The Causes of Severe Accidents in the Andalusian

Manufacturing Sector: The Role of Human Factors in

Official Accident Investigations
Jesús A. Carrillo-Castrillo,1 Juan C. Rubio-Romero,2 Luis Onieva,3
and Antonio López-Arquillos2
1 Department of Occupational Safety Research, Regional Government of Andalusia, Seville, Spain
2 School of Industrial Engineering, University of Málaga, Málaga, Spain
3 School of Industrial Engineering, University of Seville, Seville, Spain

Abstract
This study examines the associations between worker characteristics and accident causation. It is based
on the causes identified in the accidents investigated in the manufacturing sector of Andalusia (Spain)
from 2004 to 2011 by the Labour Authority. The method used to assess the association between the
categorical variables related to worker characteristics and types of causes is the phi coefficient test for
each specific combination of categories of the variables. The main results are as follows. For young
workers, the most likely causes include being assigned a task without the proper qualifications, using
inappropriate work methods, and misunderstanding instructions. For low-experience workers, the
most likely cause is a lack of experience. For nonmanual qualified workers, the most likely causes
include performing tasks without proper experience or personal protective equipment and performing
nonroutine tasks. This differential causation found, depending on worker characteristics, can be used
to design more effective preventive programs.  C 2014 Wiley Periodicals, Inc.

Keywords: Accident investigation; Causation factors; Manufacturing industry; Human factors; Ac-
cident prevention

1. INTRODUCTION performance and the mental and physical conditions

1.1. The Analysis of Accident Causation
When an accident occurs in an organization, all pre-
ventive and protective measures must be assessed and,
if necessary, reviewed by the employer. In certain cases,
the Labour Authority also conducts its own investiga-
tion. The aim of accident investigations is to identify
the causes of accidents, which Raouf (1998) classified
as immediate causes (unsafe acts and unsafe condi-
tions) and contributing causes (safety management
Received: 22 August 2013; accepted 15 October 2014
View this article online at wileyonlinelibrary.com/journal/hfm
DOI: 10.1002/hfm.20614
of workers).
Accident causation is multifactorial, and the iden-
tification of all circumstances that contribute to its
pattern can be difficult. Several accident models and
investigation methods have been proposed (Sklet,
2004). Such models aim to identify active causes
as well as latent causes, such as organizational
and personal factors (Katsakiori, Sakellaropoulos, &
Manatakis, 2009). Learning from cases where pre-
vention has already failed can thus reveal poten-
tial areas of improvement (Khanzode, Maiti, & Ray,
2012).
At the organizational, activity, task, and job levels,
personal risk factors affect the likelihood of accidents
occurring. Risk factor analysis has been one of the most
explored fields of research in occupational safety. In

68 Human Factors and Ergonomics in Manufacturing & Service Industries 26 (1) 68–83 (2016) 
c 2014 Wiley Periodicals, Inc.
Role of Human Factors in Official Accident Investigations
particular, accident investigation can be useful for iden-
tifying risk factors to improve the design of preventive
programs (Khanzode et al., 2012), which must inte-
grate aspects such as quality and ergonomics (Dzissah,
Karwowski, Rieger, & Steward, 2005). However, both
latent and active failures are needed to explain accident
causation (Bentley, 2009).
A number of individual worker characteristics have
been associated with the severity and likelihood of
accidents occurring (Dembe, Erickson, & Delbos,
2004), such as age (Salminen, 2010), type of contract
(Saloniemi & Salminen, 2010), length of shift (Vegso
et al., 2007), and sex (Taiwo et al., 2008). Moreover, pre-
vious studies of the manufacturing sector in Andalusia
(Spain) have shown that individual worker characteris-
tics can affect both the likelihood and the severity of oc-
cupational injuries (Carrillo, Gómez, & Onieva, 2012;
Carrillo & Onieva, 2012). The main relationships be-
tween accident occurrence and worker characteristics
in the manufacturing sector of Andalusia are presented
in Table 1.
From an epidemiological point of view, the identifi-
cation of groups of at-risk workers with certain char-
acteristics is the objective; however, from a preventive
point of view, it is more useful to identify the under-
lying mechanisms in order to design specific actions
to address the most prevalent accident causes in each
group of workers. The analysis of accident investiga-
tions is one of the most common tools for identify-
ing accident causes, especially detecting the preventive
barriers that have failed. Furthermore, understanding
the underlying mechanisms can help intervene in the
way in which each risk factor affects the likelihood and
severity of accidents.
The analysis of accident causation is complicated,
however. Each accident may have multiple causes, and
the relationships among different factors are complex
(Hale et al., 2007). Indeed, few scientific studies of
specific manufacturing subindustries (Jacinto, Canoa,
& Guedes, 2009) or types of accidents in this sector
(Aneiziris et al., 2013; Gardner, Carlopio, Fonteyn, &
Cross, 1999) have been published thus far.
Different statistical tools have been used in order to
analyze the factors related to accident causation. Some
authors have applied the test for differences in propor-
tions to analyze differential causation, which is useful
when factors are represented by dichotomous variables
(Kines, 2002). When there are more than two categories
(as in different categorical levels or modalities), other
techniques may be used. For example, V-Cramér and
Human Factors and Ergonomics in Manufacturing & Service Industries
Carrillo-Castrillo, Rubio-Romero, Onieva, et al.
phi coefficient calculated at the cell level of a contin-
gency table may be used to identify the specific role of
each category (Chi, Yang, & Chen, 2009). Likewise, cor-
respondence analysis (Hobbs & Williamson, 2003) and
cluster analysis (Williamson, Feyer, & Cairns, 1996)
may be appropriate with more than two categories, as
they consider all possible categories at the same time.
Other techniques such as structural equation mod-
eling have also been applied (Katsakiori, Kavvathas,
Athanassiou, Goutsos, & Manatakis, 2010).
1.2. Scope of the Present Research
This study consists of a cross-sectional analysis of the
causes identified in the accident investigations per-
formed by public officers within the manufacturing
sector in Andalusia. The manufacturing sector is de-
fined according to the European Statistical Classifica-
tion of Economical Activities (NACE).
Manufacturing is the sector with the highest number
of annual days of absence due to accidents in Europe.
According to data published by the European Commis-
sion (2007), the incidence rate of accidents with more
than three days of absence in the European Union and
Norway manufacturing sectors was 3.10 accidents per
100,000 workers. It is important to add that Andalusia
is one of the biggest regions of Europe, representing ap-
proximately 12% of the Spanish manufacturing sector
and employing more than 200,000 workers.
In the literature review performed for this study, no
previous analyses of the role of worker characteristics
in accident causation in the manufacturing sector in
Spain were found, and very little information about
this general topic is available. Most of the published
material forms part of the Workgroup Occupational
Risk Model (WORM) project that is limited to the
Netherlands (Ale et al., 2008). This study thus aims
to bridge this gap in the literature by analyzing the
role of specific human factors in the accident causes
identified in official investigations in the Andalusian
manufacturing sector.
2. MATERIALS AND METHOD
2.1. Accident Investigation Reports
When an accident occurs, the employer has to sub-
mit an official accident notification. If the Labour In-
spectorate decides that an investigation is needed, an
DOI: 10.1002/hfm 69
Carrillo-Castrillo, Rubio-Romero, Onieva, et al. Role of Human Factors in Official Accident Investigations

