Journal of Occupational Accidents, 1 (1976) 47-68 47

o Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands

ACCIDENT CAUSATION THEORIES: A SIMULATION APPROACH

ROBERT J. SMILLIE and MAHMOUD A. AYOUB

North Carolina State University, Raleigh, North Carolina 27609 (U.S.A.)

(Received February 6th, 1976)

INTRODUCTION

Although research in the area of accident phenomena is very diverse, a

main theme for many researchers in this area is: Why do accidents happen?
Can the causes of accidents be such that a general pattern of the accident
phenomenon will emerge? To put it simply, a theory of the accident causa-
tion process can be written, if most of the components of the accident pro-
cess can be discerned, and if the factors that contribute and lead to the ac-
cident can be discovered.
Many attempts have been made over the years to develop a predictive
theory for studying the accident process and it is the purpose of this paper
to systematically present these sundry theories and approaches on accident
causation. Each theory is defined and described. In addition, supportive evi-
dence is also presented where research on testing of the theory was attempted,
The theories and approaches discussed are listed in Table 1. The table also
gives the major studies which have tried to prove or disprove the various
theories.
In enumerating the various theories and approaches, several problems were
encountered. In an extensive review of the accident literature, Hale and Hale
(1972) discussed some of these problems. The theories tended to overgener-
alize with most theories being based on a relatively small number of cases.
Only a few of all possible variables were usually considered. Finally, most of
the theories were based on research efforts that were limited in scope and
limited in time.
After reviewing the various theories, the development of a modeling tech-
nique for studying the accident phenomenon is discussed. It will be shown
that the proposed modeling approach coupled with a computer algorithm
has the potential to describe and evaluate particular accident phenomena.
This method would be useful as an aid in the discovery of potential hazards
that are essential for the functioning of the accident process. Some illustra-
tive examples will be presented to emphasize the basic concepts and prin-
ciples of the proposed model.
TABLE 1

Theories of accident causation

~-_ ----.-_
Theory Initially proposed Evidence for Evidence against

Pure chance Greenwood and Woods (1919) Cobb (1940) Greenwood and Woods (1919),
Newbold (1926), Arbous and
Kerrich (1951)
Biased liability Greenwood and Woods (1919) Mintz (1954 a, b) Greenwood and Woods (1919),
Newbold (1926), Arbous and
Kerrich (1951)
Unequal initial liability Greenwood and Woods (1919) Greenwood and Woods (1919), Mintz and Blum (1949), Brown
(accident proneness) Newbold (1926), Farmer and and Ghiselli (1948), Verhaegen
Chambers (1939), Keehn (1959), et al. (1974)
Kunce (1967), Guilford (1973),
Kunce (1974)
Accident proneness (as Schulzinger (1954), Kirchner
a transient stressful (1961), Surry (1969), Shaw and
situation) Sichel (1971)
Unconscious motivation CIS (1967), Hill and Trist Castle (1956)
(1953), Verhaegen et al.
(1974), Eysenck (1962), Fine
(1963)
Kerr (1950) Kerr (1950), Kerr (1957), Verhaegen et al. (1974)
Smart and Schmidt (1962),
Thomae (1953)
Goals-freedom-alertness Kerr (1950) Kerr (1950), Kerr (1957)
Domino Heinrich (1959) Heinrich (1959)
Epidemiological Mac Iver (1961), Brody (1963),
approach Haddon et al. (1964)
Specific variables Deutch (19611, Messing (1974),
Sleight and Cook (1974)
Modeling Hale and Hale (1970), Ayoub
(1975) Brenner (1975)
 49

PURE CHANCE, BIASED LIABILITY, AND ACCIDENT PRONENESS THEORIES

The first three theories that received extensive coverage in the literature,
were the pure chance, biased liability, and accident proneness theories. These
theories were first studied in reports by Greenwood and Woods (1919) (re-
printed in Haddon et al., 1964) and Newbold (1926) (reprinted in Haddon et
al., 1964). The principles of each of these theories are briefly described below.
3. The pure chance theory states that everyone in the population has an
equal chance of sustaining an accident. It suggests that no discernible pattern
emerges in the events that lead up to an accident. It is usually treated as an
act of God, leaving one to accept the fact that prevention is non existent.
2. The biased liability theory considers that once a person sustains an ac-
cident, the probability that the same person will incur another accident in
the future has either decreased or increased when compared to the rest of
the population at risk. If the probability has increased, the theory is known
as the “contagious hypothesis”. If the probability has decreased, it is common-
ly called the “burned fingers hypothesis”.
3. Accident proneness or the unequal initial liability theory has been the
most widely discussed theory in the history of accident research. It states that
there exists a certain subgroup within the general population that are more
liable to incur accidents. This theory refers to some innate personality charac-
teristics that cause accident prone individuals to have more accidents than
non-accident prone people. Both the Greenwood and Woods and Newbold
studies found that accidents were not evenly distributed, but rather, there
existed a relatively small proportion of the workers who had most of the
accidents. Therefore, the hypothesis of unequal initial liability was proposed.

