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

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

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.

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

jonty,



Well, I wasn't defining causes, just listing possibilities, to make investigators think - they are not professionals so they need a nudge and clues.



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

And what you just said wasn't confusing? lol