Mental causes of accidents

Front matter

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Are we to blame for our minds ?

By Boyd Fisher

Preface

Waritinc a book is, of course, an educational experience. The author always comes out of it knowing much more than when he went in. It is a poor subject, indeed, that does n’t broaden and deepen before the delighted eyes of the writer as he gives months to a close examination of its meanings and relations.

The pleasure which I found in the development of this theme grew out of the fact that a topic, which began as a limited study of the mental causes of accidents for the instruction of safety men, quickly unfolded itself as a pecullarly direct and revealing approach to the whole problem of psychology in industry. The minds of men disclose themselves only in action. A text on psychology may be formulated in terms of general principles and theories without reference to the particular actions which gave rise to these generalizations. But actions, often dramatic actions — the amusing, pathetic, or tragic struggles of real human beings to find

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PREFACE comfort and happiness — were the only source of information for these dry-as-dust formule. Just as the drama is a highly useful device for teaching and for public discussion, so the dramatic incident is the best material for the study of mental laws. To give the reader a reconstructed action as the basis for a theory is not alone to render the subject easy and interesting for him, but also to permit him to form his own theories in codperation with or opposition to the author.

An accident is the most dramatic and informing occurrence of factory life. It happens only as the result of some interruption of routine — human nature breaks through, so to speak, and shows itself in some fashion that all may comprehend. And in the unprompted reactions of the victim after he has been hurt, the doings of fellow workers, of bosses, and of the sufferer’s family, there are often further interesting disclosures of minds off guard.

It is apparent, therefore, that any adequate inquiry into the mental side of industrial accidents will come close to being a wellrounded study of psychology in industry. If it

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PREFACE lose anything by being restricted to the discussion of accidents, it is likely to compensate by the vividness of its material.

If regarded only as a phase of the subject, accident prevention is certainly the most practical approach to psychology in industry. Production men have, perhaps with good reason, been rather skeptical about the theories of the mental testers, social welfare experts, and psychiatrists, and have hesitated not only to buy, but even to use their services. But, by State law, industry is taxed for accidents and rewarded for reducing them. So much of psychology as is useful in securing lower insurance rates has a definite money value, and no practical man will exclude it from his favor.

If industry will go only so far, the psychologist will be content. The scientist asks only a chance to demonstrate. He knows how economical, after all, is truth — with how little change or adaptation he can transfer his efforts from one object to another. Little is required for mental testing and for mental hygiene that will not have been rendered familiar for accident prevention. Indeed, Dr. George K. Pratt,

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PREFACE of the Massachusetts Society for Mental Hygiene, who has read and helpfully criticized this essay, has stated his conviction that accident prevention, from the psychological side is the best entering wedge for mental hygiene in industry.

It is the writer’s hope that, being himself an industrial man, he has been able to make this book interesting and familiar for safety men, foremen, and members of safety committees. It is his expectation, furthermore, for the reasons already given, that it will be useful as text material for classes in applied psychology and in industrial relations. In the belief that some practical men will find in this discussion a stimulus to further study in psychology, I have added a supplementary chapter on what to read in psychology.

The thanks of the author are due to Mr. W. H. Cameron and to Mr. Sidney J. Williams, of the National Safety Council, to Mr. E. M. Very, editor of Builders, for literary criticism; to Dr. A. B. Emmons, 3d, of the Harvard Medical School, to Mr. Hilton Howell Railey, and to Miss Marion Myers, for statistical help.

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Foreword

Many of the sponsors for the Safety Movement in America — the men supervising the safety problems in the workshops and in public places — have lamented the absence of a psychological study of the fundamental problem of safety education. The safety man in the plant has felt the need for an interpretation of the mental attitudes of his associates and workers — to understand the root causes of seemingly inexplicable mind actions and reactions to working conditions that cannot be solved by mechanical formulas. Many of these safety leaders have been puzzled in understanding the mental attitude of these men who get hurt or killed, and they have had difficulties in planning their educational programmes to encourage the individual to react fearlessly and automatically toward safe practices.

Mr. Boyd Fisher’s book is a distinctly new contribution toward the study of accident causes and will be an invaluable aid to students

FOREWORD and to safety men on the jobs. Every one interested in understanding the mental problem of the individual, who should be interested in his own safety, should own and read a copy of this book.

W. H. Cameron Managing Director National Safety Council

Contents

I. Toe Uncuarpep Minp I

Ignorance, predisposition, inattention, depression, and preoccupation as the main mental causes of accidents. The way accidents happen. The man who gets hurt.