The case for accident proneness

It was Farmer and Chambers (1939) (reprinted in Haddon et al., 1964)

that provided the impetus for many subsequent studies which proliferated
the accident proneness concept. This study examined motor vehicle accidents
and distinguished two groups of subjects: an accident free group and an acci-
dent repeater group. In an attempt to identify the personal characteristics
of the accident repeater group, various psychological tests were administered.
The means of scores on tests such as aesthetokinetic, intelligence, mechani-
cal aptitude, and perservation were obtained. The results of this research led
Farmer and Chambers to ascertain that the accident repeater group was more
likely to fail the psychological tests. Other studies perpetuated this concept
(e.g. Keehn, 1959; Davis and Coiley, 1959; Whitlock et al., 1963).
Studies that treat the concept of accident proneness as an accepted fact
still exist in the literature. Kunce (1967, 1974) constructed an accident prone
index from the scales of the Strong Vocational Index Blank. He found that a
higher than average accident rate was significantly related to the score ob-
tained on the accident prone index. Kunce concluded that the test score re-
50

vealed enduring personality characteristics. Similar conclusions were

reached by Guilford (1973) after testing 226 females in a laboratory setting.
She found significant correlations between traffic accidents, automobile
violations, and those accidents that occurred during the experimental study.

The case against accident proneness

The concept of accident proneness has been attacked as being a myth both
methodologically and experimentally. Some authors state that proneness of
any one group vanishes over time. Others have found that accident data does
not lend any support to the accident proneness concept.
Mintz and Blum (1949) maintained that the methods used to validate the
proneness concept were incorrectly applied. In addition the authors theorized
that individual differences in accident liability only account for a small per-
centage of the accidents, since 60--80% of the factors involved in the acci-
dents studied were unpredictable. Ghiselli and Brown (1955) concluded that
if there is a general personal trait of accident proneness, it is likely to play a
minor role in the determination of accidents.
In a study by Brown and Ghiselli (1948) it was found that for one type
of accident some people do incur more than others. There was however,
little evidence to suggest that an individual who had a high rate of accidents in
one type of situation would have a high rate of accidents in another situation.
In addition, the correlation coefficients for most of the data in the study were
low, ranging from -0.11 to +0.22.
Verhaegen et al. (1974) investigated the accident proneness theory at three
industrial plants. Their results substantiated the conclusions that accident
proneness seemed to vanish over time when coupled with an increase in safe-
ty awareness. They also concluded that proneness might be attributed to sub-
jects working in a more dangerous environment, rather than personal traits.
Although the evidence presented above discounts the classical view of ac-
cident proneness, it is still viable if it is re-interpreted with various restraining
parameters. According to Schulzinger (1954) most accidents are due to rela-
tively infrequent solitary experiences of large numbers of individuals. The un-
equal initial liability may result from the population’s unique.characteristics
from which the sample was drawn. Unequal initial liability may be a result of:
(1) the age or sex of the sample; (2) a transient or prolonged state of physical,
physiological, or psychological stress; (3) chronic accident proneness; and/or
(4) chance. Therefore, there are varying degrees of accident proneness rather
than the presence or absence of it.
Kirchner (1961) offered the following interpretations of accident prone-
ness:
1. Due to chance alone there are bound to be more accidents happening
to one group than to another group if only one time interval is examined. Ex-
tend the time interval and this phenomenon will balance out.
2. The accident prone group is a fluid group. It is always adding and drop-
ping new members.
 51

3. Accident proneness may exist as a result of stress but people are capable
of adjusting to stress and thus are able to build up psychological defenses
against it. Consequently this phenomenon is temporary.
In an extensive review by Surry (1969) it was also concluded that if this
phenomenon does exist, it varies over time and situation for any one individ-
ual; even if accident proneness does exist, it could only account for a vary
small number of repeaters.
Although primarily addressed to automobile road accidents, Shaw and
Sichel (1971) stated that accident proneness was still a viable issue and that
it exists on an intuitive basis. In more explicit terms the authors reported that
there is not just an unequal liability for involvement in accidents but also
there exists an unequal accident potential which varies with the socio-psychol-
ogical make-up of each individual.

