This is one of the books in the bibliography of Heinrich’s 1931 version of Industrial Accident Prevention. My main focus in this discussion/summary is an attempt to distil the main threads from this book and to identify links to Heinrich’s book, and to the other safety handbooks that came out around the same time.

So far, I have found little information on the author. I don’t even know how much of a safety professional he was. Despite his thorough discussions, the author admits in the final chapter to be a mere layman in the field of psychology. A well-read one; that much we have that much we have to admit. Boyd Fisher appears to have been management consultant. An endnote in John Burnham’s book on Accident Proneness sheds some light on Fisher’s biography, telling us that he was involved in manager training during World War I and later was involved in setting up the US Rural Electrification Administration.

Any which way, the book is quite unique. Where the other safety handbooks deal with organisation, technical remedies and approaches, and discuss the human factor to a greater or lesser degree as just one factor, Fisher dedicates his entire book to the subject of the human mind and accidents. Reading the book almost a century after it was written, my mind shifts from fascinated about Fisher’s insights and nuance, to rather being appalled by some statements that will make you shake your head. For example when he suggests proneness, or says stuff that we wouldn’t say these days, but it has to be regarded in the context of the time it was written, of course.

Speaking of writing: Fisher was a gifted author. It is very well written in a mostly nicely style and with a good sense of humour. Sometimes one feels in these old books that language is archaic, but hardly ever here.

Anyway, let us look at the contents. Or first comment the title. The word ‘mental’ should not be interpreted as some of us maybe would do: as a disease. Although the author to some degree might agree with that. It is rather causes that spring from mental processes, from the mind. And most chapters therefore discuss ‘some kind of mind’, e.g. ‘The Unguarded Mind, ‘The Puzzled Mind’, or ‘The Diverted Mind’.

The book opens with a foreword by W.H. Cameron, chairman of the National Safety Council, who acknowledges the need of safety people to understand and interpret “the mental attitudes of his associates and workers” and states that Fisher makes “a distinctly new contribution toward the study of accident causes” - my point exactly. This book is a step up from the earlier safety books by Ashe, Beyer, and Cowee, adding something completely new to the field. And indeed, Fisher sets out for a ‘new view’ of safety:

“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 wilfully. We set the cause down always as “carelessness” - which means that we assume that they knew better, but deliberately went wrong.” (p.4)

This is quite an astonishing statement, firstly because this argument could be taken from one of Dekker’s books. Secondly, because even 100 year after Fisher started looking differently at the matter, we still meet regularly the exact same attitude. Not much has changed?

Instead of seeing an accident as a deviation, or violation, Fisher proposes that we “treated accidents not as delinquencies, but as forms of mental error” (p.7), because

“Merely to say that a workman ‘failed to use the proper safety device’ does not sufficiently analyse the situation. If possible, we must get at and correct the state of mind which produced this error.” (p.7)

In part, this is super progressive, and almost aligned with today’s ‘new view’ thinking. On the other hand, however, here is also one main critique of Fisher’s work - often he looks for solutions inside the person, although he sometimes acknowledges that the problems may lie in the greater environment. One interesting element, introduced early on in the book, but not returning, is Fisher’s idea that proximate causes are merely ‘apparent’ causes. It is the most easily visible, and thus quickly appointed as ‘the’ cause. However, in the end things are caused by an infinite number of things for these the external, underlying and fundamental issues are necessary and in the end, also the proximate:

“Viewing the causation of accidents the other way round, we shall see that none of the fundamental mental causes operates, in itself, to cause an accident.” (p.21)

Fisher even makes a nice comment on adaptation,

“…consistently good judgement 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 judgement, save by the evidence of success or failure.” (p.20)

After these introductory reflections, Fisher proposes 15 major (mental) causes of accidents, divided into five main groups: Ignorance, Predisposition, Inattention, Preoccupation and Depression. I will not discuss these in detail, but just give some broad summary.

Ignorance is defined as “lack of information or of capacity to understand information about dangerous processes” (p.23). In Chapter II, Fisher discusses the three main causes of ignorance: lack of instruction, not understanding the language or not having the capacity to understand (this, by the way, is one of the more troubling elements of the book, where Fisher attributes accidents to lack of intelligence). From this chapters, we can pick a couple of great - still relevant - insights, mostly packed in one-liners:

“Unless it is interpreted, a warning on the outside of the fence is of no use to the man who has to work inside of it.” (p.29)

“Safety instruction has to be specific and personal.” (p.29)

“…safety instruction given the first day is wasted unless it is repeated a good many times.” (p.33)

“Just telling him once doesn’t make him know. Knowing is an act or condition of his mind, not of the teller’s.” (p.33)

The chapter spends a good deal on how to do proper instruction, and ends with the suggestion to work on the training of habits (a subject to return later).

