1995), Lawton(1998), Flin et al (2000),(1998), Flin et al (2000),

Forgarty et al(2001)Forgarty et al(2001)

Violations often immediate predecessor of errors,Violations often immediate predecessor of errors,

Safety climate indirectly related to errorsSafety climate indirectly related to errors

Rutter et al (1992)Rutter et al (1992) Age, sex, experience vary in prediction of errors and violations,Age, sex, experience vary in prediction of errors and violations,willingness to violate best attitudinal predictor willingness to violate best attitudinal predictor

Lawton (1998)Lawton (1998) Organizational factor - attitude/motivation, control/ situations,Organizational factor - attitude/motivation, control/ situations,rules/knowledgerules/knowledge

Battman and Klumb(1993)Battman and Klumb(1993) Safety culture and shared attitudes related to violationsSafety culture and shared attitudes related to violations

Forgarty, Saunder & Collyer Forgarty, Saunder & Collyer (1999, 2001)(1999, 2001)

Errors – Interacting causes involving physical, Cognitive, Social andErrors – Interacting causes involving physical, Cognitive, Social andOrganizational Factors.Organizational Factors.



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Hobbs (2001) Correlation between error-producing factors and unsafe actsHobbs (2001) Correlation between error-producing factors and unsafe acts

……

Feyer, Williamson and Cairns (1997)Feyer, Williamson and Cairns (1997)

• Skilled Based Errors- Individual work practices, safety equipment and personalSkilled Based Errors- Individual work practices, safety equipment and personalprotective equipmentsprotective equipments

• Rule Based Errors- General Equipment PracticesRule Based Errors- General Equipment Practices• Knowledge Based Errors- management practicesKnowledge Based Errors- management practices



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Occupational Accidents Review