CHAPTER 18

Accidents, Human
Errors, and Safety

Copyright (c) 2022 P. Neumann, BSc, MSc, LicEng, PhD, LEL, Eur.Erg
– this teaching material is not for resale or commercial use. Note that
attribution errors and missing acknowledgements may exist in this
material; for which the author apologises
 Land Acknowledgement
Toronto is in the 'Dish With One Spoon
Territory’. The Dish With One Spoon is a
treaty between the Anishinaabe,
Mississaugas and Haudenosaunee that
bound them to share the territory and
protect the land. Subsequent Indigenous
Nations and peoples, Europeans and all
newcomers have been invited into this
treaty in the spirit of peace, friendship and
respect.
F 8.2 Anthro Data usually normally distributed

F 8.2

Median
Helander 2006 bizarrebytes.com
(Sanders & McCormick 1993)
Inclusive design = Better design

Product Experience
 The impact of age

How many people have less than “Full ability”?

Source: 1996/97 Disability follow-up survey

 HF design –
front loaded costs, back-end savings
Design Change Cost

Miles & Swift 1998

 Introduction
• EU : 4.5M accidents ->
– 146M lost working days /year
– 5500 deaths at work /year
(+3000 commuting accidents)
(approx. 2002)

All of these are preventable by good

engineering.
How could an accident
happen here?

Why is this happening?

 Humans Vary in Capability

F 8.2

Helander 2006 bizarrebytes.com

T 18.1
 Accident Statistics
• Deaths at home more common than on
roads
• Reporting variation can skew
interpretation of statistics
• Fatality data usually more accurate than
for injury (although often unreported)
• Reporting influenced by compensation
laws and medical trends
– Hand/wrist in USA, Neck/shoulder in
Scandinavia
F 18.1: Smeed’s Law: Deaths /car/person
 18.3 Social & Developmental Factors

• Smeed’s Law – traffic accident death

rates decrease with # cars / pop.
– Better safety infrastructure
– 3% reduction in accident rate with
increased car sales
 Risk Taking

• People accept more risk for voluntary

activities (skydiving) than for Involuntary
activities (Power system)
– Fig 18.2
F 18.2 Risk Acceptance
What is SAFETY?
 What is “SAFETY”

Safety is no accident
 The myth of “safety systems”
• What is the safety system in a car?
 SAFETY SYSTEM
• What is the safety system in a car?
– “Seatbelts” wrong
– “Airbags” wrong
• How often do you want to be safe?
– “All the time”
• How often do you want to use your
airbags?
– “never”
• What is wrong here?
THERE IS NO SAFTEY SYSTEM
• Those things deliver crash energy
absorption in the case of an accident
NOT safety.

• What part of the system delivers safety?

– ALL PARTS deliver safety
– FMEA method
 Accidents have…

• Low degree of expectedness

• Low degree of avoidability
• Low degree of intention
• Quick outcome

• Engineers – energy transfer

• Psychologists – behavior & attitudes
• HF – Systems Perspective (multiple
elements)
 Energy Exchange Model

• Accident as ‘unexpected physical or

chemical damage’
• Not about causes
• but helps prevention efforts:
– reduce energy transfer rate to human
– reduce impact force
– extend time (e.g. highway railings)
Why is this happening?
 Chain of Events

• Accident in a ‘chain of events’

• Many factors contribute to final event
• Prevention lies in breaking the chain of
events

• Rebuilding infrastructure (roads) subject

to cost benefit considerations
 Interactive Model of Accidents

• More complex approach to ‘cause’

• Cause is from an interaction of elements
– No single cause
– Not just ‘operator error’
– No nice ‘quick fix’: ‘blame & shame’
 Systems Safety
• Systems Approach (similar to chapter 1)
Systems Analysis of Truck Accident

What factors might have contributed?