Predisposition has to do with “state of mind” which gets people into trouble (accidents). This is dealt with in several chapters. Chapter III discusses sense defects, exploring the use of physical examinations as a way of finding the right people for the job. Chapter IV takes on faulty attitudes (like “taking chances”, or the “fundamental trait of American character - cheerful recklessness” - there is a rather funny section, telling how bravery and taking chances is favoured and then people come to work and we expect them to behave safely “because we have put up a sign” telling Safety First), temperamental excitability and subconscious errors (e.g. because people expect a certain routine, only to find out that the situation is different, but they go through their learned motions anyway - there is an interesting part on pros and cons of standardization). Chapter V deals with faulty habits, and can be seen as a continuation of the part on the subconscious. Fisher discusses the building on (unconscious) skill, which is necessary in order to be efficient. He does see Scientific Management, if applied in a good and “democratic” way as a valuable tool, drawing more on Gilbreth than on Taylor. There is an interesting critique of the critique of Scientific Management,

“Resistance to efforts to form correct work habits comes less frequently from actual workmen than from theorists about industry. Precisely because scientific management, with especial reference to time and motion study, involves careful training in good habits, many social workers oppose it on the ground that it deprives the workman of initiative. This criticism, however, fails to take into account of what we know about habits. It seems to assume that, if left to himself, a workman will take conscious thought of his action or method of performing work every time he has a task set before him. But a workman who has to do this cannot be considered skilled.” (p.128)

At the end of the chapter he offers a programme for the forming of habits.

Inattention, “the state of being otherwise engaged”, is the subject of Chapter VI. It views safety as a by-product of interest in the job. It first continues from habits, stating that any performance includes automatic (skill/habit) elements, as well as conscious elements (because every situation is unique) and an element of ‘value’. The latter, Fisher connects to what he calls interest in the work. To prevent inattention, he emphasises building positive interest (e.g. through competition and incentives) and minimizing “competing interests”. The latter sounds great, but Fisher sticks mostly with the person and doesn’t take the step towards conflicting objectives like safety and production.

Preoccupation is “the surrender of the mind to claims or feeling or mental habits which are stronger in their influence than anything in the present situation.” (p.25) Chapter VII discusses worries, nervous tensions and even insanity. It is quite fun to read because it is very much a collection of stories to illustrate the message.

Finally, Depression, is the term used by Fisher to describe various forms of “psycho-motor retardation”, either by drugs, drink, disease or environmental factors like illumination and ventilation (Chapter VIII) or monotony, routine and tiredness (Chapter IX). Chapter VIII opens with looking at the work of John B. Watson, and I expected this to be about behaviourism. While Fisher discusses this briefly, it is not. Instead the chapter discusses how the body affects the mind and how circumstances in the environment, or disease and intoxication affect the mind. In the chapter on The Tired Mind, the author argues for a correct understanding of the term ‘fatigue’ and discusses the issue of tiredness and ‘energy’ from various sides.

After the discussion of the main causes, Fisher discusses a program of Accident Hygiene in the tenth chapter. This suggests individual ‘treatment’ in addition to the general methods of accident prevention as machine guarding and general education. Here he makes statements that we also here these days:

“It rarely happens, however, that old conquests can be held secure by old methods. In safety work, we need a change of methods - or, at least, a larger repertoire of methods - to maintain the gains already made.” (p.261)

As a help, he offers a chart where he maps his 15 main causes against eight types of remedy: 1) job analysis, 2) improved working conditions, 3) selection and assignment, 4) training, 5) organisation, 6) periodic personnel surveys, 7) individual adjustment, and 8) accident ‘post mortems’ (quite surprising to see this term already in 1922!!).

There is an interesting section in this chapter which seemingly contradicts the earlier reflection on deeper causes somewhat, because Fisher suggests that one does not need to go back for very remote causes, often simple solutions can be enough (an argument which we will find also in Heinrich’s work):

“The true mental hygienist never goes further than is necessary to effect a cure. Nature never expends any more energy than is necessary to accomplish a given purpose, and a true scientist, who is a servant of nature, always contents himself with the simplest explanation which will account for a phenomenon, and the simplest means which will bring it under control.” (p.281)

The final chapter is super nice, because the author here discusses available literature on psychology, blacklisting certain types of books and making a recommendation to those who want to develop themselves further in the field.

As a conclusion… One wonders what Fisher’s impact was at the time. Both DeBlois and Williams reference Fisher’s work in their safety handbooks, and especially DeBlois quite extensively so. Not so Heinrich, however. Heinrich merely mentions this book in his bibliography (and only in 1931, we do not find Boyd Fisher in the later editions) and explicit links to Fisher’s ideas are hard to find, or only vague, possibly coincidence. This book may, however, be one reason for Heinrich’s opinion that psychology is important for safety. As for further impact - I do not have the answer yet. Maybe further study will give clarity…


Read the book online or download it:


Review by Sidney J. Williams


There is another (long) review by G.F. Mischelbacher here (on page 57):