II. Tue Puzzuep Minp 28

Chapter I The Unguarded Mind

Are we to blame for our minds? Even girls with high-heeled shoes should not have fallen down that stairway. It was a straight flight, placed where you would expect it to be; it was well lighted and guided by a hand rail. The steps were wide enough and covered with safety treads. Surely, it had no hazard in itself; and yet clerks, perfectly familiar with the fact that others had been injured there, and accustomed to using the stairs every day, on several occasions plunged headlong the whole length of the flight. We held many indecisive conferences at the Aluminum Castings Company about these stairs, which seemed to have the very devil in them. One day we happened to measure the width of the steps to compare with another I flight. We were surprised to learn that the first step below the landing was two inches wider than all the rest below it. The secret was then out. A girl would take her first step down, looking where she put her foot, and adjusting it to the usual position on the edge of the step. Subconsciously she noted the width, and assumed that all of the other steps were exactly as wide. Then she placed her foot on the next lower step two inches too far forward, lost her balance, and came tumbling down to the bottom.

The remedy, of course, was to extend the landing out two inches so that the steps were, then, all of the same width. But, granting the necessity of doing that, one could not properly say that the steps were wrong. Taken singly, they were all right. ‘The cause of the accident really lay in the subconscious mental operation of the person using these stairs. And this case is suggestive of many situations in which accidents occur because a perfectly normal automatic assumption by the mind does not accord with the realities.

C. R. Lobs, the safety man of the Midvale Steel Company, has said, “The big percentage of accidents falls in that class where the difficulty, and the manner of correcting it, lie in the man’s mind.” Mr. Lobs has substantiated in his own experience the oft-stated fact that 70 per cent of the accidents are traceable directly to the worker’s fault. As he divides them up further, he finds that 60 per cent are directly the blame of the man hurt; ro per cent, a fellow workman’s fault; 2914 per cent, “nobody’s fault,” and only one-half per cent the company’s fault. He goes on to classify the types of faults of workmen, as —

Failed to use provided safety device.

Failed to use proper tool or appliance.

Improper method of doing work.

Violation of rules, such as, operating the wrong machine.

An improper act.

If we consider those cases where “the cause of the accident and the manner of correcting it lie in the man’s mind,” as being faults of the worker, and subject to blame or discipline, then perhaps we can rightly say that the company is responsible only for one-half per cent of the accidents.

But are mental errors culpable? Are we to blame for our minds? The laws of most States not only hold manufacturing companies liable for accidents occurring on unguarded machines, but also require them to provide safeguards. Is n’t it possible to consider poorly equipped minds as unguarded machines?

In the matter of industrial accidents, we seem to take for granted that the 70 per cent of men who get hurt of “their own fault” do so willfully. We set the cause down always as “carelessness”? — which means that we assume that they knew better, but deliberately went wrong. It would be reasonable, if this were so, to punish them, or, at least, to deny them compensation. Indeed, until recently they were denied compensation. Under the common law, workmen could always get restitution for injury which was clearly established as the fault of the employer. They were denied redress, however, when there was “contributory negligence,” or fault of a “‘fellow servant,” or, sometimes, “assumption of risk’? by the employee. These defenses, allowed the employer, were based upon the conception of a workman’s presumed knowledge of the sources of danger and his duty to avoid them. If it were reasonable to hold the worker responsible in such cases, the Workmen’s Compensation Acts, which require employers to pay for a// injuries, are unjust. Perhaps, in some cases, theoretically, they are — it is idle to debate that question; but the point to note here is that the law seems to assume that men are not always responsible for their own acts.

Of late years this assumption has been making headway in dealing with delinquents in general. Not only has the insanity plea in murder cases been allowed in an ever-widening range of circumstances, but the degree of moral responsibility for crime has been weighted in many other respects. We see it in the classification of prisons — one for first offenders, another for feeble-minded criminals, another — called a reform school — for youthful offenders, another for wayward girls, and so on. We see it in the amelioration of the sentence for crime, through the juvenile court system, through the parole system (which deals with an unbelievable proportion of offenders), and through the indeterminate sentence system.

The reason and justification for such leniency are found in the accumulating statistics on the relation between crime and feeble-mindedness, insanity, and other causes beyond the immediate control of the wrong-doer.

Dr. Walter S. Fernald, of the Massachusetts School for Feeble-Minded, estimates that “at least 25 per cent of the inmates of our penal institutions are feeble-minded.”! Various surveys of the white-slave traffic estimate that from 40 to 60 per cent of this class of women are defectives.

Dr. William Healy, in an analysis of the cases of 668 juvenile offenders, who came before him in the Chicago juvenile court, found that mental defects or mild forms of insanity were responsible for 35 per cent of the cases, and contributory in 9 per cent more. “Faulty environment ’”’ made up most of the other causes, and, since a child, at least, is not responsible for his environment, nearly all of Dr. Healy’s cases warranted another type of treatment than mere punishment.’

