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In the Bibliography of the first edition of H.W. Heinrich’s long-standing book, Industrial Accident Prevention, Boyd Fisher’s book is one of 15 publications listed. In all subsequent editions of Heinrich’s book, this book does not appear in the Bibliography. No one knows for sure, but this book may have influenced Heinrich’s thinking as he created his “Domino Theory.”

Meet the Author

Little is known about Boyd Fisher, but limited information is available. What involvement he had in the safety movement is not clear.

The Harvard University Directory for 1910 listed Boyde Archer Fisher as graduating in 1910 with a BA degree in social science and a residence in Kansas City, MO. Later Harvard directories listed his name as Boyd Fisher. A 1918 federal directory for the U.S. Army listed him with the rank of Captain in the Ordnance Department. A 1939 Register of the U.S. Civil Service Commission listed him under the Rural Electrification Commission as a Special Assistant in Charge of State Relations in Indiana.

An entry for his book, Mental Causes of Accidents, appeared in the 1922 Catalog of Copyright Entries, and showed his residence as Charles River, MA. He was listed with the same residence city in the 1922 issue of the Year Book of the Harvard Club of Boston and in the 1924 issue of Constitution, By-laws, Rules and List of Officers and Members of the Harvard Club of New York City. His name also appeared with the same city of residence in the 1924 Year Book of the American Society of Mechanical Engineers.

Several publications featuring his writings and presentations between 1912 and 1920 identified him as the Vice President of the Executive Club of the Detroit Board of Commerce. During that period, some of his writings included the following:


  • Industrial Loyalty, its value, its creation, its preservation, G. Routledge & Sons, Ltd, London, 1918.

Articles and Presentations:

  • “Motion Pictures to Make Good Citizens,” American City, V 7, 234-238, 1912.
  • “The Regulation of Motion Picture Theaters,” American City, December 1912, 520.
  • “Methods of reducing the labor turnover,” The Annals of the American Academy of Political and Social Science, V 65, N 1, 144-154, 1916.
  • “How to reduce labor turnover,” The Annals of the American Academy of Political and Social Science, V 71, N 1, 10-32, 1917.
  • “Determining cost of turnover of labor,” The Annals of the American Academy of Political and Social Science, V 71, N 1, 44-50, 1917.
  • “Profit sharing, its success and failures,” Handling Men, AW Shaw Co (ed), 1917.
  • “Good Housing as a Reducer of Labor Turnover,” National Housing Association, 1919.
  • “Plant administration of labor,” Journal of Political Economy, V 27 N 7, 544-560, 1919.
  • “Has mental hygiene a practical use in industry?” Mental Hygiene, V 5, 479-496, 1921.
  • “Has mental hygiene a practical use in industry?” The British Journal of Psychiatry, V 69, N 285, 241-243, April 1923.

Obviously, during his career he was involved in matters that today would fall largely under human resources.

Introducing the Book

Boyd Fisher was a pioneer in finding an application for psychology and personal behavior in the early safety movement. He used observations from data and studies of many companies to help identify how knowledge of human thinking, behavior, emotion, and other personal mental traits can find use in improving safety performance.

The author’s thinking was based not on theoretical studies of minds based on mental testing. His focus was on mental causes of accidents, particularly those useful to safety men, in safety education and to the application of psychology in industry. It is interesting that the author of the “Foreword” in 1922 emphasizes the root causes of accidents and the mind being one aspect to be investigated.

Boyd Fisher organized the book into eleven chapters. The first nine focus on different characteristic or descriptions of the mind. The author based his characteristics on his own observations and experience and not on some theoretical study of the mind. The approach sought to offer concepts that others can use to improve safety performance through safe actions or by instructing people in safe behavior.

1. The Unguarded Mind

The author noted the commonly held experience of the time that 70 percent of accidents were the fault of a worker. He also gave an example in which people often fell down a particular set of steps. After several people fell, someone made measurements and found that the first step from the top differed by two inches from all the others so that someone made a mental impression based on the first step and applied that subconscious experience to the subsequent steps, misjudged the next step down and fell.