TABLE 1. Univariate Logistic Regression Analysis of the Likelihood and Severity of Accidents in the Manufacturing Sector
of Andalusia in Year 2008

Variable Categories Odds Ratio for Likelihood (sig.) Odds Ratio for Severity (sig.)

Sex
Male 1.94–8.47 (<0.01) 1.56–2.22 (<0.01)
Female Reference Reference
Age type
16—29 0.11–0.39 (<0.01) Not significant
30—44 0.39–0.94 (0.03)
>44 Reference
Nationality
Spanish Not significant 0.56–0.83 (0.08)
Foreign Reference
Contract type
Permanent 0.95–2.50 (0.08) 1.01–1.19 (0.08)
Temporary Reference Reference
Tenure (in months)
Inexperienced (1–2) 0.08–0.39 (<0.01) Not significant
Experienced (3–6) 0.22–0.64 (<0.01)
Senior (>6) Reference
Occupation
Clerical 0.01–0.16 (<0.01) Not significant
Manager 0.06–0.46 (0.01)
Nonqualified 0.12–0.42 (<0.01)
Qualified 0.22–0.59 (<0.01)
Technical Reference
Shift type
Morning 0.30–0.77 (<0.01) 0.30–0.77 (<0.01)
Afternoon 0.29–0.84 (0.01) 0.29–0.84 (0.01)
Other Reference Reference

Note: Results already published (Carrillo et al., 2012; Carrillo & Onieva, 2012).

official accident investigation is then performed by
safety officers of the Labour Authority in Andalusia.
Medical criteria are applied by the physicians of the
Mutual Insurance System for Occupational Injuries
and Illnesses to classify the accident as slight or se-
vere, depending on the injuries and expected period of
recovery. Most severe accidents and all fatal accidents
are selected for official investigation, excluding traffic
accidents, self-employed workers’ accidents, and non-
traumatic deaths such as strokes or heart attacks. After
those exclusions, 49% of fatal accidents and 27% of
severe accidents were investigated between 2004 and
2011. This data set has been previously used to analyze
accident causation (Carrillo-Castrillo, Rubio-Romero,
& Onieva, 2013).
Accident investigations are performed according to
the standardized method approved by the Spanish In-
stitute for Safety and Hygiene at Work (Piqué, 1997).
This method is known as fault tree method in the
scientific literature (Sklet, 2004). The fault tree method
is used in all official accident investigations. Period-
ically, the Labour Authority in Andalusia organizes
training courses for public officers to ensure unifor-
mity in the task of investigating accidents.
In this study, all investigated severe or fatal acci-
dents occurring from 2004 to 2011 were included.
Although some slight accidents were investigated as
well in that period, they were not included because of
their differential causation (Jeong, 1999; Kelsch et al.,
2009) and the small proportion that were selected for
investigation.
In 2004, the Labour Authority in Andalusia adopted
a common coding system for the causes identified
in official accident investigations that includes 255
four-digit cause codes (Carrillo-Castrillo & Onieva,
2014; Fraile, 2011). The first digit identifies the group
of causes, the first two digits identify the subgroup
of causes (type of cause), and the last two digits

70 Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm
Role of Human Factors in Official Accident Investigations Carrillo-Castrillo, Rubio-Romero, Onieva, et al.

