Preventing Industrial Accidents: Reappraising H. W. Heinrich – More than Triangles and Dominoes

305 Pages·2022·5.656 MB·English

by  Carsten Busch

Preventing Industrial Accidents
Herbert William Heinrich has been one of the most influential safety pio-
neers. His work from the 1930s/1940s affects much of what is done in safety
today – for better and worse. Heinrich’s work is debated and heavily critiqued
by some, while others defend it with zeal. Interestingly, few people who dis-
cuss the ideas have ever read his work or looked into its backgrounds; most
do so based on hearsay, secondary sources, or mere opinion. One r eason for
this is that Heinrich’s work has been out of print for decades: it is notoriously
hard to find, and quality biographical information is hard to get.
Based on some serious “safety archaeology,” which provided access to
many of Heinrich’s original papers, books, and rather rich biographical in-
formation, this book aims to fill this gap. It deals with the life and work of
Heinrich, the context he worked in, and his influences and legacy. The book
defines the main themes in Heinrich’s work and discusses them, paying at-
tention to their origins, the developments that came from them, interpreta-
tions and attributions, and the critiques that they may have attracted over
the years. This includes such well-known ideas and metaphor as the accident
triangle, the accident sequence (dominoes), the hidden cost of accidents, the
human element, and management responsibility.
This book is the first to deal with the work and legacy of Heinrich as a
whole, based on a unique richness of material and approaching the matter
from several (new) angles. It also reflects on Heinrich’s relevance for today’s
safety science and practice.
Carsten Busch has studied Mechanical Engineering, Safety, and Human
Factors. He has over 25 years of experience in Safety and Quality Manage-
ment at various levels in organisations ranging from railway to oil & gas to
police in The Netherlands, the United Kingdom, and Norway. He is profes-
sionally active on various forums, owner of mindtherisk.com, tutor at Lund
University Human Factors and System Safety programme, and author of
Safety Myth 101, Veiligheidsfabels 1–2–3, and If You Can’t Measure It…
Maybe You Shouldn’t. His main research interests include the history of
knowledge development and discourse in safety.