“SYSTEMS APPROACH”

- Many layers

- Hazards can emerge

from many different actors

- Their actions may be

individual or act in
combination to increase
risk

Rasmussen (1997), Safety

Science, 27, 183-213
Svedung & Rasmussen
(2002), Safety Science,
40(5), 397-417.
N. Leveson /
Safety Science 42
(2004) 237–270
Systems Analysis of Truck Accident

What factors might have contributed?

2022: Video emerges of dump truck hitting
major Toronto highway bridge

• https://www.cbc.ca/news/canada/toronto
/dump-truck-video-401-1.6623199
‘Systems Perspective’ on Safety

Systems Analysis of Truck Accident:

- Societal / Legal
- Company & Organisational
- Technology
- Individual
- Environmental
 F 18.4:
Ramsey’s
Info
Processing
Model
(Sanders & McCormick 1993)
PERCEPTION

COGNITION

ACTION
Fail-safe?
 Accident Proneness
• ‘Risk taking’ personalities?
• Not intelligence, no ‘personality traits’
– ‘poor social adjustment’?

• Accidents happen by chance

– Blaming operator not helpful
– Poor equipment, poor design, poor
procedures, poor training, poor
management
T 18.2 – Accident Proneness myth

Accident patterns match statistical distributions

 HUMAN ERROR
• 60-90% of major accidents human error.
– E.g. Doctors make 1.7 errors / patient
– Autopilot control system case

• What causes human error?

• Errors occur in a System Context
• Engineering determines system
 HUMAN ERROR
• 60-90% of major accidents human error.
– Doctors make 1.7 errors / patient

• Human error caused by bad DESIGN

1. Poor visual discriminability(perception)
2. Memory lapses (what mode am I in?)
3. Communications breakdown
4. System Complexity
F 18.5: Reason’s error model
 Reason’s Error typology
• Knowledge Based mistakes
• Rule Based mistakes
– Pick wrong rule confidently: ‘strong but
wrong’ (“left to tighten”)
• Slips – Incorrect Execution
– Intention is close to a routine action
– Action sequence is automatic
• Lapse
– Forgetting ‘what was I saying?’
• Mode Error
– Autopilot left on
Mistake? Lapse? Slip?
T 18.3
Error in Organisational Context
• Accidents indicate organisational
deficiencies (as a root cause)
– NASA
• These deficiencies may also have other
negative outcomes (quality etc.)
• Poor management -> poor design process
-> poor design, poor training, poor
maintenance -> accidents
• So why blame the operator? (scapegoat?)
 Space Shuttle Challenger Disaster

• Booster rocket
breach @ t+73s

• 7 Crew dead

• 1.7$B vehicle

• An ‘organisational
failure’

http://0.tqn.com/d/history1900s/1/0/v/V/challenger14.jpg
Engineering Organization failure

(Nasa photo)
T 18.4
T 18.5: Safety Programs
Perception ‘error’?
 Safety Program Types
• Technological Interventions – 29% effect
– Robots -> robot deaths?
• Behaviour Modification – 39% effect
– Training & feedback programs
• ‘Comprehensive’ Ergonomics – 51.6%
effect
– Employee participation
– Monthly statistics reports
– Safety Seminars
– Ergonomics Expert advice
 More Safety Program Types
• International Safety Rating – 17% effect
– Safety audit program (like quality circles)
– Employee engagement
– Training, inspections, analyses, meetings
• Behavioural Safety
– Employee Management concensus
– Group work
– Set ‘Safety Critical Behaviors’
– Collect statistics & give feedback
– Update and improve continuously
T 18.6: Machine Safety
 Machine Safety: Lexmark Case
• Robot safety too expensive (Table 18.7)
• Product life/cycle was short
• Manual assembly more flexible
• Automation needs high volumes
• DfM approach helps manual assembly
T 18.7
 Contributing Factors?

http://besandoranas.blogspot.com/2008_10_01_archive.html
 Use a systems and information processing
perspective to identify factors contributing to this
accident.

CBC.ca
For each contributing factor, consider a design
feature that would have prevented, this accident.