TABLE 2. Classification of Causes Identified in Accidents Investigation Reports

Group of Causes Subgroup of Causes / Type

(first digit) of Cause (first two digits)

Workplace (1)
Workplace layout (11)
Housekeeping (12)
Physical environment (13)
Installations (2)
Design, construction and maintenance (21)
Protection devices (22)
Signage (23)
Machinery (3)
Design, construction, and maintenance (31)
Protection devices 32)
Signage (33)
Other equipment (4)
Design, construction, and maintenance (41)
Protection devices (42)
Signage (43)
Materials and substances (5)
Handling and storage (51)
Chemicals (52)
Biological (53)
Work organization (6)
Work method (61)
Activities planning and execution (62)
Training (63)
Equipment selection (64)
Safety management (7)
Safety management system (71)
Safety activities (72)
Personal factors (8)
Behavior (81)
Personal characteristics (82)
Other personal factors (89)
Other (9)
Other (91)
No causes (92)

Note: According to Fraile (2011).

are the different causes in each subgroup (see
Table 2). For example, the cause 7206 is used for
“inadequate training/information about risks of pre-
ventive measures”; it is classified as Group 7, which
includes causes related to safety management, and Sub-
group 72, which includes causes related to preventive
activities.
This structured coding system allows us to analyze
causation patterns. Active causes are usually classified
into groups with a first digit of 1 to 5, whereas most of
the causes classified in Groups 6 to 8 are latent (Reason,
2000). Group 6 “work organization” is used for causes
related to inadequate work organization, such as inade-
quate work methods, errors in carrying out tasks, poor
training and communication, poor selection of equip-
ment, or a lack of proper means for the task. Group 7
“safety management” is used for causes related to poor
safety management, poor implementation of safety ac-
tivities, or inadequate supervision. Group 8 “personal
factors” is used for causes related to behavior, a lack
of adequate physical or mental condition for the task,
or poor qualifications or experience. The full list of
the possible causes coded within Groups 6, 7, and 8 is
presented in Table 3.

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Carrillo-Castrillo, Rubio-Romero, Onieva, et al. Role of Human Factors in Official Accident Investigations

TABLE 3. Codes for Causes in Groups 6, 7, and 8

Subgroup of Causes / Type (Code of cause, four digits)

of Cause (first two digits) Description

Work method (61) (6101) Lack of work methods

(6102) Inadequate work methods
(6103) Inadequate design of task or work
(6104) High work speed
(6105) Monotonous or routine work without proper
countermeasures
(6106) Solitary work without proper countermeasures
(6107) Overload regarding the limits or specifications of the
equipment
(6108) Worker overload, either physical or mental
(6109) Poor coordination among workers performing tasks
(6110) Lack of proper supervision
(6111) Work organization without consideration for meteorological
conditions
(6199) Other causes related to work methods
Activities planning and execution (62) (6201) Unusual task for the worker
(6202) Task performed to avoid or resolve breakdowns, failures, or
incidents
(6203) Unusual task performed during an accident or emergency
(6299) Other causes related to task organization
Training (63) (6301) Poor communication, including language comprehension
(6302) Lack of instructions
(6303) Inadequate instructions given for the task
(6304) Inadequate training or information given for the task
(6305) Poor procedures for training or informing workers regarding
equipment and materials
(6306) Lack of proper signage or information for workers
(6307) Poor traffic or load signage
(6308) Poor lock-out tagging to avoid unexpected power usage
(6399) Other causes related to task training or information
Equipment selection (64) (6401) Appropriate equipment not provided
(6402) Selection of machines not appropriate to the task
(6403) Selection of equipment not appropriate to the task
(6404) Poor selection of materials
(6405) Inappropriate use of a machine, against manufacturer
recommendations
(6406) Inappropriate use of equipment, against manufacturer
recommendations
(6407) Use of general materials against manufacturer
recommendations
(6408) Equipment not checked before use
(6409) Poor lock-out / tag-out procedures
(6499) Other causes related to the selection and use of equipment
and materials
Safety management system (71) (7101) Poor procedures for risk assessment
(7102) Poor procedures for planning and implementing safety
practices
(7103) Inadequate procedures for training and informing workers
about risks and preventive measures
(7104) Inadequate organization for performing the preventive
measures
(Continued)

