As a team, the following scenario: On Dec. 7, 2000, the Cincinnati Occupational Safety and Health Administration (OSHA) office heard through media and police reports that there were two deaths at a nursing home in Ohio. OSHA determined that the Food and Drug Administration (FDA) should take a lead role in performing an investigation. Because the nursing home had many residents who had unhealthy respiratory systems, the nursing home routinely ordered and received tanks that contained pure oxygen. During one delivery, the supplier mistakenly delivered one tank of pure nitrogen in addition to the three tanks of pure oxygen that had been ordered. The nitrogen tank had both an oxygen and nitrogen label. An employee at the nursing home connected the nitrogen tank to the nursing home’s oxygen delivery system. This event caused two nursing home residents to die, and three additional nursing home residents were admitted to hospitals in critical condition. Within the following month, two of these three additional residents also died, bringing the total death toll to four. (Based on accident #837914 ) a 1,050- to 1,400-word paper in which your team compares the Normal Accident Theory to the Culture of Safety model. Include the following in your paper: at least 3 peer-reviewed, scholarly, or similar references, and your textbook to support your assignment.

Title: Comparing the Normal Accident Theory to the Culture of Safety Model: A Case Study Analysis


In the field of safety management, understanding and preventing accidents is of paramount importance in ensuring the well-being of workers and the general public. Two theoretical frameworks that contribute to this understanding are the Normal Accident Theory (NAT) and the Culture of Safety model. This paper aims to compare and evaluate these frameworks in light of a tragic incident that occurred at a nursing home in Ohio, resulting in the death of four residents. The incident involved the inadvertent connection of a nitrogen tank to the nursing home’s oxygen delivery system, leading to fatal consequences.

Normal Accident Theory (NAT)

The Normal Accident Theory, proposed by Charles Perrow in 1984, posits that certain complex systems are inherently vulnerable to accidents due to interconnectedness and the potential for unexpected interactions or failures (Perrow, 1984). According to NAT, accidents are not mere aberrations but rather the result of inherent system complexities. Such accidents are termed “normal” rather than exceptional, as they are an inevitable outcome within complex systems.

Applying NAT to the nursing home incident, it becomes apparent that the accident occurred due to a series of interconnected failures and latent conditions. The first failure was the supplier’s mistake in delivering a nitrogen tank instead of the ordered oxygen tanks. This error demonstrates the inherent vulnerability of the supply chain process, where the wrong item was mistakenly labeled and delivered.

The second failure occurred when an employee at the nursing home connected the nitrogen tank to the oxygen delivery system. This highlights the reliance on human operators and the potential for human error within the complex system. Moreover, the confusion arising from the mislabeling of the tank further contributed to this error.

The interconnectedness of the various components involved, including the suppliers, delivery process, and employees, emphasizes the complexity of the overall system. The accident, in this case, can be considered a product of multiple failures that are difficult to predict or mitigate entirely.

Culture of Safety Model

Contrary to NAT, which focuses primarily on system complexity, the Culture of Safety model centers on the role of organizational culture in accident prevention. This model emphasizes promoting a culture where safety is a shared value and individuals and organizations prioritize proactive risk reduction strategies (Guldenmund, 2000). By fostering a culture that prioritizes safety, organizations can effectively prevent accidents and mitigate their potential consequences.

Applying the Culture of Safety model to the nursing home incident, it becomes evident that there were shortcomings in the organization’s safety culture. Firstly, the mislabeling of the nitrogen tank indicates a lack of robust processes to ensure accurate and safe delivery of supplies. Additionally, the absence of a clear protocol for handling and verifying delivered items reflects a lack of safety culture within the nursing home.

Furthermore, the employee’s error in connecting the nitrogen tank can be seen as a result of inadequate training and awareness regarding the proper handling of oxygen tanks. A safety-conscious culture would have fostered an environment where employees are adequately trained and vigilant in ensuring the correct connection of tanks.

The incident highlights the importance of organizational culture in promoting effective safety practices. Had the nursing home implemented a culture of safety, with clear protocols, training programs, and accountability measures, the accident could have potentially been prevented.

Comparison of NAT and Culture of Safety Model

While both the NAT and the Culture of Safety model contribute valuable insights to understanding accidents, they offer distinct perspectives on accident causation and prevention. NAT focuses on the inherent complexities of systems, emphasizing the normal and expected nature of accidents within these systems. On the other hand, the Culture of Safety model emphasizes the organizational culture and proactive measures required to mitigate accidents.

In the case of the nursing home incident, NAT provides a framework for understanding the interconnected failures and latent conditions that led to the accident. The mislabeling of the tank and the subsequent error in connecting it to the delivery system can be attributed to the complexity of the organizational and supply chain processes.

The Culture of Safety model highlights the importance of organizational culture in preventing accidents. The lack of robust processes, protocols, training, and accountability mechanisms within the nursing home reflects a deficient safety culture. By implementing a culture of safety, the nursing home could have fostered an environment where safety practices are prioritized, reducing the likelihood of such accidents.


In conclusion, the Normal Accident Theory and the Culture of Safety model offer different yet complementary frameworks for understanding accidents and promoting safety in complex systems. The nursing home incident demonstrates the limitations and vulnerabilities of complex systems, as described by NAT. Simultaneously, it underscores the importance of fostering a culture of safety to prevent accidents, as emphasized by the Culture of Safety model. By implementing both systemic improvements and a safety-conscious culture, organizations can work towards reducing the occurrence and severity of accidents.