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Introduction to the Heinrich Pyramid Model Kevin Harris -Northeast Utilities
Wally Groff-Bonneville Power Administration
Event
Near Misses At-Risk
Behaviors
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Who has heard of the “Accident Pyramid?”
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How does it relate to ?
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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
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Heinrich Proposed that…
88%
10%
2%
Unsafe Acts
UnsafeConditions
Unavoidable
Accidents Caused by:
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Heinrich Domino Theory
Injuries result from accidents, caused by: • Faults of people • Social environment • Unsafe Acts • Mechanical Hazards
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Heinrich Triangle
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Is Heinrich’s theory outdated or irrelevant?
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Heinrich and Beyond…….. Kevin Harris –Northeast Utilities
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“Stay ON the Grid and OFF the Pyramid!”
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Near Hit
Near Miss
Close Call
Error with Consequence
Significant Error
Event
“Stay ON the Grid and OFF the Pyramid!”
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Near Hit
Near Miss
Close Call
Error with Consequence
Significant Error
Event
“Stay ON the Grid and OFF the Pyramid!”
Proactive
Reactive
Preemptive
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Near Hit
Near Miss
Close Call
Error with Consequence
Significant Error
Event
“Stay ON the Grid and OFF the Pyramid!”
Proactive
Reactive
Preemptive
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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!
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HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) A Human Error Approach to Accident Investigation OPNAV 3750.6R (Appendix O)
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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
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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
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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