THE THEORY OF UNCONSCIOUS MOTIVATION

The theory of unconscious motivation has its roots in psychoanalytic the-

ory. Accidents are brought about by the subconscious processes that include
guilt, aggression, anxiety, ambition, and conflict. This theory focuses only
on the individual and the interaction of his perception of the environment
with his underlying personality constructs.
In a study on human factors and safety (CIS, 1967) the possibility of cor-
relating aggression and accidents was discussed. Using a psychoanalytic basis,
it recommended the study of life histories to assess the role of such things as
broken homes, excessive parental strictness, etc. Davids and Mahoney (1957)
used a projective test to study the influence of personality dispositions and
attitudes. Using matched groups and a sentence completion task, they found
that the high accident group had low scores on positive or socially desirable
personality dispositions. This group had a low opinion of the job and their
immediate supervisor as well as a negative opinion of the employment situ-
ation in general
Several studies (Hill and Trist, 1953; Castle, 1956; Verhaegen et al., 1974)
have examined the withdrawal hypothesis; i.e., the individual perceives him-
self as the cause of accidents and tends to withdraw from the work environ-
ment. In the Verhaegen et al. (1974) study, one of the most definitive of
this type, two accident groups were compared. One group consisted of people
judged responsible for accidents while the other group consisted of employees
who sustained accidents for which they were not judged responsible. The
withdrawal hypothesis was supported with a significant difference in absentee-
ism between the two groups. This difference was lost when an accident-free
control group was used. Therefore, the belief that causing accidents leads to
a withdrawal from the work situation may be a plausible one.
Personality differences and psychological factors like the involuntary rest
period were discussed by Eysenck (1962) (reprinted in Haddon et al. 1964)
and Fine (1963). The concept of involuntary rest pauses comes from reactive
52

inhibition and states that the repetition of the same stimulus-response se-
quence causes a fatigue-like neural state that requires an involuntary rest
period during which no attention is paid to the present task. Eysenck found
that this pause differed between introverts and extroverts with extroverts
having longer involuntary rest periods. It thus follows that extroverts would
have more accidents since they experienced more and longer periods of in-
attention. This theory was tested by Fine where it was found that extroverts
formed weak, unstable conditioned responses and had significantly more
accidents when compared to the introvert group.

ADJUSTMENT-STRESS AND GOALS-FREEDOM-ALERTNESS THEORIES

The adjustment-stress and goals-freedom-alertness theories are two com-

plementary theories developed by Kerr (1950, 1957). The adjustment-stress
theory states that individuals who fail to reach some sort of adjustment with
their working environment will tend to have more accidents than others. This
adjustment is affected by physical and psychological stresses. The goals-free-
dom-alertness theory postulates that individuals have accidents due to a lack
of alertness brought about by the fact that these people had no freedom in
choosing the goals set for the working situation. Kerr (1957) stated that
freedom to set goals will result in a high quality of work performance. The
level of quality will go up as the level of alertness is raised. In this context, if
the working climate is made more rewarding, and if the individual feels that
he has some sort of control over his working environment, then the level of
alertness will increase. An increase in alertness will result in high quality per-
formance. In contrast, increases of stress on an individual in a working situa-
tion will increase the probability that accidents will occur.
In a report by Caplan et al. (1975) psychological job stresses were examined
in an effort to identify the effects of such stresses on the physical well-being
of the worker. Failing to adjust to the psychological stresses resulted in
deleterious illnesses. Because of this, an individual was more likely to initiate
a hazardous incident in the accident phenomenon.

THE DOMINO THEORY

One of the more colorful theories of accident causation was formulated

by Heinrich (1959) and is known as the domino theory. This theory explains
the accident process in terms of five factors:
1. Ancestry and social environment.
2. Fault by the person.
3. The unsafe act and/or mechanical or physical hazard.
4. The accident.
5. Injury.
These factors are of a fixed and logical order. Each one is dependent on
the one immediately preceding it so that if one is absent no injury can occur
 53

and an accident can not occur if any of the factors preceding it are absent.
The theory can be visualized as five standing dominoes in which the behavi-
or of these dominoes are studied when subjected to a disturbing force. When
the first, social environment, falls the other four automatically follow unless
one of the factors has been corrected, i.e. removed, therefore creating a gap
in the required sequence for producing an accident.