1 Michael F. Guyer, Being Well Born (Ind. 1920), p. 266. ? William Healy, The Juvenile Delinquent (Boston, 1920),

When mental unsoundness is recognized as just ground for discriminating between offenders against the law, have we not good reason, also, to recognize the existence of such grounds in the matter of accidents? Perhaps we have been taking too much for granted about the capacity of workers to take care of themselves. Our safety methods have all been based upon the presumed need of bringing home to workers a sense of responsibility — or of scaring them into looking out for themselves.

It is time that we took a hint from the prog- ~ ress which has been made in dealing with other forms of social difficulty, and treated accidents, not as delinquencies, but as forms of mental error. The mental factors in accidents may be made known, and, where they can be corrected and are not counteracted by mental safeguards, at least part of the blame for accidents which they cause should be assumed by the employer. Merely to say that a workman “failed to use the proper safety device” does not sufficiently analyze the situation. If possible, we must get at and correct the state of mind which produced this error.

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The man who gets hurt. If ten men are vaccinated at one time, there will be perhaps three with whom the operation will not “take.” Of any number of people exposed to a contagious disease, a portion will succumb to it, and others will remain immune. So, too, with mental influences. Not all men can be moved by the same causes. In the matter of accidents, there are men who appear to be born unlucky, because, without especial demerit, they are always getting hurt. We ought not to proceed to the analysis of the reasons why men fall into error without pointing out that there are certain types of men who are especially susceptible of error.

Oftentimes they are extremely able, responsive, and conscientious men, not the sort whom we should be likely, in advance, to brand as accident risks. But it is nevertheless true that there are particular temperaments which are not safe, or which require special treatment to be kept safe.

There have been attempts to discover whether particular race inheritances produce any noticeable effects on the accident rate, but to date no tables have proved that one race has any advantage over another in this regard. It has been shown that Jewish people suffer from two to three times as much from diabetes as any other race, because of their nervous temperaments and their openness to worry. This might be thought symptomatic of a tendency to get hurt, as the result of acting excitably. And yet, there appear to be offsets which equalize any such tendency, if it exists.

There does exist an age tendency to accident. Very young or very old workers are injured more frequently than middle-aged ones. Men from 20 to 29 years old get hurt more frequently than men from 30 to 39 years old. In a period of five years in a large steel plant Chaney and Hanna reported! that men in the younger group sustained, yearly, 177 accidents per 1000 300-day workers, as against 162 per 1000 among the older group, and that in another plant the accident frequency among the younger men was 234.2 per 1000 against 178.7 per 1000 of the older group. Other tables point

1 The Safety Movement in the Iron and Steel Industry, U.S. Bureau of Labor Statistics, Bul. 234.

to the same conclusion — that immaturity is a direct contribution to accident.

The special accident liability of old men is indicated in all tables of accidents by length of service groups. Note the tables given in Chapter II, which seem to indicate a rising accident rate after 30 or more years of service.

And so it is not strange that the men of any age who are most likely to get hurt are those whose temperaments are most like either the qualities of youth— responsiveness, excitability, and hastiness — or most like old age — sluggishness, indifference, and laggard reactions. “The best safety device is a safe man,” it has been said, and the safe man appears to be one who is neither so quick on the trigger that he reacts to the slightest stimulus, nor so dull as to fail to respond promptly.

There is a very wide temperamental variation in excitability due to the physiological differences between individuals. Dr. Walter B. Cannon, in his epochal book, “ Bodily Changes

, in Pain, Hunger, Fear and Rage,” has demonstrated that these emotions stimulate the discharge into the blood of an internal gland

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secretion, a chemical substance called “‘adrenin.” He has proved that this chemical stimulates increased circulation, causes the liver to throw into the tissues an excess of sugar — the most energizing food — and excites all of the nerves which control voluntary activity. At the same time, it hinders digestion, and inhibits all of the other involuntary activities in order that the entire energy of the body can be utilized, under central direction, to meet the situation of danger or need which has given rise to these emotions. Adrenin seems to have a specific effect, too, in overcoming fatigue during the period of excitement.

Some individuals have an excess of function in the adrenal glands, and if they permit emotions to rouse them, or often find themselves in situations where emotions are kindled, they are in a constant state of excitement, of highly mobilized energy, ignoring fatigue, moving spasmodically, and, most likely, with undue haste and precipitation.

