THEORY OF

CONSTRUCTION
ACCIDENTS

Ir. Akhmad Suraji, MT.,PhD.,IPM

KECELAKAAN DI
PROYEK KONSTRUKSI

2
TEORI PENYEBAB KECELAKAAN
 Pure Change Theory
 The Biased Liability Theory
 The Unequal Initial Liability Theory
 The Goals-Freedom-Alertness Theory
 The Adjustment-Stress Theory
Individual Accident The Psyhoanalytic Theory
Causation  The Distraction Theory

The Accident
 The Chain -of-Event Theory
The Domino Theory
 The Tripod Theory
 The Extended Tripod Theory
Organizational  The Japanese Theory
Accident Causation  The Socio-technical Theory
 The Constraint_Response Theory
 The Multy Factors Theory
 What is Accident?
• Unexpected event, undesired outcome, injury,
dangerous occurrence or abnormal event
• An unsafe event that could result in injury,
damage, or loss
• Rowlinson (1997) defines accident while taking
into account its causation, as follows:
“unplanned incident leading to death, injury or
property damage, which stems from inadequate
management control of work processes
manifesting itself in personal or job factors,
which lead to substandard actions or conditions,
which are seen as the immediate causes of the
accident.”
 Incident

Damage to Personnel &

Damage to Damage to
Personnel Property

Property
Accident

Near miss

Damage to Environment
 Incident & Accident
• Incident is defined as any event
interrupting the established
procedure or system operation,
whereas accident is defined as any
unplanned event or undesired event
that could produce adverse effects,
such as injury to personnel,
damage to property, or damage to
the environment.
 What is Causation?
• English dictionary: “the act or
process of causing”
• The process of causing
philosophically embraces four
different categories of causation;
sufficient cause, necessary cause,
material cause, and efficient cause.
 The Four different causes
• Fenn (1999) describes these four different causes as
follows “A sufficient cause (1) is one which is capable of
causing an event to occur but which is not essential to its
occurrence. A match, candle, and spark are each sufficient
to ignite gasoline but none are necessary. Light is sufficient
to elicit papillary contraction, but it is not necessary; drugs
and emotional state can also contract the pupil. A
necessary cause (2) is one which is essential for an event
to occur. Oxygen is essential for most substances to ignite
and burn, however it is not sufficient. Life is necessary for
papillary contraction, but it is not sufficient. A material
cause (3) is the component parts from which something
comes, such as the raw materials of a tree; earth, air,
sunlight, and water. Whilst an efficient cause (4) is the
propelling factor which sets into motion such as the axe
chop causing the tree to fall”
TEORI PENYEBAB KECELAKAAN

 Pure Change Theory

 The Biased Liability Theory
 The Unequal Initial Liability Theory
 The Goals-Freedom-Alertness Theory
Individual  The Adjustment-Stress Theory
The Psyhoanalytic Theory
Accident  The Distraction Theory
Causation
The
Accident
 The Chain -of-Event Theory
The Domino Theory
 The Tripod Theory
Organizational  The Extended Tripod Theory
Accident  The Japanese Theory
 The Socio-technical Theory
Causation
 The Constraint_Response Theory
 The Multy Factors Theory
 UPSTREAM

