Assessing a fatal HAZRIN

Thorough accident analysis often requires use of an accident causation model and causal tracing techniques. The fatality described in this article was analyzed using several, including a systematic causation model for hazards-related occupational incidents (HAZRINs). Links to the concepts of chaos and complexity are introduced. The results of the analysis dispel the belief that this death was caused by an unsafe act, and further emphasize the roles management and design play in causation. Many of the complex, interwoven causation factors identified during this investigation occur across all industrial settings. This fatality event will likely be repeated in another place, at another time, involving some unsuspecting worker whose tolerance for risk-taking will lead him/her to test the relentless nature of chance. A machine operator played his role, behaving in both predictable and unpredictable ways. The outcome was undesirable, unexpected, final and, as this analysis revealed, predictable.