Scaled Management Systems

Part 7b – The Concepts of Incident Causation

Traditional incident investigation

Traditionally and due to misconceptions of employees, executives, managers & supervisors, incident investigation was always focused on (b), (c) & (d) of the timeline.

This resulted in a focus on symptomatic causes.

Some common examples from incident investigation reports are:-

  • The employee failed to wear protective equipment.
  • The guard failed.
  • There were no guards in place and the employee lost their fingers in the machine.
  • Human error.

Issues & problems with this traditional approach are still linked with insufficient training

Deeper questions were rarely asked as a way of trying to understand management systems & the dynamism of workplaces.

  • Why was the employee not wearing their protective equipment?
  • Why did the guard fail?
  • Why were there no guards in place?
  • Why was there human error? For a good example of this often cited subjective statement & an ineffective initial investigation see – Air New Zealand Flight 901

Only management control & systems can:-

  • Train employees how to use & care for protective equipment (PPE).
  • Design machine guarding to be safe.
  •  Create continual improvement in performance.

In Part 8 we start looking at how these concepts are linked with & can be used to understand incident investigation for the identification of root causes.