THE EPIDE~IOLOGICAL APPROACH

The epidemiological approach arose out of the formalized study of epi-

demics. It is used to provide a conceptual framework for the many complex
factors that affect the human situation in an increased incidence of accidents.
This approach is really more of a description of the accident environment
rather than an analytical theory.
According to Haddon et al. (1964) the accident is caused by the conjunc-
tion of the following:
1. Host factors. These deal with the person who suffered the accident and
include such things as age and sex of the victim.
2. Agent. This is the object that directly gave rise to the accident and can
be considered as either the types of abnormal energy exchanges that produced
the injury or by the specific types of damage produced.
3. Environment. This is further subdivided into:
a. physical, e.g., geography, seasons, etc.;
b. biological, e.g., poisons, etc.; and
c. socio-economics - some individu~s are more susceptible to accidents
than others.
Many authors recommend the epidemiological approach for studying the
accident process. Brody (1963) postulated that this point of view needs to
be taken because the majority of accidents are the result of temporary stress
responses, an inadequate sense of responsibility regarding safety, and chance.
Mac Iver (1961) contended that the epidemiolo~c~ approach is needed to
account for individual differences in personal adjustment, including emotional
factors. Foote (1961) recommended this typology so that inputs from the
institutional, interpersonal, and individual factors can be considered.

SPECIFIC VARIABLES

In addition to developing various theories of causation, several attempts

have been directed at the identification and assessment of specific individual
variables as they influence the accident process. Figure 1 illustrates where, in
relation to an overall model of occupational safety, some of these variables
are located.
Sleight and Cook (1974) did a critical review of accident research and found
that accidents were a result of various physical and psychological factors of
the operator. The physical factors examined included: (1) age; (2) sex; (3)
54

. Mecharwd

ENVIRONMENT

HAZARD GENERATION
MECHANISM

THEOklE5

Fig.1. The location of specific variables in the accident process (Adapted from Ayoub, 1975).

physical work capacity; and (4) temporary or altered states, e.g., alcohol or
drugs and fatigue. The psychological factors were: (1) personality and emotion-
ality, i.e., the reasons why some people have accidents and to see if some
conditions of adjustment increase the likelihood of unsafe acts; (2) life stress,
i.e., death, divorce; (3) smoking; and (4) coronary heart disease.
~though little experimental evidence has been found, several authors
have theorized that culture may play a role in various accidents. Deutch
(1961) said that accidents may be caused by a maladaptive development of
appropriate accident prevention responses. Alpenfels and Hayes (1961) feel
that rapid acculturation tends to create a conflict and should therefore be
considered as having a part in any theory on accident causation. Such a
development was considered in a study by Messing (1974). He cited the role
of language and culture in an incident where the storage of empty gasoline
cans led to an explosion because the people did not know that the lingering
fumes of the empty cans were highly inflammable. He feels that the cause of
accidents can be traced to language and thought habits because language is a
major element in the formation of thought which structures the perception
of the environment.
All of the aforementioned theories attribute accidents to various causes
and try to explain why accidents happen. None of them, however, seem to
be able to explain why all accidents happen. Accident proneness may explain
one portion of a particular group of accidents while the unconscious motiva-
tion theory is adequate for another portion. Only the epidemiological ap-
proach attempts to account for all possible factors, but fails in one sense be-
 55

cause it is mostly a descriptive approach and lacks any real predictive power.
The need exists for an approach that focuses on the human element in the
system. Such a concentration has been suggested by Pearson and Ayoub
(1975) and Petersen (1975). Attention will now be directed at the few re-
searchers who have attempted to go beyond the epidemiological approach.

SIMULATION OF THE ACCIDENT PROCESS

The modeling approach in safety reseamh has been recommended by several

authors, e.g., Hale and Hale (1970) and Ayoub (1974). This approach allows
the investigator to graphically depict the accident phenomenon. One of the
most complete models which tried to incorporate the various factors that
contribute to accident causation was one proposed by Hale and Hale (1970).
The hypothesized model (see Figure 2) is a closed-loop system which con-
siders the major factors of: presented, expected, and perceived information;
the action; and feedback to the situation. Secondary factors such as increasing
age, past experience, etc., are also considered. The situation presents infor-
mation which may be incorrect or incomplete and can be altered by such
things as physical defects of the individual. The expected information is a
function of past experiences and population stereotypes. Presented and ex-

Fig.2 Hale and Hale’s (1970) model of accident causation.

