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Construction Accidents and theLesson Learnt from 1000 CasesAkhmad Surajiaa Department of Civil Engineering, University of Andalas,Padang 25163, IndonesiaPublished online: 10 Feb 2014.

To cite this article: Akhmad Suraji (2003) Construction Accidents and the Lesson Learntfrom 1000 Cases, International Journal of Construction Management, 3:2, 41-49, DOI:10.1080/15623599.2003.10773042

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41Construction Accidents and the Lesson Learnt from 1000 CasesThe International Journal of Construction Management (2003) 41 - 49

INTRODUCTION

Older theories of industrial accident, reviewed by Hale and Hale (1972) and Brown (1990),

address only operative behaviour. More recent theories of construction accident causation

(Reason, 1990; Whittington, 1992) include management and organisational factors that have

influence over the site situation. However, there has been no structured approach to project

management or organisational behaviour in accident causation. Current theories address how

and why operatives have accidents, but not how and why managerial or professional participants

may stimulate unsafe operative actions or site conditions. Accident investigations normally

deal only with how operatives have an accident and stop when unsafe site behaviour or

conditions are discovered.

A model has been developed to explain how and why any participant involved in a construction

project might contribute to an accident. Using such a model, investigation of all the contributory

factors could be carried out and the project roles with control over those factors identified.

This would lead to more effective accident prevention strategies. Such a strategic approach

should take account of construction management, project management and design, as well as

client and environmental factors related to project conception.

This paper describes this model, based on a theory of construction accident causation that

models the complex interaction of all project participants. This paper describes findings of

analysis of 1000 accident cases. First, basic principles of the constraint-response theory are

CONSTRUCTION ACCIDENTS AND THE LESSON

LEARNT FROM 1000 CASES

Akhmad SURAJIDepartment of Civil Engineering, University of Andalas, Padang 25163, Indonesia

akhmad.suraji@telkom.net

Abstract

The safety management of construction projects to prevent accidents requires a thorough understandingof the ‘system mechanics’ of the causation process. Generally, this paper proposes a theoretical model ofaccident causation for construction projects, representing the underlying and complex interaction offactors in the causation process. The theory describes multiple paths of causation, including the constraintsand responses experienced by all project participants, during project conception, design and construction,which may generate situations or provoke behaviours that can lead to increased risk of accidents. Itmaps causal factors of accidents, including distal and proximal factors, which may be generated byproject participants. These factors are identified as contributory factors leading to disturbances of plantor equipment, structures or temporary structures, operatives, materials, services, ground and other facilities.The proximal factors have been validated by analysis of 1000 records of accident investigation providedby UK Health & Safety Executive (HSE). Further study for validating the distal factors is required sincecurrent available accident records are incomplete to cover analysis of the distal factors. It will need indepth analysis of problems encountered in pre construction stage of project development. Therefore, in

this paper, hypothesised individual distal factors are presented without analysis.

Keywordsaccident causation, construction, constraint-response theory, distal factors, proximal factors, projectsafety management.

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described. Second, the model representing the structure of causal factors is presented. These

factors are broadly classified as distal factors and proximal factors, to distinguish between

factors which contribute directly to an accident and factors, outside the construction (site)

process, that apply constraints to project participants and hence, indirectly, increase the risk

of accidents. Finally, results of a validation programme for the proximal factors are summarised.

This model should allow more rigorous and comprehensive accident investigation and analysis

of causation. In this way, feedback to all participants, of the consequences of their decisions,

will be more informative.

THE CONSTRAINT-RESPONSE THEORY

Principles of the theoryThis theory embraces management, organisational and operational features of the construction

process modelled to assist mapping of accident causation. The features incorporate project

conception, management, design, and construction. The model incorporates many factors of

deficiency, associated with situations, conditions and operational systems in the construction

process. It shows their precursors in ‘upstream’ project activity and project environment, and

their ‘downstream’ potential consequences. These factors of deficiency are classified as:

inappropriate construction planning, inappropriate construction control, inappropriate

construction operation, and inappropriate site condition. The model also includes

inappropriate operative action that can lead directly to accident occurrence. These factors

of deficiency, because they lead directly to increased risk of accident, are classified as proximal

factors. The use of the word “inappropriate” takes account of many factors that are not, in

themselves, unsafe but in some circumstances would increase the risk of accident.

