What about the 5 M's?

Manpower, Materials, Machines, Methods, Money

As a previous poster has suggested, there is a plethora of potential (root) causes which to choose from. Incidentally, I do not use the term 'root cause' because there is not always one, indeed in most cases there are a number of causal factors which contributed to the accident/incident.

As a starter for 10, accident causation is normally divided between Active failure (operator error) and Latent failure (management error) and then subdived into their constituent parts. Prof Jim Reason is the doyen of accident causatio if you wish to research further.

God I hate this talk of root causes.

I am lumbered currently with an accident reporting system which has something like 40 root causes, none of which is genuine a root cause.

You could argue there is only one genuine root cause which is a “Failure Of Management” but to make it more interesting I would say that there are 4 root causes:

1.  Failure of the Safe System of Work: someone not either not following instructions (a violation) or following instructions which were wrong (an honest error). Could be down to a poor or non-extant risk assessment process.  Solution: look at the way that these processes are managed and risk assessed.

2. Lack of Competency by employee: employees not trained or understanding what they are doing. Solution:   better training (in its widest sense) and a drive for competency

3. Poor local line management/supervision. Local managers’ not driving H&S forward. They talk the talk but do not walk the walk.

4. Poor H&S culture: lips service is paid to H&S but nobody really cares. H&S is not embedded just treated as a paper exercise.

Originally Posted by: A Kurdziel

God I hate this talk of root causes.

I am lumbered currently with an accident reporting system which has something like 40 root causes, none of which is genuine a root cause.

You could argue there is only one genuine root cause which is a “Failure Of Management” but to make it more interesting I would say that there are 4 root causes:

1.  Failure of the Safe System of Work: someone not either not following instructions (a violation) or following instructions which were wrong (an honest error). Could be down to a poor or non-extant risk assessment process.  Solution: look at the way that these processes are managed and risk assessed.

2. Lack of Competency by employee: employees not trained or understanding what they are doing. Solution:   better training (in its widest sense) and a drive for competency

3. Poor local line management/supervision. Local managers’ not driving H&S forward. They talk the talk but do not walk the walk.

4. Poor H&S culture: lips service is paid to H&S but nobody really cares. H&S is not embedded just treated as a paper exercise.

There is of course the argument that all of the above are synonymous with a H&S culture.

Some years ago I plagiarised the Byrd/Heinrich pyramid in 3D for a presentation which depicated side two showing Behaviours, Supervision, Leadership and Culture, with side three being Planning, Communications, Unsafe Acts and Unsafe Conditions. Although based on my experiences they purely allegorical just like the Byrd/Heinrich model. 

IMHO a list of root causes or potential root causes is a dangerous path to go down.  We were sent that way by our parent company in using a specific "tool" for this and it was truly hopeless.

The root cause or causes are what they are.  They may not fit into a particular box, they may be quite random and peculiar in nature but trying to fit these into a box will only send you down a pre-destined path which may not, ultimately, help with preventing recurrence.

No two people are alike and, therefore, no two accidents are alike.  Each accident and IP must be looked at individually using your knowledge and tracing back to find the actual root cause however unlikely this might be.  I've never seen a check sheet yet that listed 'depression' or 'suicidal tendencies' as a "root cause" but I'll bet there are quite a number of accidents that have this at the actual root.

Try not to compartmentalise - people are people and they can do extraordinary things that you would never even imagine!

I use a tool generated when out in the Middle East that I call ICAM - Incident Causation Analysis Methodology, if you want a copy email or pm me, its on PPT and can be printed off to aid your analysis.  It covers both human and work place factors.

Waz