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Investigating beyond the human machinery: A closer look at accident causation in high hazard industries§


  • This article is prepared for presentation at American Institute of Chemical Engineers 2008 Spring National Meeting, 42nd Annual Loss Prevention Symposium, New Orleans, LA, April 7–9, 2008.

  • This article has not been approved by the Board and is published for general informational purposes only. Every effort has been made to accurately present the contents of any Board-approved report mentioned in this article. Any material in the article that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board. AIChE shall not be responsible for statements or opinions contained in this article or printed in its publications.

  • §

    This is a U.S. Government work and, as such, is in the public domain in the United States of America.


Human error is not a cause of an accident—it's a symptom of underlying problems. Attempting to modify operator behavior to prevent human error will not rectify those underlying problems nor will it prevent major catastrophic accidents. This article will provide evidence to support why an organization's safety focus should not be solely on behavior-based safety. It will demonstrate how an equal emphasis and focus needs to be placed on the safety systems of the organization, as these aspects of safety provide a more accurate assessment of a company's true safety state. By taking another look at the US Chemical Safety Board's completed investigations, this article will demonstrate how one must go beyond the actions and decisions of frontline operators to truly understand the causes of any given incident and to safeguard against major accident hazards. © 2008 American Institute of Chemical Engineers Process Saf Prog, 2009