Scaled Management Systems

Part 8b – The Concepts of Incident Causation

Applying the new thinking

In most cases the ‘5 Why’ approach will suffice as an investigation model for many organisations.

The ‘5 Why’ approach simply requires that everyone participate in an exercise asking ‘Why’ questions at every step of the incident analysis. Upon reaching (b) in the timeline five ‘Why’ questions are asked for each of the observed symptoms.


An example:


  1. An employee loses an eye. Why?

2. Incident:

  1. The grinding wheel shattered and struck the employee’s face fracturing a cheek bone which punctured the eye from behind. Why?

3. Symptomatic causes:

  1. They were only wearing safety glasses. Why?
  2. Employee was not wearing a face shield / visor. Why?
  3. Pieces of the grinding wheel displayed signs of furrowing. Why?

4. Management, Systems Control & Root Causes:

  1. There is no evidence that the employee had been informed, instructed or trained to use face visors as PPE. Why?
  2. There is no evidence that the employee had been informed, instructed or trained to inspect grinding wheels before using them. Why?
  3. No training system in place for employees other than tradespeople regarding pedestal grinder safety. Why?
  4. There is limited evidence to suggest occasional maintenance inspections & work included redressing of grinding wheels. Why?
  5. The hazard & housekeeping inspections lacked sufficient detail and were not specific to departmental hazards. Why?
  6. There is no site wide approach to asset & preventative maintenance. Why?
  7. Employees, managers & supervisors are not appraised on safety performance or the need to continually improve safety. Why?

5. Root Cause:

  1. Management has not been trained in the implementation and integration of safety systems with normal operations.

Other investigation models can be used for complex incidents or when planning complex operations in order to avoid catastrophes.