Theories Domino

According to C. E. Marcum s 1978 Seven Domino Sequence of Misactsidents, a misactsident is an identifiable sequence of misacts associated with inadequate task preparation leading to substandard performance and miscompensated risks. The misactsident permits 

Marcum uses the term misactsidents to emphasize the deterministic aspects of his accident causation theory. Accidents, Marcum 

---

A classic incident theory is H.W. Heinrich s domino theory of causation, which has had a significant influence on practical incident investigation. (2) Many adaptations of Heinrich s original proposal have been developed by later researchers. Heinrich labeled his five dominoes as follows ... 

Heinrich s approach is to identify, evaluate, and work on the middle dominoes, not just the last one or two dominoes in the line. The domino theory has significant limitations. The basic assumption is that there is a linear relationship between causation and progression. In other words, one occurrence follows another and ends in an incident. In the context of process-related incidents, this assumption is not always valid. Often parallel occurrences coincide to result in an incident rather than occurring as purely sequential occurrences. Nevertheless, the domino theory can provide a useful conceptual framework for simple incidents. 

This theory led to the Updated Domino Theory by Kuhlmann, Seven-Domino Sequence by Marcum, Relabeled Five-Domino Sequence by Bird, Modified Domino by Weaver, and Relabeled Five-Domino Sequence by Adams. 

From the domino theory onward, it has become apparent that there are always less severe precursors to an incident. These can he called near hits, near misses, or close calls. For every incident labeled a near miss, more... 

Analysis, that can assist with the identihcation of causal factors. The concepts of incident causation encompassed in these tools are fundamental to the majority of investigation methodologies. (See Chapter 3 for information about the Domino Theory, System Theory, and HBT Theory.) The simplest approach involves reviewing each unplanned, unintended, or adverse item (negative event or undesirable condition) on the timeline and asking, Would the incident have been prevented or mitigated if the item had not existed If the answer is yes, then the item is a causal factor. Generally, process safety incidents involve multiple causal factors. 

FIGURE 5.1 Domino theory used by safety and loss prevention professionals. 

Inspired by the domino theory, the accident chain effects (also called domino effect) are getting people s attention many scholars in their various hteratures give a different definition. 

The origin of the Domino Theory is credited to Herbert W. Heinrich, circa 1931, who worked for Travelers Insurance. Mr. Heinrich nndertook an analysis of 75,000 accident reports by companies insnred with Travelers. This resulted in the research report titled The Origins of Accidents, which concluded that 88 percent of all accidents are caused by the unsafe acts of persons, 10 percent by unsafe physical conditions, and 2 percent are Acts of God. His analysis of 50,000 accidents showed that, in the average case, an accident resulting in the occurrence of a lost-time work injury was preceded by 329 similar accidents caused by the same unsafe act or mechanical exposure, 300 of which produced no injury and 29 resulted in minor injuries. This is sometimes referred to as Heinrich s Law. Mr. Heinrich then defined the five factors in the accident sequence, which he identified as the Domino Theory. Heinrich s work is the basis for the theory of behavior-based safety, which holds that as many as 95 percent of all workplace incidents are caused by unsafe acts. See also Accident Chain Behavior-Based Safety. 

An incident evaluation tool to investigate causes leading to incidents and as a framework for incident investigation. It models the flow of actions that lead to an incident or loss (Figure L.4). It was originally developed by Herbert W. Heinrich and later modified by Frank Bird. See also Domino Theory. 

Accident causation theories include the human factors theory, the domino theory, the systems theory, the combination theory, the epidemiological theory, and the accident/inddent theory [1,2]. The first two of these theories are described below. 

Finally, the two central points of the domino theory (i.e., Heinrich theory)... 

Heinrich produced some early thinking about accident prevention. He recognized the importance of unsafe acts and conditions and created a theory called the Domino Theory because Heinrich used a row of dominos to illustrate his theory. The theory states that an accident sequence is like a series of five dominos standing on end. One falling can knock the others over. The five dominos in reverse sequence are (1) an injury caused by (2) an accident, which, in turn, is caused by (3) unsafe acts or conditions. Causes for the latter are (4) undesirable traits (such as recklessness, nervousness, violent... 

Heinrich relied on some of these theories to form his Domino Theory of accident causation. See Chapter 3. Today, other methods describe how leaders impact work-related behavior and accident prevention. 

There are several domino theories of accident causation. While each domino theory presents a different explanation for the cause of accidents, they all have one thing in common. All domino theories are divided into three phases ... 

Postcontact phase refers to the results of the accident or energy exposure. Physical injury, illness, production downtime, damage to equipment and/or facility, and loss of reputation are just some of the possible results that can occur during the postcontact phase of the domino theory. 

Domino theories represent accidents as predictable chronological sequences of events or causal factors. Each causal factor builds on and affects the others. If allowed to exist without any form of intervention, these hazards will interact to produce the accident. In domino games, where the pieces are lined up and the first one is knocked over, the first domino sets into motion a chain reaction of events resulting in the toppling of the remaining dominos. In just that same way, accidents, according to the domino theories, will result if the sequence of precontact phase causes is not interrupted. 

H. W. Heinrich developed the original domino theory of accident causation in the late 1920s. Although written decades ago, his work in accident causation is still the basis for several contemporary theories. 

The two key points in Heinrich s domino theory are that (1) injuries are caused by the action of preceding factors, and (2) removal of the events leading up to the incident, especially employee unsafe acts or hazardous workplace conditions, prevents accidents and injuries. Heinrich believed that unsafe acts caused more accidents than unsafe conditions. Therefore, his philosophy of accident prevention focused on eliminating unsafe acts and the people-related factors that lead to injuries (Brauer, 1990). 

Figure 5-2. An illustration of Heinrich s Domino Theory of Accident Causation.

---