THE CAUSE OF THE NEXT INDUSTRIAL ACCIDENT: WILL IT BE MAN...OR WILL IT BE MYTH? A response from Difford to Manuele and the ASSE regarding the ASSE ‘peer reviewed’ article - Reviewing Heinrich, Dislodging Two Myths From the Practice of Safety http://www.neucom.eu.com...s/REPLYTOASSEMANUELE.pdf

Ian. Its neither an advertisement nor vanity and it certainly was'nt put up to impress anyone. I'm quite stunned at your outburst actually. IOSH signed an MoU with the ASSE and so the response is critical info for both IOSH and its members. Have you actually read the document that the response relates to? Perhaps that’s where your difficulty lies. If you dont understand it then please elaborate here. I cant change the document because that’s how it was presented to the ASSE and the NSC. Thousands have read the response and you are the first to express difficulty with it.

It is good to see a well moderated forum. As one of the first Chartered Members of IOSH and an Honorary Fellow of the IIRSM I have the same goals in mind as everyone else here. Furthermore, I am a Fellow of the Institute of Industrial Accident Investigators and have a special interest in causation. IOSH has signed an MoU with the ASSE and the linked document is a response to an ASSE ‘peer reviewed’ article that reiterated a claimed refutation of Heinrich (1941). However, many whose central area of expertise is causation felt that the article lacked substance and I therefore invited the ASSE and the author of the article to provide the detail that was missing. I for one do not feel that the missing detail will ever materialise and the possible ramifications of that are not something that I want IOSH and the membership to fall behind on.

Thanks Mark, good point. Hope the above clarifies.

Ray. This sort of forum is a learning environment and none of us stop learning. Seeing how you have mentioned one of Professor Reason’s terms (i.e. latent failure), why don’t you start the discussion by explaining what a latent failure is. More correctly of course, we should be talking about latent conditions since the prof (many years ago) explained why the term latent failure was not quite appropriate.

Another self-publicist. "the cause of all accidents at work is the worker" Sorry, the cause of all accidents is not the worker. It is the work.

As far as I can see I can only consider this ‘response’ in full by purchasing a book costing £14.95 (as a reader of the document posted) or £23.95 (as a member of the general public). This appears to be a contravention of forum rule 6. Why not make your ‘response’ in a peer reviewed publication, in the usual manner and in the appropriate format.

Paul with respect it would be helpful if you could provide a link to the original article, since without it your "response" appears to those of us unfamiliar with the specific argument to be nothing more than self-publicity. And yes I think Rule 6 applies to your link advertising your book. ". You mustn’t use the forums for: commercial purposes (including the advertising of jobs, goods and services)"

Hi Heather Many thanks. Here is a link to the relevant ASSE article http://www.asse.org/prof..._061_F2Manuele_1011Z.pdf Am getting the reference to the book removed from the response so should be gone within the next few minutes.

Interesting and thought-provoking article. Is it really true as the author says that none of Heinrich's original data or evidence now exists and all we have to go on is what he has stated (in different ways in different editions) in his books? You are saying (I think!) that the following two statements are mutually exclusive and cannot both be true. "An unsafe act, an unsafe condition, an accident; all these are symptoms of something wrong in the management system" (From Petersen in support of multiple causation theory, which you say is discredited) and "Unpredictable and uncontrollable consequences of natural phenomena aside, human behaviour suitably defined, will be the underlying cause of any accident" (from your own paper) I should say in advance that I'm not a behavioural specialist, merely a humble safety consultant but I don't agree that the two statements can't both be correct. Surely the management system itself is written and implemented by humans? Thus even a system error is ultimately a human error if you go back far enough, which is of course the way we are all taught to do accident investigation these days. This is exactly the point that Rich made earlier in the thread. Since both theories can exist together, why are you so concerned about this article? I am not enough of an expert on the subject to refute the original article although the author does seem to make some rather sweeping conclusions and have a bit of a "down" on Heinrich (he even berates him for being sexist by using the term "man failure" - in the 1950's)

Heather Heinrich’s original data is apparently not available; but, so what some might say. Is that absence enough for anyone to be able to claim a refutation of Heinrich’s 88% when a trawl of the relevant literature of the day would have held it correct. Indeed, logical analysis of Heinrich’s work shows that he should actually have put forward 98% and that would be irrefutable today. Rich’s point is a good one (nothing smart Alec about it either since the likes of Hume, Bentham, Chisholm and Hart & Honore to name but a few would all agree) and is why the theories cant co-exist. The late Dan Petersen’s theory (i.e. multiple causation theory) effectively attributes everything to a ‘non-entity’ which results (often) in a side-stepping of the area of personal responsibility that needs to be identified if the system is to be informed of what has actually defeated it. I might clarify since its often the default reaction...its not about blame.

