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Research to Determine the Contribution of System Factors Including Human Error in the Occurrence of Underground Injury Accidents.

Peay-JM; Shaw-BE; Sanders-MS
Mng Tech Economics & Policy 1989 :585-593
The objective of this U.S. Bureau of Mines work was to perform a comprehensive analysis of underground mining accidents to determine the relative contribution of various system factors, including human error. All injury-producing (nonfatal) accidents occurring at 20 mines over a 29-month period were investigated by a human factors specialist. A total of 338 accidents was investigated. A model of contributing factors in accident causation (cfac) was developed. The cfac model includes the following major categories of casual factors: management, physical environment, equipment design, work itself, social-psychological environment, worker-coworker characteristics, worker-coworker human error, and chance. Workers and coworkers were considered separately with respect to characteristics and human error. Seven experts in human factors, accident investigation, mining, and human error were trained to assess the relative contribution of each of the cfac categories to an accident event. Each rater assigned 100 ponts to the 10 cfac categories. The ratings were then averaged across raters for each case. The resulting pooled ratings were the raw data for the analysis. Injured-employee human error was involved to some degree in 93 pct of the cases, and was a primary or secondary contributing factor in 73 pct of the cases. Management was involved to some degree in 73 pct of the cases, and was a primary or secondary contributing factor in 34 pct of the cases. Equipment design was involved to some degree in 50 pct of the cases, and was a primary or secondary factor in 20 pct of
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OP 182-90
NIOSH Division
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Mng Tech., Economics & Policy 1989 (Am Mng Congress Mng Convention, California, 9/17-20/89) Pp 585-593