Citation

Johnson WG. J. Saf. Res. 1973; 5(2): 54-57.

Copyright

(Copyright © 1973, U.S. National Safety Council, Publisher Elsevier Publishing)

DOI

unavailable

PMID

unavailable

Abstract

Accidents are usually multifactorial and develop through relatively lengthy sequences of changes and errors. Even in a relatively well-controlled work environment, the most serious events involved numerous error and change sequences, in series and parallel. Review of individual reports in organizations with good safety programs shows surprisingly frequent multiperson or interdepartment involvements leading to serious accidents. The high frequency of more complex accident causations may arise from the fact that good organizations have successfully handled at the simpler potentials. In any event, the very complexity of events leading up to an accident impolite, is that there are many opportunities to intervene or interrupt the sequences. It seems essential, therefore, that accident investigation methods and summaries give appropriate visibility to the complex realities, rather than the simplistic categorization of conditions and act so often found in accident report summaries.