You might like to look at the Court of Appeal case EWCA Civ 46 - Lisa Ferguson and British Gas - at http://www.bailii.org/ew...es/EWCA/Civ/2009/46.html Basically, the Supreme Court agrees with you: "Mr Porter also made the point that the correspondence was computer generated and so, for some reason which I do not really follow, Ms Ferguson should not have taken it as seriously as if it had come from an individual. But real people are responsible for programming and entering material into the computer. It is British Gas's system which, at the very least, allowed the impugned conduct to happen."

Hi All I think some of you should know that Paul has been having his debate as to the certainty that multiple causation is an invalid concept at some considerable international length in the Linkedin EHSQ Elite [#1 IN SAFETY] Group discussion "Heinrich's assertion that 88%....." started by Wayne 6 months ago. ....and more recently, a bit of self-publicity via IIRSM. Yet to splash out my cash on the book. The equivalent to rule 6 on this forum on the Linkedin group is not quite as specific, so the moderators there haven't taken down references to where you can buy Paul's book. I am yet to find many scenarios where things are so simply black or white, let alone the concept that you can always find "THE cause", rather than several interlinking causes as in findings of numerous investigations. "Many accident investigations do not go far enough. They identify the technical cause of the accident, and then connect it to a variant of 'operator error'. But this is seldom the entire issue." (Columbia Accident Investigation Board, NASA, 2003) "Rather a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident" (Deepwater Horizon report, BP, 2010)

Peter - I see the handbags came out in the end in the LinkedIn thread. Mind you I'm not reading 1946 comments to find out exactly why! Paul - how is a "logical analysis" of Heinrich's work possible today when we don't have his original data?

PS "nothing to do with me" that should say.

Heather. I’ve bent over backwards today (time wise and cost wise) to remove reference to the book from the foot note in the linked article. To answer your question re how is “logical analysis” of Heinrich possible requires reference to the now unmentionable so if its OK I’ll answer your question with a question. When Petersen (1971) put forward his theory on multiple causation and Bird (1974) released an updated Heinrich sequence....who saw the empirical and scientific support for those theories? Surely, if the basis of the rejection of Heinrich was an absence of data, practitioners did’nt just go ahead and accept an alternative that was equally unsubstantiated...did they?

As interesting as the nuances of identifying cause from a technical standpoint I'd have to say that there's a threat it may detract from the initial remit, to identify what went wrong and reduce the likelihood of recurrence. That's what good investigation is about, identifying the crucial information, cross referencing, being able to speak to people to get the right info out of them and then wrapping all up in a format that makes sense to those who will be involved in making any necessary changes. Part of my problem with the whole heinrich, reason, etc, name dropping is that there seems to be a lot of people who can reference the theories but fail to appreciate the human aspect of the investigation process. Things do go wrong, usually as a result of several aspects that didn't perform as required, but it's the effect on the people involved that needs to be remembered, whether that be as a result of injury or potential discipline. In terms of Heinrich, I may be incorrect but my belief was that the weighting of his findings was considered questionable because of the source of info (accident reports completed by the IP's manager) rather than the lack of info? I don't think there's a single practitioner who would disagree that for every accident there's a number of near misses, it's just the number that we're not sure about.

Big smile (110% indeed), thanks Mr J. No, the percentages still add up to 100% but I’ll answer with a question if I may. Heinrich believed that 10% of the accidents in his study had been ‘caused’ by ‘unsafe conditions’. However, one of the questions that need to be asked when considering the ‘causal’ relevance of ‘unsafe conditions’ is this; do they materialise out of thin air? That is, do they create themselves? Any thoughts from anyone other than Mr J?

Sorry Rich. Keeping rule 6. in mind (which is why I replied to Heather privately), which question would you like me to answer first?

Main point: Sell book Sell viewpoint Sell "never managers fault" viewpoint Given unsafe conditions to work IN, an operator will therefore be working unsafely. Following from that it is obvious that any accident could be attributed to the operator. In the real world, workers do what they are told to do.