56

petted combine into perceived information which is affected by such

secondary factors as fatigue or drugs. Possible actions are then listed ac-
cording to an individual’s repertoire of skills. A cost/benefit analysis is made
based on the subjective estimate of risk. Finally, an action is taken that re-
sults in feedback to the next situation.
The model, like epidemiology, is descriptive but does fit the past research
findings. Hale and Hale recommended that a data bank of information for
this detailed classification be established so that a predictive theory can be
developed.
By going from the modeling approach to computer simulation the investi-
gator is forced to carefully document the model so that the requirement for
completeness and precision is met. Computers produce readable and under-
standable output only if the input is of the same nature. Of course, this does
not preclude the possibility of constructing elegant but irrelevant models.
The present model was an integrative one that was based in large part on
Hale and Hale’s (1970) model. That model was expanded and incorporated
features from Ayoub (1975). In addition the flow of information was con-
structed according to a multilinear events sequencing approach suggested by
Brenner (1975). The flow diagram is illustrated in Figure 3.

Model description

The system begins with a combination of the human and the machine
components. The human component is a reflection of its basic characteristics,
e.g., sex, age, attitude, experience, physical status, etc. The machine compo-
nent (e.g., a pair of pliers) represents the physical characteristic that combines
with the human to produce an action. This action (physical) is next combined
with the environment of the workplace to produce a situation. The situation
transmits information to the system which is perceived by the operator
(human component). The perceived information is a function of the presented
information and the expected information anticipated by the operator. These
information components are dynamic elements of the system and are in-
fluenced by such things as stress and past experience of the operator. An
equipment failure can cause incorrect information to be presented.
The final outcome of the perceived information results in either system
homeostasis or causes a perturbation to be introduced into the system. The
perturbation requires some sort of action (failing to act is also a possible
alternative). The action path followed is influenced by other operator vari-
ables such as training, motivation, safety awareness programs, etc. The possible
courses of action have to be iterated and weighted according to the operator’s
subjective cost/benefit decision analysis.
The action decided upon can result in either adaptation, which returns the
system to homeostasis, or maladaptation which causes system disruption and
possible cascading effects on neighboring systems (e.g., other workers, ma-
chines, etc.). Thus, the accident phenomenon begins when a perturbation is
 _________--_______---.-------------------
r----I..- -------2
I I
Attltudc. Sex.
1
Agc.culture I
/i
/

Energy so”rCtf
PRESENfEDtEXPECTED
h PERCEWED

a----

C
P- CASCADING
EFFECT
-fNEXTENVIRONMENT
c__________________---
Fig. 3. Integrative model of the accident phenomenon.
58

introduced into the system and ends in system disruption, i.e., an incident.
The dotted lines illustrate how the system can be represented as a closed-
loop system.
As an example of how information flows through the system model, as-
sume that each of the system characteristics exerts a measurable influence
on each of the major components. These components combine in an inter-
action to form a cumulative index.
The situation gives off two kinds of information, presented and expected,
which may or may not change the index as a result of the earlier charae-
teristics of the three major components. At the point where information
is perceived the index would have a value which would result in either
system homeostasis or a perturbation.
If a perturbation develops the critical value of the index can still be modi-
fied to allow for system adap~tion. These modifications are the result of
determining the various possible actions and performing a cost/benefit anal-
ysis. Both the determination of the possible alternatives and the decision to
choose a particular one are a reflection of such factors as training, motivation,
safety programs, group pressure, and so on. The value of the index at this
point would now determine whether system adaptation or maladaptation
occurs.
In order to study the behavior of the accident model (as presented above)
under various human, task, and environmental constraints, the Graphical
Evaluation and Review Technique (GERT) was used. In so doing, GERT
was utilized as the computer algorithm for the simulation of the model. For
a more detailed description of GERT consult ~hitehouse (1973), and Pritsker
(1974).

GER T approach

GERT is a series of simulation packages that permit the systems analyst to

design a unique study but at the same time permits sufficient carryover of
the network building techniques to different studies. In addition, since it is
a package, a language is not a requirement to conduct the simulation. The
particular package used for this study was Q-GERT (Pritsker, 1974).
The Q-GERT approach requires the analyst to construct a network model
which then permits easy translation into Q-GERT computer input data. The
output of that data is the analysis of the network model. The network model
consists of activities and rodes. Activities or branches represent the flow and
processing of information through the system. Nodes are decision and evalu-
ation points in the network that direct the flow of information through the
different branches of the network.
The nodes used in the present network were either: deterministic, proba-
bilistic, conditions, queue, or selector. These are shown in Figure 4. A deter-
ministic node simply states that all outgoing activities will be initiated. In the
present network all deterministic nodes have only one branch emanating from
 59