72 Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm
Role of Human Factors in Official Accident Investigations
TABLE 3. Continued
Subgroup of Causes / Type
of Cause (first two digits)
Safety activities (72)
Behavior (81)
Personal characteristics (82)
Other personal factors (89)
Note: According to Fraile (2011).
For the purposes of this study, the analysis of the
role of human factors focuses on the latent group
of causes. The number of causes identified per acci-
dent investigated can vary, reaching a maximum of
nine, while in most cases, the number of causes is
between three and five. Note that all causes are con-
Human Factors and Ergonomics in Manufacturing & Service Industries
Carrillo-Castrillo, Rubio-Romero, Onieva, et al.
(Code of cause, four digits)
Description
(7105) Inadequate procedures for the coordination of activities
involving different enterprises
(7106) Inadequate purchasing practices regarding prevention
(7107) Inadequate matching of workers and tasks, not including
criteria related to training or qualifications
(7108) Failing to identify workers with inadequate characteristics
regarding the nature of the task or the risks involved
(7199) Other causes related to safety management
(7201) Hazards not identified during the risk assessment
(7202) Inadequate planning of preventive measures relating to poor
assessment or identification of risks
(7203) Poor implementation of the preventive measures planned
(7204) Lack of checks for safety plans in construction activities
(7205) Inadequate maintenance
(7206) Inadequate training or information regarding risks or the
preventive measures
(7207) Inadequate emergency planning
(7208) Adequate personnel protective equipment (PPE) not provided
or poor supervision of their use
(7209) Insufficient presence of preventive safety resources
(7210) Inadequate health supervision in relation to risks
(7211) Lack of adequate work permissions and/or procedures
involving dangerous tasks
(7212) Task assigned to a worker without adequate qualifications or
experience
(7299) Other causes related to safety activities
(8101) Performing nonassigned tasks
(8102) Failure to comply with work procedures
(8103) Failure to comply with safety rules
(8104) Inadequate use of material or equipment
(8105) Inadequate use of auxiliary devices
(8106) Failure to use personal protective equipment
(8107) Removal or override of safeguards or protective devices
(8108) Worker presence in a dangerous or unauthorized area
(8109) Inadequate posture in the workstation
(8199) Other causes related to behavior
(8201) Lack of proper physical or mental conditions for performing
the task
(8202) Poor understanding of instructions
(8203) Lack of worker qualifications or experience
(8299) Other causes related to intrinsic factors
(8999) Other causes related to personal factors
sidered to be equal in terms of causation pattern ex-
cept for those marked as the main cause (although in
some cases, no main cause is marked). The main cause
is interpreted as the root cause in the coding system
and the other causes are interpreted as contributing
factors.
DOI: 10.1002/hfm 73
Carrillo-Castrillo, Rubio-Romero, Onieva, et al.
In addition to accident causes, accident circum-
stances are also available based on the European Statis-
tics on Accidents at Work Methodology, hereinafter
ESAW (European Commission, 2002). The circum-
stances of accidents coded according to ESAW and the
reporting system within the European Union have been
analyzed by Jacinto, Guedes-Soares, Fialho, Antão, and
Silva (2011).
The circumstances according to ESAW include
worker characteristics (occupation, sex, nationality,
employment status, working time), enterprise char-
acteristics (economic activity, size of enterprise, lo-
cation), work characteristics (working environment,
working process, workstation), and the sequence
of events of the accident (specific physical activity,
deviation, mode of contact).
2.2. Worker Categories
The worker categories analyzed (see Table 4) include
variables on demographic characteristics (sex, nation-
ality, age), contractual characteristics (type of contract
and seniority), and working time (day of the week,
time, shift). To check whether there is any bias in the
selection of investigated accidents, the total number of
accidents notified is included.
2.3. Causation Pattern
The analysis of the association between categories of
workers and each cause is a straightforward process.
The same is also true when a main cause has been
marked. However, examining the association between
categories of workers and types of causes (i.e., sub-
groups of causes) is more complex, especially because
more than one cause within the same subgroup may
be identified in the accident. The criterion used is that,
if at least one of the causes is included within a certain
type of cause, then that type of cause is part of the
causation pattern. Therefore, the causation pattern is
defined by the types of causes (subgroups of causes)
with at least one cause identified.
2.4. Analysis at the Cell Level of
Contingency Tables: Phi Coefficient
The general association between two categorical vari-
ables can be tested by using the chi-square or V-Cramér
test. However, in terms of prevention, it is more impor-
tant to assess the relationship between the categories
74 Human Factors and Ergonomics in Manufacturing & Service Industries
Role of Human Factors in Official Accident Investigations
(or modalities) of the variable. Therefore, the analysis
should be performed at the cell level. For instance, the
cell level in a contingency table between the categorical
variable types of workers and types of causes is the in-
tersection between each category of workers and each
category of cause, which provides the number of times
that combination of categories is found in the data set.
Cell-level relationships can be tested by using the
phi coefficient, which is calculated for each worker cat-
egory and each subgroup of causes. For dichotomous
variables (variables with only two categories), the phi
coefficient at cell level is equal to the V-Cramér coeffi-
cient for the variable.
Only positive and significant values of phi coeffi-
cients (p < 0.05) are useful for identifying the associ-
ations between categories that could lead to possible
effective preventive interventions. Negative values in-
dicate that there is little contribution of the category to
the accident causation.
3. RESULTS
3.1. Causation Patterns
All identified causes in this study were classified into
groups and subgroups of causes. The proportion of
latent causes, even among those identified as the main
cause, was very high: 71% of all causes and 60% of
the causes marked as main causes (see Table 5). The
causes most frequently marked as the main cause of an
accident were those related to work method (19%) and
behavior (16%).
The groups of causes with the highest prevalence
were in “safety management” (23%), “work organiza-
tion” (29%), and “personal factors” (19%). Regarding
those marked as the main cause, the groups of causes
with the highest prevalence were “work organization”
(28%) and “personal factors” (24%). Figures 1 and 2
illustrate these distributions graphically.
The causation patterns were identified using the
groups of causes. Table 6 lists the possible patterns
considering all groups of active causes (Groups 1 to 5)
together and the groups of latent causes (Groups 6, 7,
and 8) separately.
Most severe and fatal accidents investigated had la-
tent causes. Without latent causes, only 11% of the
accidents could be explained. Moreover, in 60% of the
accidents, the main cause was latent. An analysis of
the causation patterns shows that in 57% of the ac-
cidents there was at least one organizational cause, in
DOI: 10.1002/hfm
Role of Human Factors in Official Accident Investigations Carrillo-Castrillo, Rubio-Romero, Onieva, et al.