The Socio-Technical Pyramid,

The Failure Initiation,
The Constraint-Response

ORGANISATIONAL
INDIVIDUAL

THEORY OF
CONSTRUCTION
ACCIDENT

The Pure Chance,

The Domino,
The Biased Liability,
The Modified Domino,
The Unequal Initial Liability,
The Resident Pathogen Metaphor/ Tripod
The Stress,
The Extended Tripod,
The Arousal/ Alertness,
The Groeneweg’s Marble,
The Psycoanalitic,
The Balloon Hazard,
The Epidemiological/Ergonomics
The Distraction
DOWNSTREAM
Theory of Accident Causation
• Individual accident causation:
Individual (personal) making an
accident
• Organisational accident causation:
Organisation involves in accident
causation in which any people in
any different level of organisation
can stimulate an accident
 The Pure Chance Theory
• This theory proposes that an accident event will
happen depending entirely on chance. In this
theory, the accident is regarded as an “Act of
God”. This theory seems not to consider that
underlying failure mechanisms and triggering
events lead to the accident. The theory suggests
that everyone exposed to the same risk has an
equal probability of having an accident. In this
theory, no any factor is regarded as causal factors
leading to the accident event. It happens due to
either unlucky or lucky.
 The Biased Liability Theory
• This theory holds that an individual who is
involved in any accident either increases or
decreases their liability to subsequent involvement
(Brown, 1990). The individual involvement in any
accident will increase apprehension when the
circumstances surrounding the accident are
perceived to recur. There will be a tendency to
avoid any similar circumstance of danger in
future. Since hazards are known previous accident,
individual will improve all operational systems
more safely under those hazard conditions.
 The Unequal Initial Liability Theory
• This theory is most known as theory of accident proneness.
The theory describes that some people are more liable to
accidents than others due to innate personal characteristics.
In this theory, two versions of proneness are addressed.
One holds that certain individuals are prone to accidents
because of their innate characteristics. The other holds that
accident proneness is a variable factor being related with
critical events in the life of an individual rather than with
situational risks (Hale & Hale, 1977). This theory assumes
that an accident is essentially just caused by personal
factors irrespective of task, working conditions, time and
organisational factors.
 The Stress Theory
• Brown (1990) explains that this theory holds that accidents
occur when a task, environmental, or individual stressor
reduces the capability of an individual to meet task
demands. The individual stressor is for instance; fatigue,
illness, or environmental heat, cold, noise, and windy.
Increasing task demands, such as information load, work
rate requirements, acceleration of work, may cause
individual to get stress and vulnerable to accident. This
theory provides some reasons that operatives to behave
inappropriate manners by which increase likelihood of
having accidents.
 The Arousal /Alertness Theory
• This theory postulates that people may have
accidents because they are not alert to their true
situations, and this lack of alertness is as a result
of a lack of involvement in their work. Brown
(1990) asserts that the hypothesis of this theory is
that relationships exist between an individual’s
level of arousal or alertness and their performance
on any task, the efficiency of which rises to a peak
as arousal increases, but then declines as arousal
becomes inappropriately high.
 The Psychoanalytic Theory
• Hale and Hale (1977) assert that this theory is
mainly due to the psychoanalytic school. The
theory postulates that an accident is a self-punitive
act of a person brought about by a number of
subconscious processes involving guilt,
aggregation, anxiety, ambition and conflict,
generated by events in childhood. The hypothesis
is that the accident is caused by individual’s
psychological background.
 Epidemiological/ Ergonomics/
Situational Theory
• This theory holds that accident causation is essentially a
conjunction of a ‘host’ as victim of the epidemic, an
‘agent’ which transmits the disease and ‘environment’
within which ‘host’ and ‘agent’ interact. This is perfectly
analogous to an accident event, in which a person (the
‘host’) interacts with tool, or technological system (the
‘agent’) in a working environment either physical or social
(the ‘environment’). Three different factors could
contribute to accident events; operatives, working
environment and operational methods.
 The Distraction Theory
• Hinze (1996) introduces the distraction theory
focused particularly on accident causation in the
construction industry. This theory stipulates a
relationship between probability of injury
occurrence, efficiency of work accomplishment,
and mental distraction(s) experienced by
operatives. It relates the construction performance
manifesting as productivity, how safely operatives
undertake a job and distracted operatives due to
unsafe physical conditions and mental diversions.
 The Domino Theory

• The domino theory was developed

originally by Heinrich in the 1930s in order
to explain sequential and multi-causal
factors in accident causation. In this theory,
accident causation is described into a series
of five standing dominoes representing a
causal process of accident event
 The Domino Theory
• Each domino depicts an element of accident
causation structure. The first three dominoes
illustrate ancestry and environment, individual
fault, and unsafe acts, whereas the last two
dominoes represent accident and injury. If one of
the first three standing dominoes collapses, it will
more likely lead to accident and injury. However,
when one of the dominoes lying in the centre can
be lifted, accident events will not likely happen
because the chain is broken
The Dominoes of Accident Causation
Management Operational Unsafe Accident Injury
structure areas condition (Loss)
and unsafe
action

The Adapted Domino Theory

The Resident Pathogen Metaphor
/ Tripod Theory
• Reason (1990) makes analogues that latent failures
in technical systems are same as resident
pathogens in human body, which combine with
local triggering factors such as life stress, toxic
chemicals, strong wind, adverse weather condition
and the like to overcome the immune system and
produce disease. Reason also argues that accidents
in defended systems do not arise from only a
single cause. The accidents occur because of the
adverse conjunction of several factors. Each factor
is necessary but none sufficient to breach the
defence
The Resident Pathogen Metaphor
/ Tripod Theory
• As in the case of the human body, all technical systems
will have some pathogens lying dormant within them.
Following this view, general assertions about accident
causation are described as follows; likelihood of an
accident event is a function of the number of pathogens
within the systems. The more abundant they are, the
greater is the probability that some of those pathogens will
come up and by combination of local triggers is necessary
to complete accident sequences. The more complex and
opaque the system will contain the more pathogens.
Simpler and less well defended systems need fewer
pathogens to provide an accident.
 INADEQUATE DEFENCES
Active failures
&
Latent failures

