Domino Theory

As mentioned in previous articles, we are going to look at accidents, mishaps, and safety management from the perspective of the people involved and not material failure or design deficiencies in equipment. The Domino Theory first proposed in 1931 by H. W. Heinrich states that:

1. Injuries come from mishaps.
2. Mishaps come from hazards.
3. Hazards come from people and,
4. People’s faults come from the social environment and their background.

This theory has been updated many times, but the basic premise remains the same. Look at one version that lists five dominoes. Keep in mind as you review them that:

Accidents Can Always Be Traced Back to Domino One

Domino Five refers to the major loss. This is what you are left with after an accident.

a. Injury: Injury to your employees, clients, bystanders, etc.
b. Property Damage: Damage to your equipment and others.

Domino Four states that contact can and does occur. This refers to the transfer of energy beyond the threshold limits.

a. Common forms of energy transfer:
• Mechanical
• Electrical
• Thermal
• Radiant
• Chemical
Accident Ratio Triangle:
Major Loss, Minor Injuries, Minor Damage, Close Calls
Focus resources on the last category, close calls.

Domino Three refers to the immediate causes or symptoms.

These are usually the obvious things.
a. Substandard Practices: Activities that contribute to probability, severity, or exposure.
b. Substandard Conditions: Conditions that contribute to probability, severity, or exposure.

c. Top 13 Errors Noted in Mishap Investigations
1. Didn’t follow instructions
2. Blundered ahead without knowing how to do the job.
3. Bypassed or ignored a rule, regulation, or procedure to save time.
4. Failed to use protective equipment
5. Didn’t think ahead to possible consequences.
6. Used the wrong equipment to do the job.
7. Used the right equipment to do the wrong job.
8. Used equipment that needed repair or replacement.
9. Didn’t look.
10. Didn’t listen.
11. Didn’t recognize physical limitations.
12. Failed to use safeguards or other protective devices.
13. Didn’t pay attention.

Domino Two refers to the basic causes or origins.

a. Personal Factors: Include the factors of physical, mental, and psychological capabilities.
b. Job Factors: Include design of equipment, work environment, sociological environment (peers, family, organization), material assets (personnel, equipment).

Domino One refers to lack of control or management dysfunction.

a. Functions of Management:
1. Planning: Defining organizational goals, strategy for achieving those goals, developing a hierarchy to integrate and coordinate activities.
2. Organizing: Determining the structure, outlining the tasks, who will do them, how
grouped, who reports to whom, where decisions are made.
3. Directing: Motivating subordinates, directing activities, selecting modes of communication, conflict resolution, directing change.
4. Controlling: Ensuring things are going as they should, compare actual performance against previous set goals and objectives. If deviations exist take action to correct them. Controlling also includes routine evaluations.

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