TABLE 4. Worker Categories

Criteria (if Number of Accidents Total Number of

Variable Category necessary) Investigated (%) Accidents Reported (%)

Sex
Male 612 (95) 1,902 (94)
Female 35 (5) 129 (6)
Nationality
Spanish 627 (97) 1,922 (95)
Foreign 20 (3) 109 (5)
Age (in years)
Young Under 25 100 (15) 277 (14)
Normal From 25 to 44 494 (76) 1,111 (55)
Older Over 44 54 (8) 643 (32)
Contract
Permanent 345 (53) 1,064 (52)
Fixed term 302 (47) 967 (48)
Seniority
(months in company) Low seniority Less than 4 173 (27) 506 (25)
Normal seniority From 4 to 12 127 (20) 422 (21)
High seniority More than 12 347 (54) 1,103 (54)
Company size
(number of workers) Micro Less than 10 208 (32) 609 (30)
Small From 10 to 49 279 (43) 866 (43)
Medium From 50 to 249 140 (22) 418 (21)
Big More than 249 20 (3) 138 (7)
Day
Monday 129 (20) 402 (20)
Rest Tuesday to Friday 465 (72) 1,485 (73)
Weekend 53 (8) 144 (7)
Time
Morning 06–14 444 (69) 1,297 (64)
Afternoon 14–22 148 (23) 599 (29)
Night 22–06 44 (7) 135 (7)
Shift part
First part Hours 1, 2, 3 303 (47) 911 (45)
Rest Hours 4 and 5 172 (27) 519 (26)
Second part Hours 6, 7, 8 158 (24) 562 (28)
Extra time After Hour 8 6 (1) 39 (2)
Without data 8 (1) — (0)
Total 647 2,031

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.

51% there was at least one personal factor cause, and in
45% there was at least one safety management cause.
The combination of active and organizational causes is
in 36% of the cases.
3.2. Associations between Groups of
Workers and Types of Causes
The phi coefficient analysis of the associations between
the types of main causes (subgroups of main causes)
and each worker category (among the worker vari-
ables considered) are shown in Table 7. The phi coeffi-
cient analysis of the association between types of causes
(subgroups of causes) and worker categories (among
the worker variables considered) are shown in Table 8.
Only significant relationships are included.
The most relevant associations include “young
workers” and “inappropriate work method” as well as
“low-experience workers” and causes related to “safety
management” or to “personal factors.” For example,

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TABLE 5. Classification of the Causes into Groups and Subgroups of the Causes

Group Subgroup (type of cause) No. Main %Main No. Total

1. Workplace
11. Workplace layout 52 41 128
12. Housekeeping 6 21 28
13. Physical environment 1 8 13
19. Other 3 75 4
2. Installations
21. Design, construction, and maintenance 3 30 10
22. Protection devices 6 32 19
29. Other 1 100 1
3. Machinery
31. Design, construction, and maintenance 50 49 102
32. Protection devices 46 39 118
33. Signage 1 7 15
4. Other equipment
41. Design, construction, and maintenance 30 44 68
42. Protection devices 8 47 17
43. Signage 2 10 21
49. Other 5 33 15
5. Materials and substances
51. Handling and storage 18 42 43
52. Chemicals 6 38 16
6. Work organization
61. Work method 113 33 344
62. Activities planning and execution 16 27 60
63. Training 10 10 104
64. Equipment selection 23 26 88
69. Other 5 22 23
7. Safety management
71. Safety management system 12 9 137
72. Safety activities 36 10 359
8. Personal factors
81. Behavior 97 37 263
82. Personal characteristics 8 21 38
89. Other 37 33 112
Total 595 28 2146

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.

one of the investigations reported that “during his first
week, a young worker used an inappropriate method.”
Furthermore, after auditing the safety system, “no evi-
dence of appropriate training was found.”
Regarding work timetables, the most relevant asso-
ciations include Monday mornings and causes related
to “task performance” or “personal factors” as well
as “night shift” and causes related to “poor perfor-
mance in preventive activities.” Finally, workers who
were “working overtime” (more than the standard shift
of 8 hr) are associated with causes related to “organiza-
tional factors,” errors in “tool selection,” and “personal
factors.”
For example, one of the investigations reported that
“one worker on the night shift began working without
checking the safety guards of a machine.” Moreover, ac-
cording to the report, “no safety supervisor was present
at that time in the factory.”
3.3. Associations between Groups of
Workers and Each Cause
Specific causes with more than 10 cases were included
for this analysis. The phi coefficient analysis of the asso-
ciation between causes and worker categories (among
the worker variables considered) is shown in Table 9.

76 Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm
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Figure 1 Distribution of the causes identified by group of causes.

Figure 2 Distribution of the causes marked as main cause by group of causes.

