How to Be a Thug.

Application Assignment 2: Accident Causation Theory

Theory

I have selected to use Heinrich's Domino Theory, and the Multiple Factor Theory.

Justification

I am using Heinrich's Domino Theory because I feel it is a very fitting theory to use for this accident, and will explain in detail what went wrong and why those factors resulted in the accident. I also chose the Multiple Factor Theory because this accident was definitely not the result of one specific single factor, but the result of specific workplace conditions.

Analysis

Heinrich's Domino Theory:

Heinrich's Domino Theory consists of 5 specific factors: environment, fault by person, unsafe act/condition/ accident, and injury. These 5 factors build upon each other causing a domino effect that leads to the injury. Meaning, if one factor is taken away, the accident will not happen.

1) Environment: The operator was initially rushed into operating this machine, with basically no training at all on how to operate the machine. The warnings posted on the machine were on the opposite side of where the operator was positioned so they had no idea of the caution they needed to exercise. Also, there was a light that signaled to the operator that the foam cutting blade was on, but it was also not visible from the operator's position. No pictorials or operational instructions were present on the machine.

2) Fault by Person: According to the ANSI standard, it is the operator's responsibility to communicate safety information to anyone who is working under them. This was not the case when the plaintiff had to replace the normal operator who gave the plaintiff a very brief explanation on how to operate the machine and what to be careful of. The day that the plaintiff was injured he was working overtime which led to fatigue and more than likely led to some of his unsafe decisions when operating the machine. The plaintiff also assumed the blade stopped when the conveyor stopped when he shouldn't have been assuming anything at all. In one case, an operator's foot was pulled in by the pressure roller when they were trying to push foam away with their foot.

3) Unsafe Act/Conditions: Before the plaintiff's injury, there was no blade guard or gate present to block a person's ability to reach in, ignoring the ANSI standard. The machine would constantly malfunction causing foam build-up because of software program malfunctions and the pressure roller malfunctions. The supervisors and operators believed reaching in to pull out the clogged foam was the best method to reduce downtime. Also, wire mesh gloves were not required at all times.

4) Accident: The accident occurred on the afternoon of May 30, 1995 to a 31 year old operator of the Horizontal Splitting Machine BSV-E while reaching in the machine to remove the foam build-up hindering operation. The accident was the direct result of the following: a hazardous environment where little or no training was given, vague warnings, and a poorly designed machine; the operator's insufficient information given to his replacement on machine operation, the poor decisions made by the plaintiff by assuming too much, working while fatigued, and obviously under trained; and the unsafe conditions of an absent blade guard, a malfunctioning machine, lack of PPE, and unsafe practices pushed by supervisors.

5) Injury: The accident resulted in lacerations on four fingers of the right hand, at the first joints, with loss of tendons in all four fingers. This