Wayne Pardy - Quality Plus Inc. 1 Heinrich Deconstructed A Safety Revolution in Progress (and reconstructed!) Presented at CSSE 2012 Professional Development

Wayne Pardy - Quality Plus Inc. 1

Heinrich Deconstructed

A Safety Revolution in Progress

(and reconstructed!)

Presented at CSSE 2012

Professional Development Conference, Niagara Falls, Canada

September 11, 2012


Some brief historical context

Heinrich’s Causation Theory: the 88-10-2 Ratio Heinrich professed that among the direct and

proximate causes of industrial accidents:

•88% are unsafe acts of persons.

•10% are unsafe mechanical or physical conditions.

•2% are unpreventable (i.e. acts of God).


Krause took this further

“In the majority of cases – from 80% to 95% - accidents are caused by unsafe behavior. This statement emphatically does not mean that the injury is the employees fault”.

Source: “The Behavior-Based Safety Process” Krause, Hidley & Hudson


Dupont went even further still

10 year study across all DuPont sites 96% of injuries resulted from ‘unsafe acts”

and “poor work practices”

Dupont, 1986


And Difford has gone even further still

“Whilst generally supportive of Heinrich (1941), Difford presents the case to revise Heinrich’s finding that 88% of accidents result from unsafe acts and proceeds to logically adjust that figure to 98%”

Keith Scott, Chairman International Institute of Risk and Safety Management


While there have been many critics of Heinrich, it is worthwhile to note that “Heinrich's 88% has been dismissed and criticized, but not refuted”

Difford on LinkedIn (EHSQ Elite)

Are Difford and Heinrich wrong?


So What?

According to Manuele, “Heinrich’s. . . ratios have had the greatest impact on the practice of safety” – How?

“It has also done the most harm” – Why?

“Since it promotes preventive efforts being focused on

the worker, rather than on the operating system”. Heinrich Revisited: Truisms or

Myths


Borderline unethical?

A Manuele colleague who is disturbed by safety professionals who reference Heinrich premises as fact, says, “It is borderline unethical on their part.”

Source: http://www.asse.org/professionalsafety/pastissues/056/10/052_061_F2Manuele_1011Z.pdf

.


Manuele’s bottom line

“The premise discussed here (unsafe acts of workers) are the principle causes of occupational accidents are wrongly based and cannot be sustained by safety practitioners”.

Source: http://www.asse.org/professionalsafety/pastissues/056/10/052_061_F2Manuele_1011Z.pdf


Manuele’s call to safety professionals

Stop using and promoting these premises Dispel these premises in presentations, writings

and discussions; Apply current methods that look beyond

Heinrich’s myths to determine true causal factors of incidents.


Enter Paul Difford and “Redressing the Balance (2011)

Accident causation

“There are many who believe that management or organizational failures are the root of all accidents”.


Redressing the Balance, 2011

Management failures cause all accidents - Myth Reason’s Swiss Cheese Model and Bird’s management

failure model - Disproved The ‘so called’ Organization Accident - Myth Petersen’s multiple causation theory - Disproved Heinrich’s Accident Causation Theory - Empirically and

logically valid with modification


“Redressing the Balance” supported by:

Ten year study about current models of causation

114 books 56 publications and papers 18 UK, EU and USA case studies, and 10 web site references


The management failure movement

Petersen, Bird, Reason, et. al. “Compelled into absurdity and the categoric

denial that workers have either right, inclination or opportunity to exercise free-will in the workplace”

“For them, error and violation are always the consequence of managerial or organizational failings”


A perspective on Heinrich’s 88%

“A common, if not ‘convenient’ misinterpretation is that this in some way equates to a theory that blames front-line workers, but that is not the case

Source: Difford, 1998


HSE (UK - 2002:1)

“The nature of accident causation has changed with engineering failures no longer being a major feature in many accidents”

“It is now largely behavioral with human failings being a significant part of the causes of most accidents. Of these, knowingly deviating from approved work practices represents a large proportion of incidents involving some form of human error. This form of human error is often termed ‘violation’.”


Interesting!

Where is the body of literature, empirical data and research that supports multiple causation theory, management failure and organizational accident perspectives?

We’re still waiting.


Some perspective - What is a Causal Factor? (in my world)

“Mistakes or failures that, if corrected, could have prevented the incident from occurring or would have significantly mitigated its consequences”

Source: TapRoot®: Changing the Way the World Solves Problems. P. 77

By Mark Paradies and Linda Unger


What does a causal factor look like? Was this a mistake made, or was

something done wrong, or What equipment failed or did not work as

intended?

NOTE! “Wrong” does not indicate blame. It is simply a statement of fact.


Causation considered

Why do so many automatically default to the organization or system when an accident happens?

Why is it not the person’s accident? Why is it someone else’s accident?

These questions have no notion or reference to blame in them. . . therefore there should be no notion or reference of blame in your answer.

Source: Difford. P. 175


Management or Organizational Failures?

Workers were asked who they thought was best placed to reduce the chance of them having an accident?

Themselves – 70%

Other workers, Supervisors Management & Unions (30%)

Are those 70% of respondents out to lunch?