For “young workers,” the main associations were
with “performing task without proper qualification
or experience,” “using inappropriate work method,”
and “misunderstanding the instructions.” For “low-
experience workers,” the most likely cause of accidents
was a “lack of experience.” For example, some of the in-
vestigation reports remarked that the worker was per-
forming a task for the first time without any proper
supervision.
For “qualified workers with non-manual tasks,” such
as managers, the most likely causes of accidents were
“performing tasks without proper experience” or a
“lack of personal protective equipment” and “perform-
ing non-routine tasks.” For example, one of the reports
states that “one manager tried to continue the task
when a worker needed to leave without a protective
glove that, had it been used, could have avoided the
injury.”

Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm 77
Carrillo-Castrillo, Rubio-Romero, Onieva, et al. Role of Human Factors in Official Accident Investigations

TABLE 6. Causation Patterns: Group of Causes with at Least One Cause Identified

Active Causes Organizational Safety management Human factors

(Groups 1 to 5) (Group 6) (Group 7) (Group 8) No. Cases % Cases

— — — X 56 9
— — X — 16 2
— — X X 20 3
— X — — 64 10
— X — X 35 5
— — X X 29 4
— X X X 46 7
X — — — 72 11
X — — X 25 4
X — X — 31 5
X — X X 23 4
X X — — 56 9
X X — X 36 6
X X X — 70 11
X X X X 62 10
— — — — 6 1

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.

The analysis of the causes of accidents among work-
ers who were “working overtime” shows associations
with specific causes such as “assigning unqualified
workers” and “inappropriate use of tools and equip-
ment” along with “other organizational causes.” For
example, one of the reports states that “they had to
work that night to finish an urgent order; however, the
specific tools were locked in the maintenance room so
they had to figure out a different procedure to change
the broken part that was inappropriate.”
than 60% of cases, the main cause was latent. In terms
of preventive priorities, work organization and safety
management should be the focus. It is necessary to draw
attention to the fact that, in 41% of the severe accidents
investigated, no active causes were identified, and thus
nothing could have been achieved by improving the
physical environment. Another important finding was
the high proportion of causation patterns with more
than one group of causes (70% of the cases included
causes from at least two groups of causes).

4. DISCUSSION 4.2. Association between Types of

Official accident investigations are a useful tool for oc-
cupational safety research. Although investigated acci-
dents are selected by Labour Authority (not randomly),
there are no significant differences in the proportion
of investigated accidents in each of the categories and
the proportion in the whole set of severe accidents.
The only category underrepresented in the sample is
older workers because nontraumatic accidents such as
strokes are not investigated, and they are an important
accident type in older workers.
4.1. Causation Patterns
The high proportion of latent causes has been found
in previous studies (Carrillo-Castrillo et al., 2013;
Gardner et al., 1999; Jacinto et al., 2009). In more
Causes and the Characteristics of the
Injured Worker
The associations between types of causes and the iden-
tified characteristics of the injured worker have a rela-
tively low intensity, with a phi coefficient below 0.2, but
some of them show high significance (lower than 0.01).
The low intensity can be explained by the fact that there
are other risk factors such as the technical and physical
conditions of workplaces and organizations that affect
all workers despite their personal characteristics.
The higher severity of injuries to young workers can
be partly explained by inappropriate work methods. In
50% of the investigated accidents among young work-
ers, at least one cause was related to the work method.
When looking at the causes of accidents, this associ-
ation was even stronger. Inappropriate work methods

78 Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm
Role of Human Factors in Official Accident Investigations Carrillo-Castrillo, Rubio-Romero, Onieva, et al.

TABLE 7. Associations between Groups of Workers and Latent Types of Causes

Category vs. Type of Causea 61 62 63 64 69 71 72 81 82 89

Sex. Male ns ns ns ns ns ns ns ns ns ns
Sex. Female ns ns ns ns ns ns ns ns ns ns
Age. Young 0.08∗ ns ns ns ns ns ns ns ns ns
Age. Normal ns ns ns ns ns ns ns ns ns ns
Age. Older ns ns ns ns ns ns ns ns ns ns
Experience. Low ns ns ns ns ns ns ns ns 0.10∗∗ ns
Experience. Medium ns ns ns ns ns ns ns 0.09∗ ns ns
Experience. High ns ns ns ns ns ns ns ns ns ns
Contract. Permanent ns ns ns ns ns ns ns ns ns ns
Contract. Temporary ns ns ns ns ns ns ns ns ns ns
Nation. Spain ns ns ns ns ns ns ns ns ns ns
Nation. Foreign ns ns ns ns ns ns ns ns ns 0.09∗
Day. Monday ns 0.17∗∗ ns ns ns ns ns ns 0.11∗∗ ns
Day. Other ns ns ns ns ns ns ns ns ns ns
Day. Weekend ns ns ns ns ns ns ns ns ns ns
Time. Morning ns 0.23∗∗ ns ns ns ns ns ns 0.08∗ ns
Time. Afternoon ns ns ns ns ns ns ns ns ns ns
Time. Night ns ns ns ns ns ns 0.08∗ ns ns ns
Shift. First part ns 0.09∗ ns 0.10∗ ns ns ns 0.11∗ ns ns
Shift. Rest ns ns ns ns ns ns ns ns ns ns
Shift. Second part ns ns ns ns ns ns ns ns ns ns
Shift. Extra time ns ns ns 0.01∗ 0.14∗∗ ns ns ns 0.09∗ ns
No. cases 280 55 90 76 22 115 244 197 36 104