Distal factors are those that can lead, with inappropriate responses from one or more project

participants, indirectly, to increasing risks of accident causation, by the introduction of proximal

factors. Distal factors are managerial or organisational constraints experienced by participants,

and their responses. This approach assists in the analysis of the influences on, and contributions

of, clients, project management, designers, construction management, planners and supervision

in the creation of a safe construction activity.

The fundamental concepts of the theory are as follows:

1. Any participant may introduce factors leading directly or indirectly to accidents. This

embraces the theory of human error, that almost all factors leading to accidents arise, at

least in part, from human action or inaction to eliminate, reduce or avoid accident risk.

2. Participants work within constraints arising from the situation of the participant’s own

organisation, another project participant or the project environment. For example, client’s

decisions at project conception can introduce resource or time constraints for any or all

participants; or a contractor can, by changing the construction sequence, produce schedule

constraints to the provision of production information.

3. A participant’s response to such constraints will influence construction activity; for example,

by providing incomplete information, leading to an inappropriate construction process

and increased risk of accident.

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43Construction Accidents and the Lesson Learnt from 1000 Cases

4. An inappropriate construction process would include inappropriate construction planning,

control, operation, and site condition, recognising the idea of a latent failure (Reason,

1990); and inappropriate operative action, often providing, in Reason’s terminology, the

triggering event.

5. Consistent with domino theory of accident causation, the structure of the model creates a

multiple path domino sequence in which an accident may have multi-factorial sources

(Petersen, 1971).

Structure of the modelFollowing the fundamental concepts described above, the causal process is structured into

three general parts: distal factors, proximal factors, and the accident. The analysis of the

accident events determines how accidents happen, whereas analysis of distal and proximal

causes provided the answers to the question why.

Mapping of the relationships ‘upstream’ of the site (Figure 1) provides structure to investigation

and analysis of distal factors, by modelling the way that participants not involved directly in

the construction process, by their responses to constraints, may provide constraints to the

other members of the project team. Though such participant’s responses may not lead directly

to accidents, responses such as increasing design and construction complexity, reducing

resources, or reducing quality of components may result in constraints in other areas of the

project. Some responses, such as late design changes, may also provide ‘upstream’ constraints

for the client and force reconsideration of, for example, project scope.

Structure of accident definitionThe term ‘undesired event’ is used to avoid the frequent assumption that an accident must

involve injury. Undesired events are defined as operational disturbances, or failure mechanisms,

and their consequences. The consequences could be injury or damage to people, to property

or the environment, or ‘near misses’ (incidents). The sequence of operational disturbance can

usually be subdivided into undesired event and ultimate undesired event. For example, a

temporary support structure collapse, causing heavy equipment to overturn and trapping an

operative, may have happened because one of the foundations failed. The failure of the

foundation is the undesired event. The collapse, overturn, and fall are the ultimate undesired

event and the consequences are damage to the equipment and injury to the operative. The

severity of the event is classified as destruction, major damage, or minor damage to property

or environment; or fatal, major or minor injury. This will permit future analysis of the

importance of causal factors by correlating them with the severity of the outcome.

ACCIDENT FACTOR DEFINITION

Proximal factorsThis classification is intended to assist investigation of the root causes and to determine which

project roles could reduce, eliminate or avoid their occurrence. These classes of deficient

construction process are defined as follows:

1. Inappropriate Construction Planning (ICP): Inadequate analysis or formulation of the

construction plan, method statement or schedule, in relation to the risk of undesired events

which may lead to injury or damage to construction personnel, the general public, the

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Fi 1 C l St t f C t ti A id t

Operative Constraints

PROJECT ENVIRONMENT

Project Conception Constraints

Client

Responses

Project Construction Constraints(Construction Management Constraint & Sub Contractor Constraint)

Main Contractor or Sub Contractor Responses

Project Design

Constraints

Project

Management

Constraints

Designer

Responses

Project Management

Responses

ACCIDENT EVENT AREA

Inappropriate

Operative

Action

Inappropriate

Construction

Operation

Inappropriate

Site Condition

Inappropriate

Construction

Planning

Inappropriate

Construction

ControlDEFICIENT

CONSTRUCTION PROCESS

Figure 1 Casual Structure of Contstruction Accident

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45Construction Accidents and the Lesson Learnt from 1000 Cases

property of either or the environment; e.g. inadequate method statement and inadequate

structural design for temporary support structures.

