Scaled Management Systems

Part 6a – The Concepts of Incident Causation

Summary of Part 5

In Part 5 we came to understand how legal application of causality is used and linked with the design & implementation of management systems.

Objectives of Part 6:

To understand & apply the basic concepts of causality when:-

  • Designing management & work procedures [Safe / Standard Operating Procedures (SOP’s) or Work Instructions (WI’s)].
  • Completing an incident investigation.

So that through continual improvement and time, elimination of hazards & the prevention of error becomes the norm.

Part 6a:           Traditional interpretations of industrial or occupational incidents

  1. Industrial incidents result only from injuries.
  2. Incidents are caused directly or only from:-
  3. The unsafe acts of persons
  4. Exposure to unsafe mechanical conditions
    1. Unsafe actions and conditions are caused only by the faults of people.
    2. The faults of people are created by environment or genetic inheritance.

Heinrich, H; Petersen, D & Roos, N. Industrial Accident Prevention

Issues & problems

Typically these types of concepts do little to help us understand the root causes of incidents & yet even after 27 years of changed legislation, continue to be present in the minds of employees and managers today.

Even if all 4 points above were true they do little to improve our understanding of how they relate directly to the working environment simply because there is little connection to analysis of dynamic workplaces.

For example:-

If a machine with entrapment hazards is guarded with electronic interlocks and these devices fail during a critical point at which an employee is required by design of the SOP to retrieve a part while ‘assuming’ the safety devices are functioning correctly, where does the unsafe act lie; with the employee, their supervisor responsible for implementing an inspection procedure or the designer of the safety devices & work method?

You can see from the above example that causation is linked with the chronology or sequence of events through time and that our own perceptions of causation are often wrong because during incident investigations we only focus on the immediate past.