He noted the change in treating workers based on the former Common Law and on the more recent worker’s compensation laws. Common Law involved legal theories, such as “assumption of risk,” “fellow servant rule,” and “contributory negligence” in which workers had a presumed knowledge of the sources of danger. Worker’s Compensation laws required employers to pay compensation for all work-related injuries. He argued that it was time to treat many accidents as a form of mental error rather than a delinquency. He advocated for a deeper analysis that addressed the state of mind which produced a behavioral error.

He observed that some people act rather impulsively and aggressively, while others act rather slowly. He pointed to the former behavior based on high accident rates for younger workers and to the latter behavior for older workers based on increased accident rates in that group.

Overall, he organized 15 major causes of accidents into five groupings: ignorance, predispositions, inattention, preoccupation, and depression.

  • Ignorance simply means not knowing. A worker may not have been told or did not understand (language as a barrier) or did not comprehend.
  • Predisposition may be one “knowing what is not so” or wrong habits or wrong ideas.
  • Inattention refers to not being engaged or focused on the task at hand…”nobody home.”
  • Preoccupation involves having one’s mind on other matters from home or past situations.
  • Depression is a medical term indicating reduced performance based on fatigue, drugs, disease and faulty plant conditions.

The author refers to these grouping again in Chapter 10.

2. The Puzzled Mind

Not everyone understands machines and technology. The author gives an example of someone who must enter a secured area marked with a sign “Danger – 2200 volts.” How many would know where the “volts” were to be found inside that area? Outside the enclosure, that is not a concern.

He also points to a variety of language barriers in his day and the effects on safety records. He cites a study of Pennsylvania coal miners and the fact that 43 percent of English-speaking workers had 28.8 percent of the fatalities, while 56 percent of non-English-speaking workers had 71.2 percent of the fatalities. He cited similar statistics from a large steel mill. From 1906 to 1913 the lost-time accident rate per 1000 300-day workers dropped from 140 to 79, while the rate for those with a language barrier remained steady at 200. He cited Ford Motor Company experience that reduced accidents 54 percent in five years for foreign language workers who through a special program were taught to speak English.

He noted that in 1909 the United States stopped admitting illiterate foreigners. During the preceding decade, many immigrants could not even read or write their native language, much less English:

Country of Origin Percent Illiterate
South Italy 54.2
Lithuania 48.8
Croatia 36.4
Poland 35.4
Greece 27.0

As a result, translating safety signs from English to native languages had little chance for improving safety.

He also pointed to inexperience and lack of instruction on how to do a job or how to do it safely or what safety rules apply at work. He notes that telling a worker once about safety is not sufficient. He cited statistics showing a very high rate of injury for workers with one to three months on the job. One source of data showed that new employees with less than one month’s service were six time more likely to have an injury compared to those with more than one month of experience.

He also discussed differences in the ability of workers to gain proficiency in a job and doing it safely. He noted statistics that some people learn little from experience, even bad experience. He emphasized that different workers have different mental ages as measured through methods of that time.

He referred to several sources of information reporting how important it is to adapt safety instruction to the interests and attention span of various workers. One publication advised: brevity, new interest and freshness, charts and fewer numbers, pictures and less print, and incorporating humor. He encouraged adapting safety education to the knowledge and experience of the workers.

He emphasized the difference between “static safety” (the standard or normal operations) and dangerous or unusual operations. He noted the importance of training for extraordinary and unforeseeable conditions and circumstances.

He differentiated safety information into four categories:

  • What every worker must know regardless of language.
  • Information involving memory and obedience to instructions.
  • Information involving experience and judgment.
  • Information involving imagination, ethics and morals.

3. The Misguided Mind

In this chapter the author focused on the physical requirements of a job. That may involve visual abilities and skills, auditory abilities, movement and other sensations. He raises a concern that pre-employment examinations by physicians are very inadequate in identifying whether a person has the capabilities to perform a job successfully and safely. He notes that with worker’s compensation, many companies introduced pre-employment physicals that may identify medical deficiencies, but he was not aware of testing that helped ensure that a new employee had effective sensory skills to perform well. His discussion provided examples for vision, hearing, sensing movement and touch or other inherent capabilities.