Excitement may be only temporary; excitability is temperamental. It is not always linked up with emotionality, for we often see

II persons of excellent emotional control and calmness who respond with great and instant bodily energy to such stimulations as they do permit to affect them. It is apparently always linked up, however, with quick and sensitive nervous responses. So, where the emotions are well controlled, and the aroused energies are guided by high intelligence and caution, there is no temperament which can be more safely trusted in dangerous places than the man of quick reactions. But where the intelligence is muddy and confused, and the emotions are permitted to exhaust the energies, as is usually the case with the highly responsive temperament, we get a condition of dangerous excitability. There will be, also, superseding periods of depression, due to the overstrain and the necessary relaxation for repair of forces. Such a person is always on the threshold of agitation or despair, using up instantly and in futile efforts his bodily energy as soon as it is generated. He becomes nervous, irritable, and weary. He seems always to be behind time, and always under pressure. Always late, he is always hurried, so that by habit he becomes precipi- 12 tate and thoughtless. He first acts and then reflects. Deliberate forethought becomes impossible. It irks him to contemplate it. With him, to imagine is to desire, and to desire is to act. Fears are translated into impulses and impulses into performances— often into accidents.

Such persons are, of course, especially sensitive to reproof, and, because of their hasty dispositions, more often merit it, so that they are constantly harried by their unfortunate blunders. Their usual recourse is to drift into occupations of a clerical, routine nature, or work that permits them a certain amount of isolation. By such defensive withdrawals from conflict they avoid excitement and find peace. But where they have to remain on jobs that keep them stirred up, they are a decided accident risk.

Corresponding to the over-active temperament we have the stupid or phlegmatic one. This type is nearly as dangerous as the other, because it is so slow to respond that it cannot “step lively” in dangerous situations. Temperamental sluggishness to the degree which is dangerous, however, is very seldom seen in persons of normal intelligence. Abnormal slowness to react is usually a part of the deterioration of old age, or else a phase of depression from disease, fatigue, or insanity. It will, therefore, be considered under those heads.

And there is, of course, a third type of man whose tendency to accident is general and inborn — the deficient of intellect. He is an unsafe man because he cannot easily learn or be taught how to take care of himself, and in critical situations he is wholly lacking in judgment. We shall speak further of him, later on. Now it is sufficient to point out that the low-grade mentality, along with the very immature, the very old, and the temperamentally excitable or phlegmatic, forms a class of people who get hurt because they are not safe men. If they are not entirely eliminated by initial selection, they must be carefully assigned to suitable tasks and especially protected against their own tendencies.

In most other cases, the mental errors which result in accident grow out of particular situations which may be altered, occasional events that may be avoided, individual traits or attitudes that may be corrected, or peculiarities in the employee that may be compensated for. In other words, the man whose whole bent is unsafe must be considered separately and treated differently from the man whose errors may be related to special and removable causes.

Real and apparent mental causes of accidents. ‘The great majority of injuries result from falls, stumbling, mishaps with hand tools, and failure to get out of the way of moving trucks, cranes, and other vehicles. Unguarded machines, falling objects, insecure staging or scaffolds, and other faulty working conditions do create sufficient havoc, but care in respect to mechanical safeguards is not sufficient to protect workmen. In an investigation of 100,708 accidents, the United States Steel Corporation found that 44.93 per cent occurred in hand labor, where no safety device could be furnished.

Most accidents, of course, are of a minor nature, such as those due to splinters, pinpricks, nail wounds, scratches from loose wires, or from tools, contusions, as from hammer blows, tripping on loose boards, slipping on wet floors. In almost every case, no mechanical safeguard could have been provided. Another important group of accidents occurs on machines where guards have been provided, or where safe rules of operating have been formulated, but where the men injured have removed the safeguards or disregarded the operating rules. An oiler, for instance, was lubricating a shaft five feet above the floor. He had rolled up his sleeve, but it had unrolled, and hung loose. He attempted to give the shaft a bit of attention while it was in motion. His sleeve caught and he was hurled around the shaft three times. His injuries caused fourteen months’ lost time and permanent disability. Another employee deliberately removed the protection from an emery wheel and failed to wear his goggles while grinding a small tool. The wheel was cracked, and at the moment happened to fly into pieces, with the result that the man lost an eye.

Clearly, such accidents are due to the “‘human element.” Just as clearly, they involve a mental cause which it will repay us to study, if we can only discover it. It is possible that the list of mental causes of accidents which I propose to analyze is a complete and accurate appraisal, and yet there might be, at the same time, great difficulty in connecting up any given accident with the right mental cause. What the safety man has a right to ask is not only a set of pigeon-holes into which to classify accidents by mental causes, but also some kind of system for sorting out his accident cases to get them into the right pigeon-holes.