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.
a
61. Work method; 62. Task performance; 63. Task training and information; 64. Tools and equipment selection; 69. Other
organizational factors; 71. Safety management system; 72. Safety activities; 81. Behavioral factors; 82. Personal factors;
89. Other personal factors.
∗
p < 0.05; ∗∗ p < 0.01; ns = not significant.

are related to a lack of experience and training, which
is a serious concern for young workers.
Of all the accidents with causes related to personal
factors, 50% had a low-experience worker involved.
These facts indicate that the process of safety training
is in need of improvement. Regarding this issue, the as-
sociation between safety management failures and low-
experience workers can be explained with the results of
the First Andalusian Working Conditions Survey (In-
stituto Andaluz de Prevención de Riesgos Laborales,
2009). In that survey, 20% of the low-experience work-
ers who participated answered that they were badly in-
formed in safety methods, whereas the proportion was
9% for more experienced workers. At the same time,
more than 22% of young workers answered that they
were badly informed about work methods and safety
procedures compared with only 10% of other workers.
In relation to the time of accidents, previous stud-
ies conducted in Spain have found evidence of the
higher prevalence of accidents on Monday mornings
(Carrillo et al., 2012). This lack of safety awareness
should be addressed with specific actions at the begin-
ning of the working week.
Considering unusual schedules such as working at
night or working overtime, the associations identified
suggest that specific actions are needed to provide the
same safety level for all workers in all circumstances
and at all times of day. Appropriate measures should
be planned when workers extend their working time
or need to work at night.
4.3. Association between Specific
Causes and the Characteristics of the
Injured Worker
The association of the characteristics of the injured
worker with specific causes provides another useful
piece of information. The associations found for young
workers with a lack of proper training can be ex-
plained by the results of the First Andalusian Working

Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm 79
Carrillo-Castrillo, Rubio-Romero, Onieva, et al. Role of Human Factors in Official Accident Investigations

TABLE 8. Associations between Groups of Workers and Types of Causes Marked as Main Cause

Category vs. Type of Causea 61 62 63 64 71 72 81 82

Sex. Male ns ns ns ns ns ns ns ns
Sex. Female ns ns ns ns ns ns ns 0.16∗∗
Age. Young ns ns ns ns ns ns ns ns
Age. Normal ns ns ns ns ns ns ns ns
Age. Older ns ns ns ns ns ns ns ns
Experience. Low ns ns ns ns 0.14∗∗ ns ns 0.12∗∗
Experience. Medium ns ns ns ns ns 0.08∗ 0.11∗∗ ns
Experience. High ns ns ns ns ns ns ns ns
Contract. Permanent ns ns ns ns ns ns ns ns
Contract. Temporary ns 0.09∗ ns ns ns ns ns ns
Nation. Spain ns ns ns ns ns ns ns ns
Nation. Foreign ns ns ns ns ns ns ns ns
Day. Monday ns ns ns ns ns ns ns ns
Day. Other ns ns ns ns ns ns ns ns
Day. Weekend ns ns ns ns ns ns ns ns
Time. Morning ns ns ns ns ns ns ns ns
Time. Afternoon ns ns ns ns ns ns ns ns
Time. Night ns ns ns ns ns 0.09∗ ns ns
Shift. First part ns ns ns ns ns ns 0.09∗ ns
Shift. Rest ns ns ns ns ns ns ns ns
Shift. Second part ns ns ns ns ns ns ns ns
Shift. Extra time ns ns ns ns ns 0.12∗∗ ns ns
No cases 114 16 10 23 13 36 98 8

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.
a
61. Work method; 62. Task performance; 63. Task training and information; 64. Tools and equipment selection; 71. Safety
management system; 72. Safety activities; 81. Behavioral factors; 82. Personal factors.
∗
p < 0.05; ∗∗ p < 0.01; ns = not significant.

Condition Survey (Instituto Andaluz de Prevención de
Riesgos Laborales, 2009) that identified young workers
as the worst informed and least trained. In this survey,
more than 70% of respondents indicated that they had
received no safety training in the past 2 years compared
with only 50% for other workers. Similar findings are
available for other sectors and countries throughout
Europe (Verjans, de Broeck, & Eeckelaert, 2007). It is
remarkable that most studies have identified only the
risk factors of young workers but not the underlying
mechanisms (Laberge & Ledeux, 2011), although a few
of them have already proposed targeting the most fre-
quent causes of accidents in training programs. Such
training inadequacy has previously been identified as
an indicator of a deficient work design (Katsakiori et al.,
2010).
For low-experience workers, the most likely cause of
accidents was a lack of experience. This is related, of
course, to the short period of time they had been on
the job but can also be caused by deficient training. It
seems that an initial training period of labor contracts
is not used properly to ensure that a worker is properly
trained before the real assignment. Moreover, some ac-
cident reports remarked that the accident happened the
first time the task was carried out. It is thus necessary
to plan supervision until new workers are prepared to
perform new tasks alone.
A greater severity of accidents has been found in the
manufacturing sector of Andalusia for high-qualified
workers (Carrillo & Onieva, 2012). One of the specific
associations found offers a plausible explanation, as
qualified workers are more likely to be involved in ac-
cidents when they perform tasks without proper train-
ing and protection. This issue could be related to an
excess of confidence after years without experiencing a
severe accident. The association of qualified and expe-
rienced workers with the nonuse of personal protective
equipment has already been identified by Gardner et al.
(1999).
In addition, for workers involved in overtime tasks,
the associations found in this study suggest that specific
attention is needed to ensure that safety conditions are

80 Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm
Role of Human Factors in Official Accident Investigations Carrillo-Castrillo, Rubio-Romero, Onieva, et al.