2. Inappropriate Construction Control (ICC): Inadequate, either in quantity or quality,

effort to direct or supervise the factors of construction such as to cause deviation of the

construction operations from plan, and increase the risk of undesired events; e.g. inadequate

control of plant or equipment operation or inadequate supervision of operative work.

3. Inappropriate site condition (ISC): Unsuitable physical environment, in which a

construction operation takes place, which may impinge on the performance of the operation

and directly increase the risk of undesired events; e.g. unsuitable existing topography or

unsuitable weather for the operation being undertaken.

4. Inappropriate construction operation (ICO): Unsuitable process of production of

permanent or temporary works that increases the risk of undesired events; e.g. improper

construction procedure or improper plant or equipment operation.

5. Inappropriate operative action (IOA): Improper action or inaction, either intentionally

or unintentionally, by an operative which may result in increasing the risk of undesired

events; e.g. carelessness or failure to adopt standard procedures.

Distal factorsDistal factors are defined as follows:

1. Project Conception Constraints (PPC): Constraints arising from the internal or external

project environment that confront clients during the project conception phase; e.g.

difficulties in obtaining funding or environmental legislation.

2. Client Responses (CR): Action (or inaction) by the client in response to constraints during

development of a project brief; e.g. reduce project budget or add new project criteria.

3. Project Design Constraint (PDC): Limitations or problems confronting designers during

the design process. These may be stimulated by client’s responses, project management

responses or the business environment of the design organisation; e.g. modified technical

requirement or accelerated design programme.

4. Designer Response (DR): Action or inaction by designers to confront the constraints

existing during project design stage; e.g. increase design complexity or sub-let part of

design process.

5. Project Management Constraint (PMC): Difficulties arising from the internal or external

organisation which confront the client or client’s professional team during project planning

and design or construction phases; e.g. late delivery of design detail or limited availability

of suitable contractors.

6. Project Management Response (PMR): Action or inaction by the client or client’s

professional team to confront an existing constraint during the project implementation

stage. These are for example: increase time pressure on design team or inadequate contractor

pre-qualification.

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7. Construction management constraint (CMC): Is defined as difficulties arising from

client, project management and designer responses, or the project environment, which

confront contractors during the project construction stage; e.g. short programme time scale

and design variations.

8. Construction management response (CMR): Action or inaction by construction managers

to confront construction management constraints or problems created by the project

environment; e.g. adjust level of supervision or fail to supply safety equipment.

9. Subcontractor Constraint (SSC): Similar constraints to those that confront main

contractors; e.g. cash flow problems or pressure from other contracts for resources.

10. Subcontractor response (SCR): Action or inaction by the subcontractors to confront the

constraints; e.g. slow down work or reallocate resources to another site.

11. Operative constraint (OC): Any factor, from whatever source, which may distract

operatives in carrying out construction activity; e.g. social or domestic pressure or physical

disability.

LESSON LEARNT FROM 1000 ACCIDENT CASES

Accident analysis

Analysis of accident data provided by the UK Health & Safety Executive (HSE) was conducted

to validate the proximal causal factors previously described. Data from inspectors’ investigation

reports contained in the HSE FOCUS Database, generally only covers proximal factors.

Therefore, further validation by direct accident studies has been undertaken as part of an

HSE-funded project at Loughborough University. The proximal factor analysis involved

systematic recording of every fact present in the investigation reports, by textual analysis.

Only those proximal factors specifically alluded to in the report were recorded and the use of

inferential logic avoided.

ResultsA study of 1000 construction accident records was undertaken. Of the 1000 samples of accident

records, 93.5 % contains the individual proximal factors. It was found that 68 of the 71

hypothetical individual proximal factors have occurred in real construction accident causation.

33 of them were found as major contributory factors to construction accidents. 72.07 % of the

accident record samples have more than one individual proximal factor. The mean of number

of individual proximal factor per accident record is 2.7, whilst the range of number of proximal

factor in accident record is 0 - 11. Analysis at the level of type of proximal factor is shown in

Table 1. Percentages total more than 100 as 72.07% accidents have multiple proximal factors.