4. The Stubborn Mind

This chapter addressed attitudes that impact safety. At the time this author crafted his book, employers faced a culture in the United States which he called “cheerful recklessness.” Not everyone working during the early safety movement wanted safe work conditions, even in cases where a person was generally committed to safety. While growing up at the time, many workers (mostly young men) developed a risk-taker mind set. The author listed numerous examples. As a result, it was difficult to get workers to comply with actions that protected them. The author differentiated the desire to be safe and to comply with rules from a way of thinking and acting that is contrary to that. Horseplay and devilment were common behaviors based on this alternate mentality.

He also pointed to the thinking of many workers who have a fatalistic view that injury and death are acts of Providence and that the cause of accidents lies outside themselves. Unsafe behaviors for some have roots in superstitions. One example cited was the practice of wearing lucky charms.

In this context, the author also identified a common fear of doctors and medicine. That led to workers not seeking attention for small scrapes, cuts and other minor injuries, relying on home remedies and leading to infections. Many people at the time did not have appropriate outcomes when treated by physicians or hospitals and gained a fear of them.

The author discussed the issues of emotions, resistance to reason and other factors in the workplace that lead to people acting reluctantly, uncooperatively, or excitedly. Those involved in promoting safety need to understand the attitudes of individual workers and find ways to adjust their behavior to ensure their safety.

An additional factor discussed involves “subconscious errors.” There is a tendency for the mind to act in a learned, orderly manner, such as a sequence that is safe (see uneven stairs example in Chapter 1). However, if a situation is not the normal one, that behavior pattern may not be safe because the normal, subconscious pattern is no longer the safe behavior. One example is a subtle change in a machine that requires a change in behavior. The author pointed out that in accident investigations, one must look for subtle changes that lead to unsafe behavior. He noted that “standard conditions” may lead to mental errors when conditions change, even when subtle.

5. The Involuntary Mind

In this chapter Fisher explored habits and skills. He pointed to a musician who has developed skills in playing a piano and seldom has to look at his fingers. He also points to others who develop bad habits coupled with automatic performance and the need to develop efficient movement and actions to help ensure safety.

He stated that habits often takes the place of thinking. He emphasized the importance of developing good habits through indoctrination and training and with respect for authority. That produces discipline and morale. He offered several procedures to achieve proper habits.

6. The Diverted Mind

This chapter is somewhat of an extension of the previous chapter. Here he discussed three mental phases that are part of the performance of any task. The first, “standard phase,” is making the work methods automatic, even with necessary variations. The second phase, “immediate phase,” is responding to conditions that cause an adjustment in automatic task performance. This phase requires attention to variable conditions. The third phase, “value phase,” involves adding meaning and value to task performance. Failure to address all three phases can lead to accidents.

He listed the four roles of safety leaders regarding problems of attention and habit:

  1. Inculcate safety habits.
  2. Assist in establishing correct performance habits – automatic performance.
  3. Build value in a job and build positive interest in it.
  4. Minimize distractions, confusion, competing interests, and needless difficulties.

He discussed boredom and values in further detail and offered examples of individuals and how they encounter both. He also discussed distraction and inattention further and provided a variety of examples of jobs encountering these characteristics. He offered suggestions on how to minimize distractions and factors leading to inattention.

7. The Troubled Mind

The author pointed to emotional situations at work that he characterized as the troubled mind. Emotions may elevate as a result of bad things happening, from disputes between a worker and a supervisor, perception of blame for something gone wrong or not performing well. He notes that different workers may have varying personalities or bring different feelings based on personal or family situations. As a result, some are more likely to elevate emotions that affect work performance and safe behaviors.

He also noted that some individuals are chronically maladjusted in their lives and at work. He also discussed mental health that can affect behavior at work. One example is alcoholism. He suggests that “mental hygiene Footnote ” may have a place in industry in the future.