UNSAFE ACTS

Active failures

PYSCHOLOGICAL
PRECURSOR OF UNSAFE
ACTS
Latent failures

LINE MANAGEMENT
DEFECIENCIES

Latent failures

FALLIBLE DECISIONS

Latent failures

Reason’s Accident Causation Theory

 Tripod Theory
• In addition, Reason describes his concept of
accident causation as ‘tripod theory’ representing
a relationship between accident, unsafe act and
resident pathogen. Resident pathogens encompass
design and construction deficiencies, management
failures, maintenance errors, component
weaknesses, bad procedures and routine
violations. The causal structure of tripod theory is
given as follows.
 The Extended Tripod Theory
• Groeneweg (1994) has extended the tripod theory
by introducing a mechanism of generating
accident causation called General Failure Types
(GFTs). Groeneweg postulates that an accident is
the direct result of breached barrier(s) caused by
operational disturbance. The operational
disturbance happens since there are many
substandard acts (SAs) in the specific situation
generated by underlying mechanisms called
General Failure Types.
 The Extended Tripod Theory
• Groeneweg (1994) has extended the tripod theory
by introducing a mechanism of generating
accident causation called General Failure Types
(GFTs). Groeneweg postulates that an accident is
the direct result of breached barrier(s) caused by
operational disturbance. The operational
disturbance happens since there are many
substandard acts (SAs) in the specific situation
generated by underlying mechanisms called
General Failure Types.
 The Extended Tripod Theory
• Groeneweg (1994) has extended the tripod theory
by introducing a mechanism of generating
accident causation called General Failure Types
(GFTs). Groeneweg postulates that an accident is
the direct result of breached barrier(s) caused by
operational disturbance. The operational
disturbance happens since there are many
substandard acts (SAs) in the specific situation
generated by underlying mechanisms called
General Failure Types.
 The General Failure Types
• The meaning of GFTs refers to root cause related factors
initiating any substandard act and situation within
organisation. There are eleven factors classified as GFTs.
Those factors are design, hardware, procedure, error
enforcing conditions, housekeeping, training, incompatible
goals, communication, organisation, maintenance
management and defences. GFTs are also convinced as
root causes of accident. Any failure on these factors will
likely stimulate substandard act and specific condition
enabling systems state becomes risky to accident events.
GFT
1 SA1 SA2

barriers

ACCIDENT
Operational
disturbance
GFT
2
SA3 SAn

breached
GFT
Specific SA4
3
situation

General Failure Theory of Accident Causation

 The Balloon Hazard Theory
• The balloon hazard theory introduced by Turner
(Blockley, 1996) is based on the observation that
most systems failures are not caused by a single
factor and that the failure conditions do not
develop instantaneously. The theory describes the
development of an accident or failures or disasters
as analogous to the inflation of a balloon. The
process starts when air is blown into the balloon at
which the first preconditions for an accident are
established.
 The Balloon Hazard Theory
• In addition, imagine that the pressure of air
as analogous to the ‘proneness to failure’ of
a project. The higher of air pressure, the
balloon grows in size, and proneness to
failure will increase. If the pressure builds
up until the balloon is much stretched, then
only a small trigger event, such as a pin or
lighted match, will enable to explode.
 The Balloon Hazard Theory
• Blockley (1996) argues that the trigger
event is often confused with the cause of
accident. The trigger event is less important
factors compared with the preconditioning
failures. In this theory, the amount of
preconditioning failure is considered as
significant contributory risk factors
increasing likelihood of system state having
accidents.
 The Japanese Theory
• The accident causation is described as a
combination of causation structure; focusing type,
chain type, and mixture type respectively. The
first type figures out that an accident event is
generated by multiple factors by which each factor
independently contributes directly to the accident.
The second type requires a sequential form for
initiating an accident. All factors serially make
configuration in the chain of causal effect. The
third is irregularly mixture of the focusing type
and the chain type.
 The Kitagawa Theory
• Japanese also classifies accident causation
into two causes of accidents as physical
causes related and human causes related.
The physical causes encompass layout,
machine and facilities, materials, work
method and conditions, and environment.
Whilst human causes consist of any defect
in operative factors such as lack of working
motivation and working ability degradation.
 The Kitagawa Theory
• The work methods and conditions are
associated with working situation such as
isolated, cooperative, posture, severity,
monotonous, precision, and rhythm.
Whereas, physiological abilities, mental
abilities, task conditions, labour condition,
basic motivations and direct motivation are
prerequisite leading to the lack of
motivation and the working ability
degradation.
 The Nishizima Theory
• Nishizima (1989) has proposed four related
factors interfacing any unsafe state and
unsafe behaviour. These four factors are
basic causes of accident comprising of
human related factors, equipment related
factors, work related factors, and
management-related factors. These factors
are resulted from deficient safety
management applied within an
organisational system.
 The Nishizima Theory
• This paradigm introduces that those basic
causes are only interference factors in
which unsafe state and unsafe behaviour
arise and system state fall down to risky
conditions. In order to map the causes of
accident event, a fishbone diagram
Equipment
Environmental Material cause
and facilities
Factors
factors
Defective
Defective Fire source
ventilation
design

