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arising from the person and ulti- mately the ancestral and social bag- gage that a person brings with them to work, is the proper focus and cause of industrial injury was not limited to Heinrich. As generations of safety professionals and manu- facturing managers were taught this concept, it has found its way into the belief system of individuals and influential organizations.


Why Human Error Is Not a Root Cause


Human acts are involved in a


majority of metalcasting injuries. Seldom is it true that a worker, properly engaged in their duties, is suddenly and without his/her own action injured by their environment. The question is whether the actions of the worker are the root cause of such injury. To assist in making this distinction Heinrich’s dominoes can be examined using a common qual- ity problem solving tool of why-why analysis (Fig. 3). With an examination of Hein-


rich’s theory via why-why analysis, it is clear why Heinrich recommends various psychological and awareness strategies to the correction of indus- trial accidents. He recognizes he cannot address the true root cause (in his view) of the background


Figure 1. The diagram shows the total case incident rate using the standard formula found in Table SNR05 of BLS.


of the employee, their upbringing and socialization prior to coming to work for a company, so he must attack the problem at the next level up: the employee himself. But the tacit assumption in


Heinrich’s view is the prevailing influence on employee behavior is already established prior to their hire, external to the organization and that this influence is largely a detriment to good safety perfor-


mance. This ignores the massive amount of current research on the significant correlation between an organization’s culture and the safety performance of that organization. Heinrich’s link between employee act and past social environment and ancestry also ignores the struc- tural influences that exist through management choices that directly or indirectly influence worker behavior. These two alternate answers to the final “why” in Figure 3 are illustrated in Figure 4. Organizational culture can be


defined as the shared perceptions among employees concerning the procedures, practices and kinds of behaviors that get rewarded and supported with regard to a specific strategic focus. These shared percep- tions are driven by contributing factors such as: • Leadership values and consis- tency of action.


• Supervisory communication and follow up.


Figure 2. The diagram shows the incident rate for days away and restricted time (DART) using the standard formula found in Table SNR05 of BLS.


24 | MODERN CASTING June 2017


• Reward systems. • Measurement systems. • Processes for investigation, communication and closure of incidents. The practical experience of many


foundries has supported the link between safety climate/culture and


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