Source: Hale and Perusse (1977) citing McKenna


HSE (UK) 2002 & 2004 studies

Violations were linked to between 70%-90% of accidents (2002)

Problems stemming more from known violations than from lack of knowledge (2004)

“A Deadly Maintenance. . . 30% of the 739

deaths to which he refers could not possibly have been rooted deeper in management” (1985)


Management Failure School of Philosophy

Based almost exclusively on the belief that a man is never the cause of his own behavior, i.e. that a man is never responsible for his own actions.

On the one hand, Petersen stated that management ‘invariably’ causes

all accidents. . . Yet Petersen himself was even forced to concede:

“a painfully obvious and simple truth. . people, not things cause accidents”

(Petersen 1979:15)

Source: Difford, p. 161


Bird & Reason

“ Moved a million miles away from Heinrich’s findings in order to claim (based on their own subjective

re-labeling of things) that the cause of a man’s behavior, without exception, is due to management or organizational failures”

Difford. . . P. 74


Difford

“If they are right that only management can cause an accident, then only management can prevent one since. . .

. . . with no opportunity for sharp-end man to cause one, logic dictates that he cannot possibly have any opportunity to avert one either”.


I am not an animal!

Management failure theory: “Presumes a workplace full of mindless automatons devoid of any free will. . . such that, regardless of what anyone does, it will always be someone else’s fault (i.e. attributable, ultimately and without exception, to management or the organization”.)

Source: Difford. P. 101


Can you or I control ourselves?

For Difford and his supporters, “the notions of so-called organization accident (Reason, 2004) and the organizational model of human error are pure fiction”.

“They reply largely, if not exclusively, on the belief that workers (you and I) have neither right, inclination, ability or opportunity to exercise free will.”

Difford, P. 103


Difford’s 10 year study

At a stretch, error is behavior (Bogner, 2004)

. . . But, it is not a system driven phenomenon insofar as it has not been found to be caused by the environment in the academic, epidemiological or multi-factorial sense.

More often than not, it results from an individual’s assessment of the environment’s ability to either prevent or support the behavior that they are contemplating

(Ajzan, 1991)


How many dominos do we need?

If Bird genuinely believed that management failures always cause accidents then there is no reason for his domino sequence to look anything other than the depiction below:

Management failures

Accidents


So what are the challenges?“Academics have confused themselves and each other over causation. . . That aside, the MCT (multiple causation theory) approach is extremely attractive to regulators and so it is not surprising that they force the philosophy into the H&S community.

“For now, they need to realize that people, not things, cause accidents and that something is seriously out of balance”.


Why Difford’s work is unsettling for many in the safety community:

It requires a questioning of the widely held belief that management or organizational failures are the root causes of most, if not all, accidents.

“ There is, in fact, no such thing as an organization accident” (it being an academically miscalculated invention).”

For some, all their rhetoric and money making ideas and programs are seriously challenged


Challenges to the safety community

Many have put too much on the line to even read Difford.

It would mean a change in approach to a lifetime of what some safety practitioners have written and practiced.

Many have said so much in support of management system failure theory of accidents, MCT and organizational accidents that they are now not able to ‘save face’ if they in any way accept Difford’s work/conclusions.


Will anyone listen?

“The extent of the programming is such that many will be unable to change”.

Source: Difford in email to W. Pardy


So where does this leave us?

We have 2 very distinct camps, both supported by their research/perspectives and theories

They cannot co-exist

Management failures, organizational accidents and multiple-causation theories of causation

vs.

Management cannot possibly cause all accident approach


What to believe and why?

Acts of God aside, (or more correctly, the unpredictable

and uncontrollable consequence of natural phenomena) human behavior, irrefutably, will be the proximate cause of any preventable accident.

OR


Management or organizational failures cause all accidents

What to do?


You make up your own mind after considering the evidence (I’m simply a messenger).

Consider: Redressing the Balance (Difford) Heinrich Revisited: Truisms or Myths As well as the followingThe following links will be helpful:http://www.nsc.org/safetyhealth/Pages/Examiningthefoundation1011.aspx#.UDFonPVHCVohttp://www.asse.org/professionalsafety/pastissues/056/10/052_061_F2Manuele_1011Z.pdfhttp://www.neucom.eu.com/documents/REPLYTOASSEMANUELE.pdfhttp://www.neucom.eu.com


Final thought

Don’t be bullied by those ‘experts’ who have a great deal to lose by maintaining their ‘theory’ of accident causation (academics, consultants, regulators, etc.)

Read and absorb all you can and then decide based on the logic, rationale and argument of your own research.

Don’t dismiss Difford outright, as some have done. Fear won’t progress our efforts in causation.

Do your homework, assess the evidence, and make up your own mind.


So what? Why should I care?

It will help us determine effective prevention strategies It will put our resources in the right place, for the right

reasons It’s about people – let’s emphasize what’s important Alternatively, we’ll continue to be polarized We’ll have no accepted body of knowledge on causation Let’s get our own house in order Safety is still in growth and pursuing maturity.

How about you. . . What will you do?

Documents

Wayne Pardy - Quality Plus Inc. 1 Heinrich Deconstructed A Safety Revolution in Progress (and reconstructed!) Presented at CSSE 2012 Professional Development