Preventing Industrial Accidents

Reappraising H. W. Heinrich – More than Triangles and Dominoes

Carsten Busch

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000346190
• Edition: 1
• Topic: Business
• Subtopic: Management
• Index: Business

Herbert William Heinrich has been one of the most influential safety pioneers. His work from the 1930s/1940s affects much of what is done in safety today – for better and worse. Heinrich's work is debated and heavily critiqued by some, while others defend it with zeal. Interestingly, few people who discuss the ideas have ever read his work or looked into its backgrounds; most do so based on hearsay, secondary sources, or mere opinion. One reason for this is that Heinrich's work has been out of print for decades: it is notoriously hard to find, and quality biographical information is hard to get.

Based on some serious "safety archaeology, " which provided access to many of Heinrich's original papers, books, and rather rich biographical information, this book aims to fill this gap. It deals with the life and work of Heinrich, the context he worked in, and his influences and legacy. The book defines the main themes in Heinrich's work and discusses them, paying attention to their origins, the developments that came from them, interpretations and attributions, and the critiques that they may have attracted over the years. This includes such well-known ideas and metaphor as the accident triangle, the accident sequence (dominoes), the hidden cost of accidents, the human element, and management responsibility.

This book is the first to deal with the work and legacy of Heinrich as a whole, based on a unique richness of material and approaching the matter from several (new) angles. It also reflects on Heinrich's relevance for today's safety science and practice.

Chapter 1

Introductions

1.1 Why this book?

There is this quote, commonly attributed to Dan Ariely, which I have paraphrased on several occasions. It says, “Big data is like teenage sex: everyone talks about it, nobody really knows how to do it, everyone thinks everyone else is doing it, so everyone claims they are doing it.”¹ It serves as an icebreaker in some settings, often leading to nervous laughter. At the same time, there is truth in it.

I think it also applies to the work of Herbert William Heinrich. Pop into a random professional safety forum, and there is a high chance of finding a discussion about one of Heinrich’s concepts.² If you hang around for a while, you may notice that little of that discussion is fuelled by actual knowledge. Many, instead of researching and trying to understand, “fall into the Heinrich was a god versus Heinrich was a monster argument” (La Duke, 2019).

This is not restricted to practitioners. In recent years, Heinrich’s legacy received increasing critique from contemporary safety authors, from those counted among the “new view,” as well as some rooted in more traditional approaches. However, few authors seem to engage with Heinrich’s work properly and systematically. Instead, many authors and safety professionals revert to an extreme position by either unquestioningly accepting and echoing Heinrich’s ideas (or a contemporary derivate) or dismissing them entirely – with rather little middle ground (Busch, 2019b).

This book aims to rectify some of that, by diving deep into Heinrich’s work and (re)viewing it in its context and in combination with older and contemporary thinking in safety. This book offers safety professionals and students (and others interested in backgrounds and history of safety science and practice) to acquire good second-hand knowledge of Heinrich’s work and some of its backgrounds.

Heinrich’s work is out of print for decades and most of it is hard to find. One of the aims of this book is to make Heinrich’s work accessible for others. Still as a secondary source, but more complete and hopefully more nuanced than alternative sources and with some new insights. On a few occasions the book will also try to figure out why it made sense for Heinrich to write what he wrote at the time.

The text will do so by extracting cues and looking for patterns (Weick, 1995), and by exploring questions that inform us about what could have been his local rationality.³ What was his knowledge at the time? What were his objectives? What outside factors affected him? What was the context he acted (wrote) in? Applying the local rationality perspective to some topics in Heinrich’s writings that we may perceive as strange, bizarre, or erroneous, but possibly were entirely sensible to him, may give us better understanding.

1.2 Isn’t the past, the past?

One may wonder whether it makes any sense to dive this deep into theories and ideas that go back eight decades and more. Should time and resources be spent on theories and ideas that have been used and abused so much that most of their contemporary use is rather counterproductive? Should we instead follow Marriott’s suggestion when he finishes his discussion of the “triangular fallacy,” stating, “Unfortunately, it has been so tainted now, that it would be better to remove it altogether and consign it to history” (Marriott, 2018, p.30)? He is not alone, also others advocate leaving the past behind and look forward, “…it is time for the old ideas to be swept into history…” (Gesinger, 2018, p.2).

My immediate reply to the question whether we should bother at all is a clear “Yes!” Heinrich’s work has been of great importance for safety practice and theory. Dwyer pinpoints Industrial Accident Prevention, as the start of safety as “an academic and a practical discipline” (Dwyer, 1992, p.266). As we will see later, this assessment is open for discussion. More correct and reasonable is Manuele’s statement from his seminal book On the Practice of Safety, “H.W. Heinrich has had more influence on the practice of safety than any other author. Heinrich’s premises have been adopted by many as certainty. They permeate the safety literature” (Manuele, 2013, p.57).

