Consider 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 www.osha.gov)

Write a word paper in which you compare the Normal Accident Theory to the Culture of Safety model. Include
the following in your paper:
Explain what factors can play a role in organizational accidents similar to the one highlighted in the scenario.
1.-How do organizational processes give rise to potential failures?
2.-How can certain conditions influence errors and violations within the workplace (e.g., operating room,
pharmacy, intensive care unit)?
3.-What are the errors and violations committed by “sharp end” individuals?
4.-How does the breaching of defenses or safeguards affect these accidents?