Input I c$yt
side
1

Determnistic

Probability

Condkmal

Selector

Fig.4 Types of nodes used for the Q-GERT network.

it. A probabilistic node allows only one output branch to be taken. A par-
ticular activity is selected on the basis of the probability assigned to it. For
the first set of simulations of this study, probabilities were assigned so that
any particular branch associated with a probabilistic node would be randomly
selected. A conditional node selects an outgoing activity on the basis of the
conditions assigned to a branch. For example, if one branch is assigned the
condition: “take this branch only if the value of the incoming activity is less
than or equal to a”, then only incoming activities that meet this requirement
will take this branch. A queue node is used in conjunction with a selector
node in order to channel an activity to the selector node. The selector nodes
in the present network randomly chose one of the outgoing branches eman-
ating from it. Different types of priorities can also be assigned to selector
nodes.
Besides type, nodes are also characterized by input and output sides. The
input half of the node is used to specify the requirements for release of the
node, e.g., how many incoming activities are required to release the node.
The output half of the node is used simply to identify the node, i.e., give it
a name.
An activity has certain time parameters associated with it. For this net-
work, each activity was assigned a constant value so that a running index
could be tabulated.
The network also included modifications represented by the dotted lines.
What happens here is that when a certain branch is taken in one part of the
network, the output of a node in a different part of a network will be changed.
 I I
I
I
I
I I
I I
I I
I I
I 1

I I
I I
I I

Fig. 5. Q-GERT network description.

 61

Network description

The network used to simulate the present model is shown in Figure 5. The
first three major components of the network: human, machine, and environ-
ment (nodes 3 through 16); are set up in order to establish an index for an
operator functioning in a given situation. The index is composed of the values
in Table 2. It is a cumulative one that reflects the interactive aspects of the
system variables. Generation of a specific set of attributes (i.e., combinations
of man, machine, and environmental variables) is a random process that is
controlled by the probabilities associated with the attributes of the network
branches (activities).
The value of the index, generated as a result of the different conditions in
the network, represents one of two states: (a) decrement condition, zero for
most cases, and (b) normal or close to normal, with assigned values greater
than zero.
Starting with these components, basic attributes are combined in accordance
with the probabilities assigned to them. This results in a basic value that is
then modified to reflect such things as correct/incorrect presented information
(node 17) and experience influenced expected information (node 19). For
example, if the operator’s index path was the first attribute of the impairment
element (e.g., say the operator had defective vision), then chances are greater
that the presented information will be perceived incorrectly. Homeostasis is
maintained at node 26 only if the index has a value of 7 or more which would
be indicative of operator possessing such qualities as proper attitude, no

TABLE 2

Values used to determine index

Major component Element Attribute Value

Human 1. Impairment (1) Physical impairment

e.g. defective vision 0
(2) No impairment 1
2. Attitude (1) Very careless 0
(2) Careless 1
(3) Cautious 2
(4) Very cautious 3
3. Experience (1) None 0
(2) Past experience 1
Machine Condition (1) Old 0
(2) New 1
Environment 1. Time (1) Night 0
(2) Day 1
2. Temperature (1) Stressful 0
(2) Normal 1
3. Humidity (1) Stressful 0
(2) Normal 1
 62

physical impairments, past experience, and working in a favorable environ-

ment.
Nodes 28 and 38 represent the possibilities of reducing the severity of the
pe~urbation to allow for proper corrective action. In the network, the index
is given a chance to increase if motivation is high and safety programs are
provided. The end point in the network is either system adaptation or system
maladaptation, i.e., a critical incident.

Results of the s~rnulut~o~

In order to test the model one hundred simulations were conducted; the
computer output of the simulation results are shown in Figure 6. The final
results of the simulation indicated that out of 100 simulation runs, i.e., 100
hypothetic~ human operators passing through the accident system model,
17 maintained homeostasis (node 27 was the terminal point in the network).
This means that 17 out of 100 operators proceeded through the system safe-
ly without any perturbations. The mean index as well as other statistics are
provided by the program.

There were 83 perturbations in the model (sum of observations of nodes

31 and 32). Out of these, 67 managed to take adaptive action and regained
system homeostasis (node 32). The other 16 (node 31) failed to adapt to the
perturbation.
In addition to the already mentioned statistics, GERT also provides infor-
Final results for 100 simulations

Node Probability Mean Std. dev. Std. dev. Coeff. No. of Min. Max.
of mean var. ObS.

