Scaled Management Systems

Part 8a – The Concepts of Incident Causation

Summary of Part 7

In Part 7 we came to understand not only how human and social factors can influence our perceptions of incident causality we also determined that incident investigations can be a valuable tool for concentrating efforts on the continual improvement of management systems.

Objectives of Part 8:

By combining an engineering & social approach, 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 8a:           Modern or recent incident investigation techniques

There are a variety of models available for incident investigation.

  • Can you choose the one that is right for you &/or a variety of incident scenarios?
  • Is there a ‘one size fits all’ model that can be used for everything like environmental, quality & safety incidents?

The answer to both these questions is yes, only if we redirect our thinking to the analysis & continual improvement of management systems because all systems direct & influence the way employees, executives, managers & supervisors operate.

This means focusing our techniques on (a) in the timeline and progressively working backwards through time to recall & trace the sequence of events.

 This is the only way we can create a culture that is focused on prevention rather than reaction.

Thought about carefully this model can be applied to any incident, not just one involving employee illness or injury.

Some examples:

  1. Product or service recall following a customer’s complaint.
  2. A chemical spill that found its way into a natural water system.
  3. A financial error causing incorrect allocation of resources.
  4. A safety device which failed when being used by an employee under standard conditions.
  5. Protective equipment being used incorrectly by an employee