Welcome Guest! The IOSH forums are a free resource to both members and non-members. Login or register to use them

Postings made by forum users are personal opinions. IOSH is not responsible for the content or accuracy of any of the information contained in forum postings. Please carefully consider any advice you receive.

Notification

Icon
Error

Options
Go to last post Go to first unread
Safety Man 1  
#1 Posted : 30 August 2013 17:56:44(UTC)
Rank: Super forum user
Safety Man 1

Hi All Looking for some advice on accident root and immediate causes
Chris L  
#2 Posted : 30 August 2013 20:57:16(UTC)
Rank: Forum user
Chris L

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
SHV  
#3 Posted : 31 August 2013 07:42:09(UTC)
Rank: Super forum user
SHV

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
RayRapp  
#4 Posted : 31 August 2013 09:01:15(UTC)
Rank: Super forum user
RayRapp

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
andybz  
#5 Posted : 02 September 2013 07:47:29(UTC)
Rank: Super forum user
andybz

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
redken  
#6 Posted : 02 September 2013 08:33:48(UTC)
Rank: Super forum user
redken

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.
redken  
#7 Posted : 02 September 2013 08:34:48(UTC)
Rank: Super forum user
redken

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."
JohnW  
#8 Posted : 02 September 2013 13:47:11(UTC)
Rank: Super forum user
JohnW

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
jontyjohnston  
#9 Posted : 02 September 2013 14:30:28(UTC)
Rank: Super forum user
jontyjohnston

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?
JohnW  
#10 Posted : 02 September 2013 15:34:07(UTC)
Rank: Super forum user
JohnW

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
RayRapp  
#11 Posted : 03 September 2013 10:29:08(UTC)
Rank: Super forum user
RayRapp

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
Clairel  
#12 Posted : 03 September 2013 10:38:57(UTC)
Rank: Super forum user
Clairel

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
Users browsing this topic
Guest
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.