Chapter 32: Models of Causation – Safety

Chapter 32: Models of Causation - Safety


Understanding accident causation is intrinsic to their successful prevention. To shed light on the accident phenomenon, over the years authors have developed a plethora of conceptual models. At first glance they seem as diverse and disparate as the accident problem they purport to help solve, yet closer scrutiny reveals there are some common themes. There are linear models which suggest one factor leads to the next and to the next leading up to the accident and there are complex non linear models which hypothesise multiple factors are acting concurrently and by their combined influence, lead to accident occurrence. Beginning with a look at the historical context, this chapter reviews the development of accident causation models and so the understanding of accidents. As this understanding should underpin OHS professional practice the chapter concludes with a consideration of the implications for OHS professional practice.

Keywords: accident, occurrence, incident, critical incident, mishap, defence/s, failure, causation, safety

First year of publication: 2012

Current Version Pending Review: 2012

Chapter 32: Models of Causation - Safety

Table of contents

1 Introduction
2 Historical context
3 Evolution of models of accident causation
3.1 Simple sequential linear accident models
3.2 Complex linear models
3.3 Complex non linear accident models
4 Implications for OHS practice
5 Summary

Associate Professor Yvonne Toft
DProf.(Trans Stud), MHlthSc, GDipOHS, GCertFlexLearn, FSIA, MHFESA, MICOH.
Faculty of Sciences, Engineering & Health, CQUniversity

Yvonne combines teaching in human factors, worksite analysis, accident analysis, systems safety and research and design with active research interests in engineering design, accident analysis, prediction of error sources, systems safety and transdisciplinary communication and design,

Associate Professor Geoff Dell PhD, M.App Sci OHS, Grad Dip OHM, CFSIA, MISASI
Faculty of Sciences, Engineering & Health, CQUniversity
Geoff is a career system safety, risk management and accident investigation specialist with 30 years experience across a range of high risk industries and is a qualified air safety investigator. He is currently implementing a suite of investigation education programs at CQ University.

Karen K Klockner, CQUniversity

Allison Hutton, CQUniversity


Dr David Borys PhD, MAppSc(OHS), GDipOHM, GCertEd, AssDipAppSc(OHS), FSIA
Senior Lecturer, VIOSH Australia, University of Ballarat

Professor David Cliff MAusIMM MSIA, CChem, MRACI, MEnvANZ
Director of Minerals Industry Safety and Health Centre, Sustainable Minerals Institute, University of Queensland

David Skegg, GDipOHM, CFSIA, FAICD
Manager, Health, Safety and Environment, CBH Australia Pty Ltd

Learning Outcomes: Models of causation: Safety

The OHS Body of Knowledge takes a conceptual approach which enables it to be applied in different contexts and frameworks.

To optimise its value for education and professional development learning outcomes have been developed for each technical chapter in the Body of Knowledge.

The learning outcomes as described give an indication of what should be the capabilities of an OHS professional; it is up to those developing OHS education programs, OHS professionals planning their CPD or recruiters or employers selecting or developing people for the OHS function to consider the required breadth vs. depth .

Please read the section on using the learning outcomes before delving into the leaning outcomes of the individual chapters.

The numbers against each learning outcome refer to the chapter number of the BOK download page. No learning outcomes have been developed for the chapters considered introductory or underpinning knowledge (that is chapters 1, 2, 3, 4, 5, 6, 7, 1, .13, 14, 15.)

Find Out More About Using the OHS BOK Learning Outcomes


Safety of Work Podcast: Ep 61: Is swiss cheese helpful for understanding accident causation?
Why the model represents the presence of folklore in safety. The methods used in Good and Bad Reasons. The cognitive processes that lead to errors. Whether the model represents accident causation appropriately. A defense of the model.
Presenters: Drew Rae & David Provan

Safety of Work Podcast: Ep: 57 What Is the full story behind Safey I and safety II (Part 1)?
First of a 3-parts series on the full story behind the book Safety I and Safey II: The past and future of Safety Management. Interpretations of new theories. Hollnagel being the direct intellectual descendant of Professor Rasmussen. Chapter 1: The Issues. The denominator problem. The regulator paradox. The problems with defining safety. Overall thoughts on Chapter 1. What to skim and what to read closely.
Presenters: Drew Rae & David Provan

Safety of Work Podcast: Ep: 58 What Is the full story behind Safey I and safety II (Part 2)?
Part two of our three-part series on Safety I and Safety II by Erik Hollnagel. Chapter 3. Habituation. Preoccupation with failure. Work as imagined vs. work as actually performed. A definition of Safety I. Chapter 4. The four myths of Safety I. Causality. Misinterpreting Heinrich. Human error. Chapter 5. Deconstruction. Linear and non-linear systems. Cause and effect.
Presenters: Drew Rae & David Provan

Safety of Work Podcast: Ep: 59 What Is the full story behind Safety I and safety II (Part 3)?
A recap of the chapters we’ve covered thus far. Chapter 6. Dealing with complexity. The role of resilience. Chapter 7. Correct and incorrect functions. Determining the cause of accidents in complex systems. The faulty definition of Safety II. The purpose of Safety II. Chapter 8. Recognizing, monitoring, and controlling performance variability. Why Hollnagel criticizes Safety I. Methods and techniques. Chapter 9. Hollnagel’s predictions about the creation of Safety III.
Presenters: Drew Rae & David Provan

Safety of Work Podcast: Ep 45: Why. Do we need complex models to explain simple work?
Using FRAM. Vulnerable Systems Syndrome. STAMP diagrams. How the researchers collected their data. Functions that are common and functions that are outliers. The benefits of implementing a FRAM model. Conclusions drawn by the research paper.
Presenters: Drew Rae & David Provan

Safety of Work Podcast: Ep 17: What did Heinrich really say?
The impetus behind Carsten’s paper. Why Heinrich’s ratio is so important. Why capable workers are the most important factor in safety. How corporations use Heinrich’s ratio in testing. Heinrich’s overall impact and legacy.
Presenters: David Provan & Carsten Busch