Proximal Factor % of Accidents caused by the proximal factors

Inappropriate Construction Operation 83.48%

Inappropriate Operative Action 27.03%

Inappropriate Construction Planning 26.23%

Inappropriate Construction Control 14.71%

Inappropriate Site Condition 6.01%

Table 1 Types of Proximal Factors Involved in the Accident Causation

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47Construction Accidents and the Lesson Learnt from 1000 Cases

Analysing each of these types of proximal factor has identified the major contributors to

accident causation, as shown in Table 2 to Table 6.

CONCLUSIONS

The constraint-response theory of construction accident causation was found to be suitable

for developing a comprehensive causal model. In this theory, causal factors of accidents are

conveniently categorised as proximal factors and distal factors. The proximal factors include

inappropriate construction planning, inappropriate construction control, inappropriate

construction operation, inappropriate site condition, and inappropriate operative action that

can be identified as the immediate causes of construction accidents. The distal factors include

project conception constraints, project design constraints, project management constraints,

construction management constraints, sub-contractor constraints, and operative constraints

precipitating potentially unsafe responses by clients, designers, client’s project team,

contractors, sub-contractors and operatives.

An analysis of 1000 accident records provided by the HSE validated 97% of the hypothetical

proximal factors. From the analysis of the HSE data, the most frequent category of proximal

cause is Inappropriate Construction Operation, occurring in 83.48 % of all construction accidents.

Inappropriate Construction Planning and Inappropriate Operative Action are also frequently

encountered. Inappropriate Construction Control does not feature as frequently as might be

expected, when compared with the frequency of Inappropriate Operative Action. This might be

explained, at least in part, by HSE inspectors’ possible focus on legal requirements and possible

prosecution, rather than on uncovering all the contributory factors. A more structured and detailed

investigation process would promote a clearer understanding of the relative importance of all

proximal and distal factors. This is essential if the full accident causal process is to be properly

understood and future accident investigation thoroughly carried out.

ACKNOWLEDGEMENT

This research was supported by the UK Health and Safety Executive. Thanks are due to Blair

Hilton of HSE in Bootle for assistance in the use of the Focus database and to Stephen J.

Peckitt of HSE, Borough, London, for his extensive advice during the process of the research.

REFERENCES

Brown, I.D. Accident reporting and analysis, In: Evaluation of Human Work, In: Wilson, J.R. and Corlett,

E.N. (1990), A practical ergonomics methodology, Taylor & Francis, London, pp. 21-35.

Hale A.R. and Hale, M. (1972). A review of the industrial accident research, The National Institute of

Industrial Psychology, HMSO, London.

Petersen, D., (1971). Techniques of safety management, McGraw-Hill, New York.

Reason, J. (1990). The Contribution of latent human failures to the breakdown of complex

systems, In: Broadbent, D.E, Baddeley. A, and Reason, J.T, (1990). Human Factors in

hazardous situations, Proceeding of a Royal Society Discussion Meeting, Oxford Science

Publications, Oxford, pp. 112-120.

Whittington, C., Livingston, A. and Lucas, D.A. (1992). Research into management,

organisational and human factors in the construction industry, HSE Contract Research

Report No. 45/ HMSO, pp. 47-63.

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CODE INAPPROPRIATE CONSTRUCTION CONTROL % Involved in accidents

