Heinrich's Domino Model of Accident Causation

Heinrich’s domino model of accident causation
Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931

publication Industrial Accident Prevention: A Scientific Approach [Heinrich 1931]
was based on the analysis of large amounts of accident data collected by his employer, a
large insurance company. This work, which continued for more than thirty years, identified
causal factors of industrial accidents including “unsafe acts of people” and “unsafe
mechanical or physical conditions”.
Heinrich is most famous for originating the concept of the “safety pyramid”. He also
developed the “five domino model” of accident causation, a sequential accident
model which has been influential on occupational safety thinking. His “domino theory”
represents an accident sequence as a causal chain of events, represented as dominos that
topple in a chain reaction. The fall of the first domino leads to the fall of the second,
followed by the third, etc
as illustrated below.
The domino model of accident causation, as depicted by H. Heinrich in the 1950 edition of
his book Industrial Accident Prevention: A Scientific Approach
Heinrich saw the occurrence of a “preventable injury” as the culmination of a series of

events that form a sequence, similar to a row of dominos placed so that the toppling of a
first domino knocks down the next, which makes the third fall down, and so on until the
entire row is toppled. If this series is interrupted by the elimination of even one of the
several factors that comprise it, the injury will not occur, as illustrated in the figure below:
Accident prevention by interrupting the accident sequence, from the 1950 edition of the
book Industrial Accident Prevention: A Scientific Approach
In the first version of this model, published in 1931, the five factors identified were:
 domino 1: ancestry and the worker’s social environment, which impact the worker’s
skills, beliefs and “traits of character
and thus the way in which they perform tasks
 domino 2: the worker’s carelessness or personal faults, which lead them to pay
insufficient attention to the task (see box about “accident-proneness” theory)
 domino 3: an unsafe act or a mechanical/physical hazard, such as a worker error

(standing under suspended loads, starting machinery without warning…) or a
technical equipment failure or insufficiently protected machinery
 domino 4: the accident
 domino 5: injuries or loss, the consequences of the accident
Over time, the idea of attributing workplace behaviour to ancestry and to ingrained personal
faults was found to be inappropriate, and more recent versions of the model replace the
labelling of the first two dominos by aspects related to planning, work organization and
leadership, or more generally management’s control of organizational factors of safety.
This theory of accident causation was later further developed by Frank Bird, who improved
the description of managerial “dominos”, and who generalized the last “accident” domino
to cover any loss (lost production, damage to equipment or other assets, and not only
injuries).
Interpretation
This linear accident model is simple and easy to understand. Compared with the very
simplistic analyses that were common at the time (“accident caused by worker error”), it
helped managers to think about and identify underlying causal factors that could contribute
to accidents. Its promise of allowing the interruption of the accident sequence by acting on
underlying causal factors (“pulling out a domino”) helps to convince people to adopt the
corrective actions suggested by the accident investigation.
However, the model can contribute to a focus on the search for culprits or people to blame
in the accident sequence, rather than on a detailed understanding of all the factors that may
have contributed to the accident. It encourages an interpretation of workplace safety in
which workers as seen as generators of accidents, rather than as people who do their best to
run imperfect systems as well as possible given all the competing demands.
Criticism
The domino model is widely seen today as being too simplistic to be a useful tool to help
understand the causal factors of accidents:
 It leads to an excessively simple view of the contribution of human performance to

accidents, and to a focus on training and procedural compliance (including
“behaviour-based safety” programmes), rather than on system design, workload and
incentives.
 It adopts a purely linear and mechanical model of causality, which is inappropriate

in complex systems where accidents are generally caused by many interacting,
partially competing and unpredictable factors. (“Complex systems fail in complex
ways” is a useful tagline.)

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Heinrich’s domino model of accident causation

Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931

as illustrated below.

Heinrich saw the occurrence of a “preventable injury” as the culmination of a series of

 domino 3: an unsafe act or a mechanical/physical hazard, such as a worker error

 domino 4: the accident

 domino 5: injuries or loss, the consequences of the accident

 It leads to an excessively simple view of the contribution of human performance to

 It adopts a purely linear and mechanical model of causality, which is inappropriate

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