Breaking and
Defective leaking
Defective lighting
material
quality

EXPLOSION
ACCIDENT
Human
relation
Inadequate
operational
standard
Missing
operation
Personality

Human factors Managerial Human Causes

factors

Structure of Accident Causation

 The Sociotechnical Theory

• This theory believes that an accident or a failure

happens within a sociotechnical framework. In the
sociotechnical framework, risks of accident and
safety matters are viewed from not only technical
or engineering point of view but also human,
social, and management as a whole integration. In
this theory, an accident can be caused to some
extent directly or indirectly by operative factors,
technical/ engineering factors and managerial or
organisational factors.
 The Sociotechnical Theory
• Bellamy and Geyer (1992) classify the
sociotechnical system into five elements forming a
‘pyramid’ structure. The five elements are
engineering reliability, operator reliability,
communication, organisation, management, and
system climate. The five tiers of the sociotechnical
‘pyramid’ depict five different levels of failures.
This theory considers remote causes of accidents
by looking at the system climate.
 ACCIDENT

ENGINEERING
RELIABILITY

OPERATOR RELIABILITY

COMMUNICATION AND FEEDBACK

CONTROL

ORGANISATION AND MANAGEMENT

SYSTEM CLIMATE

Sociotechnical Pyramid of Accident Causation

 System Climate
• Technological know-how
• Lessons learned from previous incidents in the industry
• Industry norms, engineering standards and company codes of
practice.
• Legislation and regulatory systems
• Public opinion and pressures
• Political climate
• Resource availability i.e. people and equipment etc.
• Interface with other systems, e.g. emergency services, regulatory
bodies
• Economic climate
• Nature of the hazard
• Location in relation to population, country and natural hazards.
 The Failure Initiation Theory
• This is an organisational theory of construction
accident causation. Whittington et al (1992) have
looked at more detail failures initiation leading to
accident events. They incorporate management
and organisational factors into construction
accident causation. It is thought that accident
events in construction projects are resulted from
failures initiated by individual, site management,
and project management as well as company
policy.
Failure initiation theory of
construction accident causation
In this theory, the failures at higher level will increase
the probability of failures at lower level. For example;
failures at a company policy level will increase
probability of failures at a project management level.
The failures at the company level are, for example,
inadequate training policy or poor methods of
procurement. The failures at the project management
are, for instance, lack of planning, poor scheduling of
work, or choice of inappropriate construction methods.
At a site management level, failures can be as poor
communications, lack of supervision or failure to
adequately segregate work. Whilst, failures at an
individual level can be as use of wrong equipment or
failure to comply with an agreed method of work.
Suraji, Duff, & Peckitt (2001)
THE CONSTRAINT-RESPONSE THEORY
 PHENOMENA
YANG
MENYEBABKAN PERISTIWA
PERISTIWA KECELAKAAN
KECELAKAAN
TERJADI
 Undesired Event:
The buckling of the scaffold column

Ultimate Undesired Event:

The scaffold collapses and the worker falls

Undesired Outcome:
Injury to the worker and damage to the scaffold
THE CONSTRAINT-RESPONSE THEORY

• The theory incorporates causal factors of

construction accidents generated by project
participants throughout project conception,
design, and development in which many
features associated with management,
organisational, and operational factors are
take into account as underlying factors of
construction accident causation.
 5 PRINCIPLES OF THE CR THEORY
• Project participants may introduce factors leading directly
or indirectly to accidents. This embraces the theory of
human factors, that almost all factors leading to accidents
arise, at least in part, from human action or inaction to
eliminate, reduce or avoid accident risks.
• Project participants work within constraints arising from
the situation of the project participants’ own organisation,
another project participant or the project environment.
• A project participant’s response to such constraints will
influence construction activity; for example, possibly,
providing incomplete information, leading to an
inappropriate construction process and increased risk of
accident.
 PRINCIPLES OF THE CR THEORY