ICC-01 Inadequate supervision of operative work 4.60%

ICC-02 Inadequate control of the stability of temporary structures 3.40%

ICC-03 Inadequate control of systems of work 3.40%

ICC-04 Inadequate control of plant or equipment operation 2.30%

ICC-05 Inadequate control of work-site condition (housekeeping) 1.30%

ICC-06 Inadequate control of safety facilities and protective equipment 1.00%

ICC-07 Inadequate control of dangerous chemicals or substances 0.60%

ICC-08 Inadequate control of ground conditions 0.40%

ICC-09 Inadequate control of material or component storage & handling 0.00%

ICC-10 Inadequate control of weather effects 0.00%

ICC-11 Others 0.00%

Table 3 Inappropriate Construction Control

CODE INAPPROPRIATE SITE CONDITION % Involved in accidents

ISC-01 Unsuitable weather or climatic conditions 3.30%

ISC-02 Inappropriate ground condition 1.70%

ISC-03 Unsuitable existing topography 1.00%

ISC-04 Unacceptable noise or crowded surrounding site 0.30%

ISC-05 Restricted working area 0.10%

ISC-06 Others 0.10%

Table 4 Inappropriate Site Condition

CODE INAPPROPRIATE CONSTRUCTION PLANNING % Involved in accidents

ICP-01 Inadequate method statement 9.51%

ICP-02 Inadequate identification and assessment of risk. 8.91%

ICP-03 Inadequate preparatory training 7.11%

ICP-04 Inadequate planning of construction work 3.40%

ICP-05 Inadequate structural design for temporary support structures 2.70%

ICP-06 Inadequate safety plan 2.10%

ICP-07 Inadequate site investigation 1.00%

ICP-08 Inadequate planning & design of plant or equipment operation 0.80%

ICP-09 Inadequate design of access structure 0.60%

ICP-10 Inadequate structural design for M & E installation workK 0.50%

ICP-11KK Inadequate site layout plan 0.30%

ICP-12 Inadequate planning & design of site services 0.20%

ICP-13 Others 0.00%

Table 2 Inappropriate Construction Planning

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49Construction Accidents and the Lesson Learnt from 1000 Cases

CODE INAPPROPRIATE OPERATIVE ACTION % Involved in accidents

IOA-01 Improper or inadequate use of PPE 6.31%

IOA-02 Failure to adopt standard procedures 5.31%

IOA-03 Failure to follow instructions 3.90%

IOA-04 Judgement error, underestimate, overconfidence 3.20%

IOA-05 Carelessness, Recklessness, Irresponsibility 3.10%

IOA-06 Improper working position 2.70%

IOA-07 Improper use of tools or instruments 1.70%

IOA-08 Omission: missing something, out from sequence of steps 1.30%

IOA-09 Confusion: incorrect choice from range of option 0.90%

IOA-10 Unawareness or lack of concentration 0.90%

IOA-11 Commission: adding or including something they should not 0.50%

IOA-12 Annoyance, horseplay 0.40%

IOA-13 Exceeding prescribed limits: load, strength, speed, etc. 0.30%

IOA-14 Others 1.90%

IOA-15 Working under the effects of alcohol or drugs 0.10%

IOA-16 Arson, burglary, vandalism. 0.00%

IOA-17 Physical or mental assault on or violence to persons 0.00%

Table 5 Inappropriate Operative Action

CODE INAPPROPRIATE CONSTRUCTION OPERATION % Involved in accidents

ICO-01 Breach of regulation or code of practice 56.16%

ICO-02 Access/ egress defective or unsuitable 20.32%

ICO-03 Inadequate safety facilities 12.81%

ICO-04 Improper construction procedure 12.41%

ICO-05 Defective equipment or vehicle 7.51%

ICO-06 Inadequate provision of safety warnings 5.81%

ICO-07 Inadequate working platform 5.51%

ICO-08 Improper plant or equipment operation 5.21%

ICO-09 Inadequate temporary structure 4.80%

ICO-10 Inadequate working tools or instruments 4.60%

ICO-11 Improper instruction to operatives 3.50%

ICO-12 Untrained or inexperienced workforce 3.50%

ICO-13 Defective services 3.20%

ICO-14 Unsuitable plant or equipment 2.90%

ICO-15 Inadequate communication or co-ordination 2.10%

ICO-16 Unsuitable material or component 1.60%

ICO-17 Inadequate provision of PPE 1.50%

ICO-18 Confined working space 1.30%

ICO-19 Inadequate traffic control system 1.20%

ICO-20 Improper stacking and routing of materials 1.00%

ICO-21 Inadequate maintenance of equipment or plant 0.90%

ICO-22 Inadequate ventilation 0.90%

ICO-23 Untidy workplace or poor housekeeping 0.90%

ICO-24 Others 0.90%

ICO-25 Inadequate illumination or poor lighting 0.80%

ICO-26 Inadequate working drawings 0.70%

ICO-27 Improper maintenance of temporary structure 0.50%

ICO-28 Inadequate setting out 0.10%

Table 6 Inappropriate Construction Operation

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