8. The Physical Mind

Fisher made a point that the mind and the body are integrally linked. However, impairment of the body does not necessarily impair the mind and its intellectual functions. He gave examples of famous individuals who lived great lives after their bodies were impaired. Similarly, he identified many cases from history in which disease did not change the ability of individuals because their minds were not impaired.

He discussed injuring one’s own health through alcohol, drugs, smoking, etc. He also pointed to studies of entire communities in which mental performance may have been affected by environmental conditions. Here he used thermal conditions, ventilation and humidity levels as essential for human performance. He discussed the importance of illumination to prevent accidents. A focus on physical conditions at work were just beginning to gain attention at that time.

9. The Tired Mind

Many assume that accident rates increase as workers get fatigued. The author cited several studies that showed increases in accidents late in the morning shift and again late in the afternoon shift. He also cited other sources that do not show these relationships. In some cases, efficiency of work parallels this cycle, while in other cases productivity holds steady or increases late in a shift. He also cited studies that show physically tired athletes can increase output at the word-of-mouth urging of coaches. He noted that some factories provide opportunities for workers to take in some food at mid-shift and the practice appeared to reduce the onset of fatigue. As a result, the author stated it is not sufficient to define fatigue as a diminished power to produce work. He argued that fatigue involves several factors such as changes in blood, diminished nerve performance and termination of food intake, among other factors.

In summary, the author suggested that analysis is essential to determine what actually leads to fatigue and how fatigue as reported correlates to accident trends. The goal is to remedy those contributing factors in order to reduce accidents.

10. Accident Hygiene

After describing the different mind characteristics, Fisher address some general matters. He identified two primary areas of emphasis in the early safety movement. One is ensuring that dangerous places on machines are properly guarded. Factory inspectors helped to ensure that those protections were in place. The second area of emphasis early on was posting signs that reminded workers of dangers associated with their work. There were general signs, such as “Safety First,” and others pointing out more specific dangers. He stated that these efforts treated all workers alike. He provided statistics from several companies to illustrate the large reduction in accidents and injuries that resulted from these two efforts.

He then introduced a term, “accident hygiene.” He defined it as a technique for dealing with individual cases and special approaches applicable to each worker. He made the comparison to public heath that completes inspections of water supplies, food processing and sewage treatment to achieve health of the public in general and private medicine which treats the illnesses of individuals.

He noted that accident hygiene begins with proper diagnosis including the characteristics of individual workers. He referred to eight types of remedies: 1) job analysis, 2) improved working conditions, 3) better selection and assignment, 4) training, 5) organization, 6) periodic personnel surveys, 7) individual adjustments, and 8) accident “post-mortems.” He advocates for “fitting the man to the job.”

He provided a matrix of the five mental causes of accidents listed in Chapter 1 on one axis and the eight kinds of remedies on the other axis. In each cell of the matrix he offered recommendations to reduce accidents and improve safety. One example of an action listed in the matrix is individual education in safety that goes beyond general knowledge of safe practices applicable to all workers. While bulletin boards, safety meetings, and safety committees providing improvement recommendations each contribute to improved safety, he emphasized the need to understand the mental aspects of each worker in defining what personal education is important. He provided examples of how this can work. He encouraged accident “post-mortems,” using lessons learned from accident investigations to achieve constant improvement of work methods and conditions. He offered a detailed table of considerations when doing an accident “post-mortem.”

11. The Self-Guided Approach to Psychology

In this chapter he offered guidance on learning the fundamentals of psychology and what sources from psychology literature would be helpful. Those involved in improving safety need to understand the psychology of safety and some available tools.


Overall, the author provided many details for understanding human characteristics, the mind, and behaviors that are essential in improving safety. He offered many examples to help readers understand the details. He recommended that those involved in the safety movement improve their understanding of how human minds work. He provided a structure for using this information and applying it to the task of making work safer.

This is an innovative and thoughtful addition to the safety literature from nearly 100 years ago, especially during the early safety movement. The author offered a new dimension to accident prevention thinking that focused on individual workers and the mental aspects that affect their work performance and job safety.

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