A man stumbles and falls. Perhaps it was due to some basic mental factor. But how are you going to discover which one? Does the man himself know? Isn’t every accident unique; is n’t it due to a peculiar set of circumstances, a temporary mental condition that just happened, and which, if it had come at any other time or place than when and where the accident occurred, would have caused no trouble?

The answer to such queries is not to be found in any set of fundamental accident causes alone, because we have to deal also with a set of apparent or proximate causes.

If we should take for analysis any given set of one hundred accidents, of which we knew all of the attendant circumstances, and set down in writing the immediate situation of the man hurt, we should get statements something like the following:

“He was running to shut off the power on a picker which had caught fire inside, and slipped on the floor and cut his forehead on the end of a lap-rod.”’

“Jones was cleaning a mule spinning frame which was inadvertently started up by another hand. The frame had been stopped on the way in instead of on the way out, and he was caught before he could get out.”

“The oiler was in a hurry to get home for the day, and failed to secure the ladder properly.”

And so on. In most cases no strictly mental feature would show up on first examination. Haste might be cited as a cause in two of the above cases, and, assuredly, hurry is a mental state. But is not the cause of hurry usually something external and cannot an infinite number of things cause a man to hurry?

Or, in the case of the man caught in the mule spinning frame, we might say that another man could have got out in time, and that this one is mentally slow. But isn’t there something back of his being caught in the frame at all, which is more truly the cause of the accident?

And so, if we went on and analyzed the entire one hundred accidents, we should be likely to feel considerable doubt of our preliminary mental diagnosis. It would be possible, however, to simplify the confusion somewhat by sorting them roughly into these various classes:

1. Cases where the victim was hurried; where he wasn’t given or didn’t take time to think, or where, in his haste, he was led to omit some necessary step, or slight some safeguard.

2. Cases where the victim was too slow; where he did n’t react quickly enough to get out of the way of danger when warned.

3. Cases where the victim showed lack of judgment — through confusion, ignorance, or neglect.

While these are, all three, mental classifications, we cannot rest content with these diagnoses, because they are not diseases, but symptoms; they present us with nothing we can cure. Hurry may be only spasmodic; the steadiest man loses his head sometimes. Slowness is only relative. Merely failing to “beat the machine _to it,” so to speak, counts for little as a mental ‘trouble, because on a slower machine the accident might not have happened. And it is idle to stigmatize bad judgment, because judgment cannot be cultivated as a mental faculty. It is always appraised in relation to a given situation, and consistently good judgment is a by-product of experience. Indeed, it includes so many mental elements that it is almost a synonym for successful adjustment to the environment. We cannot always be sure, in any given case, what is good or bad judgment, save by the evidence of success or failure.

The value of making, nevertheless, such a provisional classification lies in the fact that, roughly speaking, it does make the first main subdivision. Generally, being too slow or too fast does not involve judgment, but situation. In such cases, not so much a wrong decision as lack of any decision brings on the trouble. And a too rapid action usually points to a very different set of possible mental causes from those indicated by a laggard motion.

Viewing the causation of accidents rhe other way round, we shall see that none of the fundamental mental causes operates, in itself, to cause an accident. Excitement, for instance, growing out of mental disease, cannot hurt a man, but a hurried movement growing out of excitement can cause an accident. Fatigue, or disease, or depression from worry, cannot in themselves cause accidents, save as they cause aman to move too slowly to get out of the way of trouble, or cause his judgment to be poor.

It would be tedious here to trace back all of the precedent causes of hurry, lag, or poor judgment, which show up as apparent causes of almost’ any avoidable accident. We shall rather go directly on to the more fundamental causes, and, as we deal with them, indicate how they affect the immediate behavior of the victim of accident. But at no time ought we to forget that there are both immediate or proximate causes of accidents — such as hurry, lag, and poor judgment — which can only be dealt with by tracing back to more fundamental errors; and that basic mental troubles are likely to obscure themselves behind these immediate causes.

The main outlines of this analysis. The distinctions between various mental causes of accidents made in this book are perhaps faulty in some respects — very likely arbitrary. As this essay appears to be the first attempt to embrace in a single classification all the mental factors which may affect the man who gets hurt, it is necessarily provisional and limited by the personal capacity of a single investigator. Yet there appears to be some logical consistency and a certain appearance of completeness in the arrangement.

Fifteen major causes of accident are dealt with, and these are susceptible of grouping under five heads: ignorance, predispositions, inattention, preoccupation, and depression. These words do not immediately tell the story, but they are useful words to sum up what I shall say more fully. They are, furthermore, classifications which may stretch over the whole field of mental error.