• 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.
• Consistent with domino theory of accident causation, the
structure of the model creates a multiple path domino
sequences in which an accident may have multiple sources
(Petersen, 1971).
 PROJECT ENVIRONMENT
P P
R Project Conception Constraints R
O O
J J
E Client Responses E
C Project Management Project Design C
T Constraints Constraints T

E E
N N
V V
I
Project Management Responses Designer Responses I
R R
O O
N Project Construction Constraints N
M (Construction Management Constraint & Sub Contractor Constraint) M
E E
N N
T Main Contractor or Sub Contractor Responses T

Operative Constraints

Inappropriate Inappropriate
Construction Planning Construction Control
DEFICIENT
CONSTRUCTION PROCESS

Inappropriate Inappropriate Operative Inappropriate Site

Construction Operation Action Condition

66
ACCIDENT EVENT AREA
 THE CRANE ACCIDENT
• “Careless operative positioning and stabilising of a mobile
crane leads to failure of the crane outrigger support (UE),
such as sinking into soft ground, the crane overturning
(UUE) and, thus, to injury of a site operative and damage
to the materials being lifted (UO). It should be noted that
the undesired outcomes of an accident sequence could be
injury to any persons (construction personnel or members
of the public), or damage to property, or the environment.
The investigation of the causal process then moves to the
second area of the model, the immediate event area, to
deal with proximal factors.
 THE CRANE ACCIDENT
• The model identifies five types of proximal factor,
Inappropriate Construction Planning (ICP),
Inappropriate Construction Control (ICC),
Inappropriate Site Condition (ISC), Inappropriate
Construction Operation (ICO), and Inappropriate
Operative Action (IOA). The failure to properly
position and stabilize the crane is the
inappropriate operative action (IOA). Lack of
adequate supervision may well have been a
contributing factor and would be classified as
Inappropriate Construction Control (ICC).
 THE CRANE ACCIDENT
• In the event that the crane was not suitable for the
operation being attempted because, for example, its
outrigger could not have reached stable ground, then this
factor would be classified as Inappropriate Construction
Operation (ICO). This may have arisen as a result of
ground conditions surrounding the operation, which were
unsuited to the use of a mobile crane, one of the factors
classified as Inappropriate Site Conditions (ISC). The
failure to recognize this situation is often caused by
inadequate site investigation by the contractor, a factor
classified in the model as Inappropriate Construction
Planning (ICP).
• The third, and often ignored, area of focus of the
model represents the distal factors, the constraints
and responses upstream of the immediate event
area that create the situations in which the
proximal factors are generated. In the complete
model (Figure 3) the distal factors and their
relationships are developed to show the influence
of the client, the design team, and the project
management team, as well as recognizing the
specific influence of subcontractors in the
construction management process.
• The range of interactions in the model,
necessary to take account of all the
working relationships between
construction project participants, leads to a
complex model. However, any attempt to
simplify it would inevitably ignore many of
the real, but distal, influences of some
participants on the safety and health of
construction sites. The ultimate value of
the model, as a guide to accident
investigation and prevention, would be
prejudiced.
• In the development of the Constraint-
Response Model, no account is taken of the
procurement system being used. Whilst
varying this does change both the
operational and contractual relationships, it
is argued that all the functions; design,
project management, construction
management etc., and the people that carry
them out are found in all procurement
systems. The only thing that changes is the
organizational location of the function. The
relevant safety responsibilities remain,
wherever the function is located.
• The client will be under a number of economic,
social and political pressures, in the conceptual
development of the project, which we call Project
Conception Constraints (PCC), and these will
provoke Client Responses (CR) in the
development of the project brief to the project
management and design teams. These responses
will provide many of the constraints, Project
Management Constraints (PMC) and Project
Design Constraints (PDC), within which the
project management and design participants have
to operate.
• Their responses will, in turn, provide Construction
Management Constraints (CMC), within which the
construction process will take place. These will
provoke responses from Construction Management
(CMR), Subcontractor Constraints (SCC) and
Subcontractor Responses (SCR). This cause and
effect process has the potential to increase Operative
Constraints (OC) and directly, or indirectly through
Inappropriate Construction Planning (ICP) or
Inappropriate Construction Control (ICC)
procedures, lead to the Inappropriate Site
Conditions (ISC), Inappropriate Operative Action
(IOA) or Inappropriate Construction Operation
(ICO”).
Thank you very much for listening