27 0.1700 7.1176 0.3321 0.0805 0.0467 17. 7.0000 8.0000

31 0.1600 2.8125 0.5439 0.1360 0.1934 16. 1.0000 3.0000
32 0.6700 5.1642 0.7507 0.0917 0.1454 67. 4.0000 6.0000
16 1.0000 4.4400 1.4861 0.1436 0.3347 100. 1.0000 8.0000

Average No. of completions of activities with counters prior to realization of

statistics nodes

Node Countertype Mean Std. dev. No. of Min. Max.

obs.

27 1 0.4118 0.5073 17. 0.0 1.0000

27 2 0.4118 0.5073 17. 0.0 1.0000
31 1 0.6375 0.4787 16. 0.0 1.0000
31 2 0.8750 0.3416 16. 0.0 1.0000
32 1 0.5522 0.5010 67. 0.0 1.0000
32 2 0.5075 0.5037 67. 0.0 1.0000

Fig. 6. Computer output from first test of the model.

 63

mation on particular segments of the network. This is done by labeling a par-

ticular branch with a counter type. For this simulation two branches were
monitored. One was the branch that indicated physical impairment, counter
type 1, this introduced a network modification that increased the likelihood
that a perturbation would occur. In like manner the lack of experience,
counter type 2, also caused a modification and increased the likelihood of
perturbation.
The statistics kept on these counter types are also illustrated in Figure 6.
For the complete homeostasis outcome (node 27), an operator had a physi-
cal impairment 41.18% of the time and lacked experience 41.18%. For the
system adaptation (node 32), there were 68.75% physical impairments and
87.5% who lacked experience. For the maladaptation process the respective
figures were 55.22% and 50.75%;
Node 16 was included as a statistics node in order to keep track of the
range of values up to that point, 1 to 8 in this example. It also provides the
average value of the index up to that point given the present model con-
straints. The mean was found to be 4.44.
In addition to the described model three more variations were introduced
to illustrate how varying the parameters of the model would influence the
outcome.
The first variation reflected the following system changes: (1) Instead of
equal probability for the impairment characteristic, the values were changed
to show there was only 5% chance of a physical defect, i.e., the probability
of the top branch of the activity between nodes 3 and 4 was changed to 0.05
while the bottom branch was changed to 0.95. (2) The experience charac-
teristic was changed to 0.95 for no experience and 0.05 for experience. (3)
It was assumed that there was a 75% chance that old equipment would be
used and a 25% chance for new equipment. (4) Temperatures and humidity
were changed to reflect the greater probability that these characteristics of
the work environment were stressful, i.e., 0.75 for the stressful branches and
0.25 for the normal conditions. The results are illustrated in Figure 7. The
main differences from the first simulation are shown in the counter types.
For example, when node 32 was realized, system adaptation, no run of the
58 runs that ended on node 32 took the physical impairment branch of the
impairment characteristic.
The second variation was essentially the same as the first variation except
that instead of equal probabi~ties for the attitude characteristic, the follow-
ing probabilities were used: very careless (p = .05), careless b= .lO), cauti-
ous (p = .40), very cautious Cp= .45). The machine component was changed
back to reflect equal probabilities for old and new. The results are shown in
Figure 8. Again differences between the original and this variation are shown
in the output. The range of values for the index was reduced from 1.00-8.00
to 2.00-7.00. Counter type 2 for node 31, system m~adaptation, shows
that every one of the 8 runs that ended in a disruption of the system took
the no experience branch.
 64

Final results for 100 simulations

Node Probability Mean Std. dev. Std. dev. Coeff. No. of Min. Max.
of mean var. obs.

27 0.1500 7.1333 0.3519 0.0909 0.0493 15. 7.0000 8.0000

31 0.2700 2.7037 0.5417 0.1043 0.2004 27. 1.0000 3.0000
32 0.5800 4.8966 0.7652 0.1005 0.1563 58. 4.0000 6.0000
16 1.0000 3.9400 1.6195 0.1619 0.4110 100. 1.0000 8.0000

Average no. of completions of activities with counters prior to realization of

statistics nodes

Node Countertype Mean Std. dev. No. of Min. Max.

obs.

27 1 0.0667 0.2582 15. 0.0 1.0000

27 2 0.8667 0.3519 15. 0.0 1.0000

31 1 0.1111 0.3203 27. 0.0 1.0000

31 2 0.9630 0.1925 21. 0.0 1.0000

32 1 0.0 0.0 58. 0.0 0.0

32 2 0.9310 0.2556 58. 0.0 1.0000

Fig. 7. Computer output from first variation of the model.

