Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931 publication Industrial Accident Prevention: A Scientific Approach [Heinrich 1931] was based on the analysis of accident data collected by his employer, a large insurance company. This work, which continued for more than thirty years, identified causal factors of industrial accidents including “unsafe acts of people” and “unsafe mechanical or physical conditions”. Heinrich also put forward the domino model of accident causation, a simple linear accident model.
The work was pursued and disseminated in the 1970s by Frank E. Bird, who worked for the Insurance Company of North America. F. Bird analyzed more than 1.7 million accidents reported by 297 cooperating companies. These companies represented 21 different industrial groups, employing 1.7 million employees who worked over 3 billion hours during the exposure period analyzed.
The most famous result is the incident/accident pyramid, also known as the “safety pyramid” or the “accident triangle”. The pyramid, as illustrated by Heinrich in his 1931 book, is shown below.
F. Bird’s later work revealed the following ratios in the accidents reported to the insurance company:
For every reported major injury (resulting in fatality, disability, lost time or medical treatment), there were 9.8 reported minor injuries (requiring only first aid). For the 95 companies that further analyzed major injuries in their reporting, the ratio was one lost time injury per 15 medical treatment injuries.
This work suggested that the ratio between fatal accidents, accidents, injuries and minor incidents (often reported as 1-10-30-600, and sometimes called “Heinrich’s Law” or the “Heinrich ratio”) is relatively constant, over time and across companies. Note that these numbers refer to accidents that were reported to the insurance company and incidents discussed with the researchers, which may be rather different from the real number of accidents and incidents. Indeed, more recent research suggests that these ratios are likely to be misleading:
It is impossible to conceive of incident data being gathered through the usual reporting methods in 1926 in which 10 out of 11 accidents could be no-injury cases.
Other empirical studies. Analysis of occupational accidents in the Netherlands [Bellamy et al. 2008] suggests that the “shape” of the incident/accident pyramids is dependent on the type of activity and risk type. Empirical studies in the medical area (emergency department attendance, medication errors) [Gallivan et al. 2008] find little evidence for a stable ratio between minor, intermediate and high severity events.
Disputed findings on accident causality
Heinrich’s work was pioneering in analyzing the causal factors that led to workplace accidents, highlighting the associated costs and encouraging managers to think about and invest in prevention of occupational accidents (interrupting an accident sequence). However, some of these findings on causality were affected by biases.
One conclusion of Heinrich’s work is that 95% of workplace accidents are caused by “unsafe acts”. Heinrich came to this conclusion after reviewing thousands of accident reports completed by supervisors, and interviewing these supervisors as much as ten years after the relevant incidents. These supervisors are likely to often have blamed workers for causing accidents without conducting detailed investigations into the root causes, which would probably have revealed other causal factors such as unsafe machinery, management pressure to work quickly, and poor information on hazards. These other causal factors are the responsibility of managers, and it is well known that people have natural psychological tendencies to downplay their own contribution to negative outcomes and attribute them instead to other factors (in this case, the “sharp end” workers/victims).
Another disputed finding in Heinrich and Bird’s work concerns the causality of minor incidents and of major accidents. Heinrich stated that:
predominant causes of no-injury accidents are, in average cases, identical with the predominant causes of major injuries, and incidentally of minor injuries as well.
This is incorrect in high-hazard industry today, and can lead to inappropriate allocation of resources. In particular, it leads some companies to an excessive focus on “behavioural safety” and the prevention of low-consequence incidents such as slips and falls, to the detriment of investment in maintenance and technical safety improvements. Contrary to Heinrich’s assertion above, in industries concerned by major accident hazards, there are significant differences between major accidents and minor incidents: these differences include the activities involved, the amounts of energy released, the characteristics and the numbers of safety barriers that were or could have been relevant to the event.
Accident causality is often more complicated than Heinrich’s quote suggests, as indicated by the following extract from the BP report into the Deepwater Horizon accident:
The team did not identify any single action or inaction that caused this incident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident.
