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Toolbox Tips #1 (Part 7b) - The Concepts of Incident Causation

Kevin Stretton - Friday, March 11, 2016


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.
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