Final results for 100 simulations

Node Probability Mean Std. dev. Std. dev. Coeff. No. of Min. Max.
of mean var. obs.

27 0.1900 7.0000 0.0 0.0 0.0 19. 7.0000 7.0000

31 0.0800 3.0000 0.0 0.0 0.0 8. 3.0000 3.0000
32 0.7300 5.1781 0.7517 0.0880 0.1452 73. 4.0000 6.0000
16 1.0000 4.6200 1.2126 0.1213 0.2625 100. 2.0000 7.0000

Average no. of completions of activities with counters prior to realization of statistics nodes

Node Countertype Mean Std. dev. No. of Min. Max.

obs.

27 1 0.0 0.0 19. 0.0 0.0

27 2 0.9474 0.2294 19. 0.0 1.0000

31 1 0.1250 0.3536 8. 0.0 1.0000

31 2 1.0000 0.0 8. 1.0000 1.0000

32 1 0.0548 0.2292 73. 0.0 1.0000

32 2 0.9178 0.2766 73. 0.0 1.0000

Fig. 8. Computer output from second variation of the model.

The last variation was the same as the third except that the probability of
old machine characteristics was 0.75 while the probability for new charac-
teristics was 0.25. The environment was also changed to reflect the probabili-
ties of a more normal working environment, i.e., stressful temperature and
humidity probabilities were only 0.25 while the normal ones were 0.75. The
 65

Final results for 100 simulations

Node Probability Mean Std. dev. Std. dev. Coeff. No. of Min. Max.
of mean var. obs.

27 0.1200 7.0000 0.0 0.0 0.0 12. 7.0000 7.0000

31 0.1100 2.8182 0.4045 0.1220 0.1435 11. 2.0000 3.0000
32 0.7700 5.0909 0.7 288 0.0831 0.1432 77. 4.0000 6.0000
16 1.0000 4.3100 1.2528 0.1253 0.2907 100. 1.0000 7.0000

Average no. of completions of activities with counters prior to realization of statistics nodes

Node Countertype Mean Std. dev. No. of Min. Max.

obs.

27 1 0.0 0.0 12. 0.0 0.0

27 2 0.6667 0.4924 12. 0.0 1.0000

31 1 0.3636 0.5045 11. 0.0 1.0000

31 2 0.9091 0.3015 11. 0.0 1.0000

32 1 0.0260 0.1601 77. 0.0 1.0000

32 2 0.9610 0.1948 77. 0.0 1.0000

Fig.9. Computer output from third variation of the model.

results are shown in Figure 9. The most noticeable change here in regard to
the original simulation is that while there were 83 perturbations (sum of ob-
servations for nodes 31 and 32) for the original there were 88 for this last set
of runs. In the original 67 of those managed to adapt, node 32. This last vari-
ation had 77 reaching the system adaptation node thus reflecting the lower
probabilities for environmental stress.

DISCUSSION

This network model is only a first step in simulation of the accident

phenomenon. It was developed to show that the simulation of a multilinear
event approach to accident investigation, as discussed by Brenner (1975), is
feasible. The network was arbitrarily constructed with the chosen attributes
of the three major components (man, machine, and environment) of the
system. Further modifications can be easily introduced to account for all the
elements that are necessary to describe the major components of any safety
system. Still further revisions can be introduced to provide for interactive
aspects of training, group pressure norms, operator variability, etc.
This simulation approach has great potential as a tool for studying the
accident process. The three variations of the original model illustrate how
different gaming strategies influence the outcome of the model. With such
a technique the safety analyst can enter an occupational situation, observe
and analyze it to obtain the necessary information such as accident rates,
characteristics of the human operators that may be contributing factors to
the accident phenomenon, and any factors that influence the safety process -
66

e.g., safety training, incentive programs, group pressures to follow or not

follow safety procedures, etc. Armed with the necessary information about
an industrial situation, the safety analyst can then model and simulate the
process. This would allow him to follow the accident phenomenon from the
beginning to the end while at the same time providing a means for discover-
ing the relevant factors involved. That is, he will be able to examine the com-
puter output to discover where potential hazards in the system might be
developing. From this, the necessary steps for corrective action can be deter-
mined and evaluated.

ACKNOWLEDGEMENT

Preparation of this paper was supported in part by the US. Navy under
contract number N68335-75-C-1129.

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