Although Heinrich’s legacy has proven to be a subject of discussion among practitioners and academics for years, many safety professionals (and scholars) have not even read his work. However, lack of information and knowledge has never stopped humans of having an opinion. The analysis in this book, and the discussion of numerous misconceptions and attributions, shows us that there is some need for clarification and better understanding. It is important to have an informed opinion, which means one must engage and study. Study critically, taking in view both how things looked back then and from the benefit of today’s knowledge.

Knowing about history and where one comes from is important, also as a profession, and for science, “…safety should be examining its history for trends and at least trying to use that study to identify the challenges it may have to face in the future” (Townsend, 2013).

To study, one needs to engage with an open mind. Instead of flatly rejecting an “old” approach as some seem to suggest, it may be wise to first take a look at the baby and only throw out the dirty water from the bath – even though there may be the possibility that there is only dirty water to be found in the tub. However, I think that much of Heinrich’s work is still relevant today, at least within certain applications.

Manuele’s On the Practice of Safety quotes Dan Petersen from the 1998 edition of Techniques of Safety Management saying,

In the safety profession, we started with certain principles that were well explained in Heinrich’s early works. We have built a profession around them, and we have succeeded in progressing tremendously with them. And yet in recent years we find that we have come almost to a standstill. Some believe that this is because the principles on which our profession is built no longer offer us a solid foundation. Others believe they remain solid but that some additions may be needed. Anyone in safety today at least ought to look at that foundation – and question it. Perhaps the principles discussed here can lead to further improvements in our approach and further reductions in our record.

(Petersen, 1998, p.27 quoted in Manuele, 2013, p.13)

I think there is some truth in this. More and critical research and reflection with a non-binary view is advisable, and I hope this book kickstarts some.

1.3 Citing Heinrich in safety literature

Before we turn to Heinrich’s life and work, let us have a quick look at how safety science publications reference Heinrich. Heinrich’s work has been influential for safety theory and practice for many decades. Still, reviewing the academic attention for his work shows some surprising results. A simple search in Scopus, showing the number of publications citing Industrial Accident Prevention,⁴ indicates a continuously increasing number of publications citing Heinrich’s book. Almost nine decades after the publication of the first edition, four decades after the publication of the last version, and with the book being out of print for a long time, “common sense” might suggest a picture of declining interest as new theories and new authors enter the field. Figure 1.1 seems to paint another picture, however.

Figure 1.1 Citations of Industrial Accident Prevention per year.

Source: Scopus.

From the first citation in 1970, the diagram shows a slow increase until the early 2000s. The average number of citations per year from 1970 to 1999 is below five. Some years see no citation at all. In 2002, the number of citations suddenly starts a steep climb, peaking in 2015 (119 times referenced) and 2019 (170). Even the half year shown for 2020 is higher than any year before 2010.

The below picture only shows academic quotations. However, the vast amount of safety literature is rather practical than academic. Much of safety literature aimed at practitioners can be found in professional magazines (e.g. from associations as ASSE, NSC, IOSH, or NVVK), books, course materials, guidance documents, and websites.⁵ These sources are rarely found in academic databases like Scopus, and attempting some form of systematic bibliographic research in “practical” literature encounters serious difficulties.

Another limitation of the search is that it returns mainly papers published in academic journals and hardly any books. A cursory check shows that books by for example Dan Petersen (multiple works from the 1970s to early 2000s), Dekker, and two of Fred Manuele’s notable works, dealing (partly) with Heinrich’s work, On the Practice of Safety and Heinrich Revisited, are missing. Interestingly, several of Hollnagel’s books are included – but not all of them. Neither is Frank E. Bird’s work, strongly influenced by, and continuing many of Heinrich’s core concepts, included.

The search and diagram above are thus a rather crude way of looking at the matter, but it may nevertheless suggest a direction and indicate a growing number of academic papers citing Heinrich. Whether this is due to the general increase of safety publications in the 2000s (Busch, 2019b), an increased interest in his work, or the fact that authors cite him because they feel they should do so as part of the “academic name dropping” (Hopkins, 2014, p.8),⁶ one cannot say without diving deeply into the material.⁷

1.4 Limitations

Literature-based research, and especially studying “ancient” literature, brings a number of implicit limitations that one must acknowledge.⁸ In order to keep the scope and material, depth and width within what fits within this book, there have to be some additional limitations, which means that there must be efficiency thoroughness trade-offs (ETTO) (Hollnagel, 2009) on the way.

1.4.1 The lenses of today (1)

Jean-Christophe Le Coze remarked,⁹ “history is always seen through the lenses of today.” This creates challenges when reading literature from past generations. One encounters archaic language. One do...