Rank: Super forum user
|
Hi All
Looking for some advice on accident root and immediate causes
|
|
|
|
Rank: Forum user
|
Hi Derek, what advice exactly are you looking for in relation to the immediate cause and underlying causes of an accident? Not to teach you to suck eggs, but there are a number of avenues that you can go down in relation to that particular topic. If you can be more specific I would be happy to try and give you some advice if I can. Chris
|
|
|
|
Rank: Super forum user
|
Derek
In order to get accident immediate causes and root causes, you need to get much data as you can regarding accident, then use some of accident investigation Techniques such as Top Set/ Tap Root ..etc..if you have been trained ..With correct logic thinking and sound brainstorming you will reach to immediate and root causes...It took time and depend to complexity of accident.. Hope it could help
SHV
|
|
|
|
Rank: Super forum user
|
Derek
Question is a bit vague and open...that said, the Immediate Cause is literally what occurred - simples. The underlying causal factors can be very complex and contain a number of different latent and active failures.
Root cause, now that's an interesting one. I have always preferred not to include Root Cause in my investigations. Mainly because it implies that there is one dominating factor which is often not the case. Contemporary thinking in accident investigation also discredits the Root Cause theory and Event Tree Analysis - it is too simplistic.
Possibly opened up a can of worms...
Ray
|
|
|
|
Rank: Super forum user
|
Ray
Can you provide references for your statement "Contemporary thinking in accident investigation also discredits the Root Cause theory and Event Tree Analysis." I was not aware of this and would like to find out more.
I find development of causal trees to be a very good way of tracing from immediate to root causes. Take a look at this video on Youtube
|
|
|
|
Rank: Super forum user
|
From thge horse's mouth - an HSE presentation at an IOSH seminar.
"Immediate Cause
Obvious reason of an adverse event
There may be several causes
blade, substance, dust, open wrong valve etc.
Underlying Cause
Less obvious system or organisational reasons for an adverse event
Unsafe acts & unsafe conditions (guard removed, ventilation switched off etc.
Root Cause
Initiating event or failing, which all other causes or failings spring
failure to assess or little use of risk assessments, failure to identify training needs, assess competence, Etc.
|
|
|
|
Rank: Super forum user
|
From the horse's mouth - an HSE presentation at an IOSH seminar.
"Immediate Cause
Obvious reason of an adverse event
There may be several causes
blade, substance, dust, open wrong valve etc.
Underlying Cause
Less obvious system or organisational reasons for an adverse event
Unsafe acts & unsafe conditions (guard removed, ventilation switched off etc.
Root Cause
Initiating event or failing, which all other causes or failings spring
failure to assess or little use of risk assessments, failure to identify training needs, assess competence, Etc."
|
|
|
|
Rank: Super forum user
|
Over several years now I've developed an accident investigation procedure, and we have a flowchart type document that I encourage supervisors to use so they are doing the investigation with me. In identifying immediate cause I separate two types of causes: unsafe act and unsafe condition.
examples of unsafe act:
not following procedure
not authorised/trained
not using guard
poor lifting posture
failure to wear PPE
over-riding safety device
inattentive behaviour
reckless behaviour
influence of drugs/alcohol
lone worker
doing two jobs at once
rushing/insufficient care
examples of unsafe condition:
unsafe procedure
poor housekeeping
poor equipment
improper maintenance
no guard
inadequate guard
poor environment: ventilation, noise, temperature, poor or bright light, work space restriction
then, looking at underlying causes, we have lists for each of these three:
the individual
the job
the organisation
and those look at training, attitudes, risk assessment, procedures, materials, tools, whether company has ignored warnings/previous etc
It used to be quite a small flowchart, but it seems to grow every time we have an accident :o)
JohnW
|
|
|
|
Rank: Super forum user
|
Not to open another can of worms a few thoughts....
I think all the different names and definitions of cause(s) are confusing at best.
Key is to identify the cause of the particular accident and to be able to logically verify this using whatever tool or model you are familiar with.
But be careful that you properly identify the actual transitive causes and not just all the unsafe conditions or antecedents that were around for the last week when no accident happened! Otherwise your investigation defaults to a workplace inspection / audit.
What was different immediately preceding the accident outcome?
|
|
|
|
Rank: Super forum user
|
jonty,
jontyjohnston wrote: Not to open another can of worms a few thoughts....
I think all the different names and definitions of cause(s) are confusing at best.
Well, I wasn't defining causes, just listing possibilities, to make investigators think - they are not professionals so they need a nudge and clues.
jontyjohnston wrote:
Key is to identify the cause of the particular accident and to be able to logically verify this using whatever tool or model you are familiar with.
Tool? Well verification for me is usually starts with talking to the injured person and witnesses, have you tried that??
.... assuming they tell the truth or actually know what happened. If not, that will be a barrier to investigation.
JohnW
|
|
|
|
Rank: Super forum user
|
andybz wrote:Ray
Can you provide references for your statement "Contemporary thinking in accident investigation also discredits the Root Cause theory and Event Tree Analysis." I was not aware of this and would like to find out more.
I find development of causal trees to be a very good way of tracing from immediate to root causes. Take a look at this video on Youtube
Andy, my premise was based on a accident investigation course I attended earlier in the year. Accident causation has moved on, there was a time when it was a case of 'stick to the facts' which is no longer the case either. The principle causes are those underlying ones - rarely in a serious incident is there one ie root cause. Please PM if you want further details about the course, provider, etc.
Ray
|
|
|
|
Rank: Super forum user
|
jontyjohnston wrote:
I think all the different names and definitions of cause(s) are confusing at best.
But be careful that you properly identify the actual transitive causes and not just all the unsafe conditions or antecedents that were around for the last week when no accident happened! Otherwise your investigation defaults to a workplace inspection / audit.
And what you just said wasn't confusing? lol
|
|
|
|
You cannot post new topics in this forum.
You cannot reply to topics in this forum.
You cannot delete your posts in this forum.
You cannot edit your posts in this forum.
You cannot create polls in this forum.
You cannot vote in polls in this forum.