Preventing Industrial
Accidents
Reappraising H. W. Heinrich – More
than Triangles and Dominoes
Carsten Busch
First published 2021
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
52 Vanderbilt Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Carsten Busch
The right of Carsten Busch to be identified as author of this
work has been asserted by him in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from
the publishers.
Trademark notice: Product or corporate names may be
trademarks or registered trademarks, and are used only
for identification and explanation without intent to infringe.
“Every effort has been made to contact copyright-holders.
Please advise the publisher of any errors or omissions, and
these will be corrected in subsequent editions.”
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book
ISBN: 978-0-367-34380-4 (hbk)
ISBN: 978-0-429-32539-7 (ebk)
Typeset in Times New Roman
by codeMantra
Contents
List of figures xi
Preface xiii
Acknowledgements xv
List of abbreviations xvii
1 Introductions 1
1.1 Why this book? 1
1.2 Isn’t the past, the past? 2
1.3 Citing Heinrich in safety literature 3
1.4 Limitations 5
1.4.1 The lenses of today (1) 5
1.4.2 Conflicting aims 5
1.4.3 Was Heinrich right? 6
1.4.4 Developments and critique 6
1.4.5 Standing in Heinrich’s shoes 6
1.4.6 The lenses of today (2) 7
1.4.7 100,000 Words 7
1.5 About references 8
2 A biography 11
2.1 Early years 11
2.2 The Travelers 13
2.3 First steps in safety 14
2.4 Emerging foundations 16
2.5 The book 20
2.6 Dominos and cause code 22
2.7 Meanwhile at Travelers 22
2.8 Teaching, speaking, and another book 24
2.9 War! 25
2.10 Post-war work 27
vi Contents
2.11 Heinrich, the person 28
2.12 Retirement 29
3 Heinrich’s work 34
3.1 General overview 34
3.1.1 Phases 35
3.1.2 Developments and changes 35
3.1.3 Industrial Accident Prevention – an overview 37
3.2 Main themes 39
3.2.1 Scientific approach 40
3.2.2 The economics of safety 40
3.2.3 Causation 40
3.2.4 The human element 40
3.2.5 The role of management 41
3.2.6 The triangle and reacting on weak signals 41
3.2.7 Axioms of safety 42
3.2.8 Professionalisation of safety 42
3.2.9 Practical accident prevention 42
3.2.10 Safety management 42
3.2.11 Social engagement 43
3.2.12 What about risk? 43
3.3 Influences 44
3.3.1 “Best of” or original work? 44
3.3.2 The Travelers 45
3.3.3 Bibliography 47
3.3.4 Associates and acquaintances 54
3.3.5 Others 55
3.4 Success and longevity 56
3.5 Heinrich’s influence and developments 58
3.5.1 Lateiner 59
3.5.2 Bird and loss control 59
3.5.3 Petersen and the fifth edition 60
3.5.4 Behaviour Based Safety 62
3.5.5 Manuele 65
3.5.6 Serious injuries and fatalities 66
3.5.7 “New view” safety 67
3.5.8 Heinrich or not Heinrich? 68
3.6 Conclusion 69
4 A scientific approach 73
4.1 Introduction 73
4.1.1 Critique 74
Contents vii
4.2 Why did “scientific” make sense? 75
4.2.1 Understanding the term 75
4.2.2 Structured method, facts, and principles 77
4.2.3 Practicable and useful 80
4.2.4 Marketing 83
4.2.5 Scientific management and Heinrich 84
4.3 What about the missing data? 88
5 The economics of safety 94
5.1 Early safety and economics 94
5.2 Efficiency 96
5.3 Hidden costs 99
5.3.1 The idea 99
5.3.2 Research and the 1:4 ratio 100
5.3.3 The study’s importance 101
5.3.4 After Heinrich 102
5.4 Heinrich and the Great Depression 104
5.5 A continuous theme 105
6 Accidents are caused 109
6.1 The importance of causes 109
6.1.1 Early 1900s causation 110
6.1.2 Real causes? 112
6.1.3 Why did “real cause” make sense? 113
6.2 Dualism of causation 115
6.2.1 Origin of accidents 115
6.2.2 Developments 118
6.2.3 Cause code 120
6.2.4 Critique 122
6.2.5 Dismantling the “grand statement” 124
6.2.6 Another reflection 127
6.3 Accidents as processes 128
6.3.1 The dominos 129
6.3.2 A powerful metaphor 131
6.3.3 Critique 1: linearity 131
6.3.4 Why did linearity and simplicity make sense? 133
6.3.5 Critique 2: direct causes 134
6.3.6 Why did focus on direct causes make sense? 135
6.3.7 Evolution 138
6.4 A more complete accident model 140
6.4.1 Multiple causes 140
6.4.2 Reasons and subcauses 141
viii Contents
6.4.3 Underlying causes 143
6.4.4 Enhancing Heinrich’s accident model 145
6.5 Final reflections 146
7 The human element 150
7.1 Humans as an element to control 150
7.1.1 Why did this make sense? 151
7.1.2 Dealing with humans 152
7.1.3 Causes and actions 156
7.2 Various concepts 158
7.2.1 Psychology 158
7.2.2 Accident proneness 161
7.2.3 Ancestry 163
7.2.4 Human error? 165
7.2.5 Carelessness 166
7.2.6 Shame and blame 168
7.3 Humans as an asset 169
7.3.1 The reward of merit 171
8 The role of management 176
8.1 Foremen and supervisors 177
8.1.1 Contemporary thinking 177
8.1.2 Heinrich and foremen 179
8.1.3 Professionalisation 180
8.1.4 Supervisors and investigation 183
8.1.5 Post-Heinrich 185
8.2 Top management 186
8.2.1 Planning 188
8.3 Responsibility 189
8.4 Integrating safety 191
8.5 Safety management 193
8.5.1 Early developments 193
8.5.2 Axioms 194
8.5.3 Structured management tools 197
8.5.4 Another metaphor 198
8.5.5 Misconceptions 201
9 The triangle 205
9.1 Origin and development 205
9.1.1 Conception 205
9.1.2 A ziggurat 206
9.1.3 Researching and building 209
Contents ix
9.1.4 Earlier ideas 210
9.1.5 1931 211
9.1.6 The triangle 212
9.1.7 Variations 212
9.1.8 1950 214
9.1.9 The triangle expanded 216
9.1.10 Post-Heinrich triangles 217
9.2 Studying the triangle 221
9.2.1 Ways to read the triangle 221
9.2.2 Underlying principles 224
9.3 Interpretations and critique 230
9.3.1 Behaviour 231
9.3.2 Fixed ratios 232
9.3.3 Proportional reduction 234
9.3.4 Prediction 234
9.3.5 Metric 237
9.3.6 Zero 238
9.4 Some reflections 240
9.4.1 Opportunity 240
9.4.2 Challenges and limitations 241
9.4.3 Conclusion 244
10 Other main themes 248
10.1 Professionalisation of safety 248
10.2 Social engagement 250
10.3 Practical remedy 252
11 Heinrich in the 21st century 254
11.1 Famous last words 258
Appendix 1: The Heinrich bibliography 259
References 263
Index 281