Major accidents in high-hazard industries are generally caused by some unlikely combination of circumstances that was not controlled due to poor decision-making, management pressure for performance at the expense of safety, poor communication, or unexpected interactions between different components of complex systems. These causal factors are very different from “unsafe acts”, and require specific action by safety specialists, system designers and system managers that is unrelated to behavioural safety.
In fact, the rate of minor events (measured by personal injury rates, with indicators such as TRIR) is often mistakenly used as a proxy for overall safety performance, and can lead top management to an incorrect view of the safety of an activity. This occurred at BP’s refining activities and contributed to the Texas City accident in 2005. Indeed, as the 2007 Baker report on the explosion indicates:
BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its US refineries. BP’s reliance on this data, combined with an inadequate process safety understanding, created a false sense of confidence that BP was properly addressing process safety risks.
Similarly, Andrew Hopkins writes [Hopkins 2001] concerning the 1998 gas explosion at an Esso plant in Longford, Victoria, Australia:
Ironically Esso’s safety performance at the time, as measured by its Lost Time injury Frequency Rate, was enviable. The previous year, 1997, had passed without a single lost time injury and Esso Australia had won an industry award for this performance. It had completed five million work hours without a lost time injury to either an employee or contractor. […] LTI data are thus a measure of how well a company is managing the minor hazards which result in routine injuries; they tell us nothing about how well major hazards are being managed. Moreover, firms normally attend to what is being measured, at the expense of what is not. Thus a focus on LTIs can lead companies to become complacent about their management of major hazards. This is exactly what seems to have happened at Esso.
The work of Heinrich and Bird, and the “safety pyramid” model, are widely used in safety training to justify a focus on behavioural safety (reducing the occurrence of unsafe acts, wearing individual protective equipment, following work procedures strictly, increasing attention to identify workplace hazards). It is a useful mental image that helps highlight that
- major injuries are rare events
- more frequent, less serious events provide opportunities to improve safety
The pyramid metaphor is sometimes combined with that of an iceberg, where the visible part above the waterline consists of reported injuries and fatalities, and the invisible part under water are all the unreported incidents and near misses. This mental image helps emphasize that there is potential for safety improvement in incidents that do not always get registered in the official reporting system, so it’s worthwhile trying to increase the visibility of these events.
While this image is positive in helping prevent occupational accidents, it is often misinterpreted in ways that reduce attention paid to major accident hazards. One common misinterpretation is “frequency reduction will trigger a severity reduction”. This is a “structuralist” view of the Bird pyramid, a mistaken view or myth1 that “chipping away at the minor incidents forming the base of the pyramid will necessarily prevent large accidents” [Hale 2002]. It assumes that there is a common cause between minor incidents and major accidents (“what hurts workers is also what kills them”), which is only partly true, as discussed above. It suggests an intervention strategy that is fairly easy to implement (if paternalistic): “focus people’s attention on avoiding minor incidents (slips, trips and falls) and their increased awareness of minor safety problems will prevent the occurrence of major events”. This interpretation is false concerning process safety and major accident hazards, which require specific focus, as mentioned above.
We have seen that the descriptive validity of the Heinrich/Bird incident/accident pyramid is lower than many safety professionals believe. More importantly, its predictive validity concerning major accident hazards is very low, because the factors that cause low-severity incidents are typically quite different from the factors that cause high-severity accidents. It is time to put this safety myth to rest.
Bellamy, Linda J., Ben J. M. Ale, J. Y. Whiston, M.L. Mud, H. Baksteen, Andrew R. Hale, I.A. Papazoglou, A. Bloemhoff, M. Damen, and J. I.H. Oh. 2008. “The software tool Storybuilder and the analysis of the horrible stories of occupational accidents.” Safety Science 46 (2): 186–97.
Hale, Andrew R. 2002. “Conditions of occurrence of major and minor accidents: Urban myths, deviations and accident scenarios.” Tijdschrift Voor Toegepaste Arbowetenschap 15 (3). Delft. http://www.arbeidshygiene.nl/-uploads/files/insite/2002-03-hale-full-paper-trf.pdf.
Heinrich, Herbert William. 1931. Industrial accident prevention: A scientific approach. New York. McGraw-Hill.
Andrew Hale refers to “beliefs which seem so plausible that they command immediate acceptance”.↩