Behind Human Error, 2nd Edition

3LINEAR AND LATENT FAILURE MODELS

THE SEQUENCE-OF-EVENTS MODEL

Accidents can be seen as the outcome of a sequence, or chain, of events. This simple, linear way of conceptualizing how events interact to produce a mishap was first articulated by Heinrich in 1931 and is still commonplace today. According to this model, events preceding the accident happen linearly, in a fixed order, and the accident itself is the last event in the sequence. It has been known too as the domino model, for its depiction of an accident as the endpoint in a string of falling dominoes (Hollnagel, 2004). Consistent with the idea of a linear chain of events is the notion of a root cause – a trigger at the beginning of the chain that sets everything in motion (the first ...