introduction to the heinrich pyramid model - wecc.org hpwg session 1 introduction to... ·...

Introduction to the Heinrich Pyramid Model Kevin Harris -Northeast Utilities

Wally Groff-Bonneville Power Administration

Event

Near Misses At-Risk

Behaviors

Who has heard of the “Accident Pyramid?”

How does it relate to ?

Herbert William Heinrich

Began his career as an apprentice machinist and later became the Assistant Superintendent of the Engineering and Inspection Division of Traveler’s Insurance

1941 wrote: Industrial Accident Prevention,

A Scientific Approach

Accident Pyramid History

Heinrich Proposed that…

88%

10%

2%

Unsafe Acts

UnsafeConditions

Unavoidable

Accidents Caused by:

Heinrich Domino Theory

Injuries result from accidents, caused by: • Faults of people • Social environment • Unsafe Acts • Mechanical Hazards

Heinrich Triangle

Is Heinrich’s theory outdated or irrelevant?

Heinrich and Beyond…….. Kevin Harris –Northeast Utilities

“Stay ON the Grid and OFF the Pyramid!”

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Proactive

Reactive

Preemptive

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Proactive

Reactive

Preemptive

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Proactive

Reactive

Preemptive

Organizations Culture, Issues, Processes,

Procedures, Guidelines and Work Practices!

HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) A Human Error Approach to Accident Investigation OPNAV 3750.6R (Appendix O)

Just Culture

Organizational Practices

Department Procedures

Administrative Procedures

Organizational Guidelines

Human Factors

Work Practices

Leadership

James Reason

Swiss Cheese

Metaphor

Slic

e in

to t

he

Org

aniz

atio

n

Organizational Weakness

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Just Culture Organizational Practices Department Procedures

Administrative Procedures Organizational Guidelines

Human Factors

Work Practices

Leadership

Proactive

Preemptive

Reactive Sharp End

Blunt End

Conklin Heinrich Reason Dekker

Near Hit

Near Miss

Close Call

Error with Consequence

Significant Error

Event

“Stay ON the Grid and OFF the Pyramid!”

Just Culture Organizational Practices Department Procedures

Administrative Procedures Organizational Guidelines

Human Factors

Work Practices

Leadership

Proactive

Preemptive

Reactive Sharp End

Blunt End

Conklin Heinrich Reason Dekker