TABLE 9. Associations between Groups of Workers and Specific Causes with at Least 10 Cases

Category vs. Causesa 8203 8999 7208 7212 6102 6201 6301 6406 6999

Age. Young ns ns ns 0.06∗∗ 0.08∗∗ ns 0.09∗∗ ns ns

Experience. Low 0.10∗∗ ns ns ns ns ns ns ns ns
Nationality. Foreign ns 0.08∗∗ ns ns ns ns ns ns ns
Job. Qualified non-manual 0.11∗∗ ns 0.10∗∗ ns ns 0.08∗∗ ns ns ns
Day. Weekend ns ns ns ns ns ns ns 0.08∗∗ ns
Hour. Afternoon ns ns ns ns 0.06∗∗ ns ns ns ns
Shift. Extra ns ns ns 0.07∗∗ ns ns ns 0.08∗∗ 0.06∗∗
Number of cases 36 112 40 16 231 31 10 14 23

Note: Severe accidents investigated from 2004 to 2011 in the Andalusian manufacturing sector.
a
8203. Lack of experience; 8999. Other personal causes; 7208. Non-provision of personal protection equipment; 7212.
Task assigned to worker with lack of qualification or experience; 6102. Inappropriate work method; 6201. Task non habitual
for the worker; 6301. Misunderstanding of instructions; 6406. Use of tools or equipment not advised by the manufacturer;
6999. Other organizational causes.
∗
p < 0.05; ∗∗ p <0 .01; ns = not significant.

maintained with appropriate planning for those extra
time assignments. These results may also provide a
useful tool for managers’ motivation in a macro-level
learning environment (Swuste, 2008).
5. CONCLUSIONS
Although the analysis of accident causes is a useful
tool in occupational safety, it is important to keep
in mind that it focuses on the circumstances and causes
of accidents and not on the general situation in the
industry as a whole. In spite of this limitation, the con-
clusions can be used to design preventive actions for
combating the most prevalent causes of accidents or
those most strongly associated with certain groups of
workers in Andalusia.
The analysis of differential causation offers an insight
into the risk factors and potential preventive measures
for reducing them. Labor authorities should thus de-
velop programs to obtain useful information from of-
ficial accident investigations. For that purpose, just as
there is a common coding system for the circumstances
of accidents, it would be desirable to have a common
taxonomy and coding system for accident causes within
the European Union. That future common coding sys-
tem would enable comparison between accident causes
in different territories.
One of the main findings of this research was the
high proportion of latent causes, even among those
causes marked as the main cause, which poses a seri-
ous concern for safety practitioners. According to the
accidents investigated, the real challenge for safety in
manufacturing is to fight organizational and personal
risk factors. Although safety improvements made to
equipment are still needed, the most crucial areas to
target are work organization, safety management, and
personal factors.
The results of our causation tests indicate that pre-
ventive actions should be oriented to the most likely
causes of severe and fatal accidents, depending on the
characteristics of the worker. These data suggest the
following areas are in need of improvement: training
for young workers, enforcement in the use of personal
protection equipment, and programs to increase at-
tention and motivation during the part of the working
shift that is most likely to be dangerous. Moreover,
workers ought to be examined before being exposed to
risky tasks and not assigned to them without having
appropriate skills demonstrated first.
Another conclusion is that preventive activities are
poorly performed for overtime tasks. As certain pre-
ventive activities are not usually carried out after
the end of normal shifts, specific preventive activities
should also be planned for those working overtime, and
adequate resources need to be assigned so that levels of
safety are guaranteed on every type of shift.
For the associations that involve organizational fail-
ures, one possible explanation is that exposure to cer-
tain organizational risks and latent causes could not be
equally distributed among different groups of workers.
Differences in the employment terms and individual
characteristics of workers as well as unequal training
and differences in task assignment are possible expla-
nations. Nevertheless, the important conclusion is that

Human Factors and Ergonomics in Manufacturing & Service Industries DOI: 10.1002/hfm 81
Carrillo-Castrillo, Rubio-Romero, Onieva, et al.
the preventive actions would be more effective if their
design considered the causes expected for each worker,
depending on his or her characteristics.
These results were obtained from Andalusian manu-
facturing sector data. The conclusions cannot therefore
be extended to other territories or industries directly.
Future research should focus on studying workers ex-
posed to the same risks and circumstances but not
injured. This approach would provide a broader per-
spective, enabling an understanding of the safety mech-
anisms instead of concentrating only on the cases where
safety fails. For that purpose, additional information
about workers such as level of training, previous acci-
dent experience, or physical and psychological aptitude
would offer additional insight into the role of individ-
ual worker characteristics in accident causation, given
the same environment and risk exposure. It would
be necessary, therefore, to include those additional
pieces of information in accident investigations pro-
moted by future programs. Another important need
is to incorporate random selection in official accident
investigation in order to avoid possible bias.
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