Posted By TonyB
Hi Jonf,

Immediate causes tend to be unsafe acts or conditions.

Underlying Causes tend to be the reasons for the unsafe acts or conditions.

Root Causes tend to be failures in management control and/or the safety management system.

Hope this helps (trainers perspective on the matter!)

TonyB.

Posted By TonyB
Jonf,

Have you tried HSG 245. It's the HSE guidance on investigation, but written for the lay-person. Its very good, but a priced document.

All the best,

TonyB

Posted By Merv Newman
When looking for "immediate" and "underlying" causes there is a tendency in each category to look at "the" cause. And stop when we find it.

I like to go back to the "domino" theories, Heinrich, Bird et al, where the different levels of cause are lined up like dominoes. When one fails it causes the rest of the sequence to fail.

Typically the sequence is :

* Strategic or higher management error or failure

* Operational or middle management error or failure

* Tactical or supervisory error or failure

* Practical or employee error or failure

* Equipment or process error or failure

Immediate causes are typically found in the last two categories. Underlying causes are more often related to the higher categories.

"Corrective" action tends to implicate action at the third, fourth or fifth level. Easy peasy.

"Preventative" action at the first or second levels can be a right grind.

But fun.

Merv

Posted By jom
Jonf,

May I suggest that you have a go at determining your own understanding of "immediate" and "underlying" causes?

I guess you are not simply after definitions, but have practical reasons for gaining understanding.

What value do you yourself see in having these definitions? Will you be able to make use of the definitions? How would you use them?

If we are clear about our purpose, we can then specify the tools we need to progress in that purpose. Definitions are just tools. Maybe knowing how to use tools is more important than possessing the tools.

All that's a bit philosophical, but much is written about defining causes, without explaining how to use the definitions.

John.

Posted By steve e ashton
Jonf:

To take your example - all the contributing factors which you identify would be immediate / proximate causes in my own definitions...

The underlying causes would be poorly designed containers (why were the doors not automatically restrained from blowing in the wind?) Inadequate site layout (Why were container doors so close to the obstruction?) Inadequate site size (Same question as above?) inadeqaute delivery specification? (Why have a container on site when the materials could have been delivered by a smaller van?) Inadequate resources (It was a windy day - the local risk assessment should have identified the need for sufficient manpower to hold the door...)

On the basis that 'what you don't have can't hurt you' - for me the 'underlying causes' are found by asking questions like 'why have we got this here?' Or 'how could we reduce our exposure to this risk?' or 'Why do we have so much of this stuff on site'. Asked properly, and with an open-minded approach, this type of question can sometimes lead to drastic changes in the way organisation operates - rather than finding ways to 'blame' individuals as the victims (or supervisors) of misfortune.

If a man falls from a ladder, you might find poor footwear, poor maintenance, distraction, poor instruction. I would like to think a deeper question might identify the need for stairs (when appropriate). Or designing the system so it doesn't need maintainenance at high level. Or designing the system so that bits that do need maintenance can be lowered to the ground for inspection.. Or purchase of a cherry picker and removal of all ladders..... Asking 'Why have a ladder?' is likely to get more benefit than 'why did he fall from the ladder?'

Hope this helps clarify a little...
Steve