A Systemic Causation Model for Hazards-Related Incidents

A SYSTEMIC CAUSATION MODEL FOR HAZARDS-RELATED INCIDENTS... 

I conducted workshops on selected incident reports they had sent me. To help the attendees explore the reality of accident causation, they were given copies of the exhibit A Systemic Causation Model for Hazards-Related Incidents shown in Chapter 10. It works as a reference base. The point to be made was this The employees in that entity could do a good job of investigation if management so required. 

Chapter 10, A Systemic Causation Model for Hazards-Related Incidents ... 

In Chapter 3, Serious Injury Prevention, an outline for such a study was presented under the heading Proposing a Study of Serious Injuries. Such a study will not be time-consuming since the data to be collected and analyzed should already exist or can be obtained easily. To assist in such a study, two addenda are provided at the conclusion of this chapter. Both are reprinted Ifom the third edition of On The Practice Of Safety Addendum A, A Systemic Causation Model for Hazards-Related Incidents, and Addendum B, Reference for Causal Factors and Corrective Actions. Another good reference when completing this evaluation, in terms of its comments on human errors that may be made above the worker level, is Chapter 4 here. 

It is a necessity that the advice given by safety professionals be based on an understanding of the reality of causal factors and actually serves to attain a state for which the risks are judged to be acceptable. I will develop a systemic causation model for hazards-related occupational incidents that represents the thoughts set forth in this chapter. 

In recognition of the need to further our knowledge of hazards-related incident causation, a chapter offers A Systemic Causation Model for Hazards Related Occupational Incidents. ... 

A sound causation model for hazards-related incidents must take into consideration the entirety of the socio-technical system— applying a holistic approach to both the technical aspects and the social aspects of operations. It must be understood that those aspects are interdependent and mutually inclusive. 

Systemic Socio-Technical Causation Model for Hazards-Related Incidents At least 25 incident causation models are referenced in safety literature. They present a great diversity of thinking. None of those models have achieved anything close to universal acceptance. Yet, safety professionals are obligated to have the advice they give be effective as clients take action to avoid, eliminate, or control hazards and to achieve acceptable risk levels. That advice must be based on a sound and studied thought process that takes into consideration the reality of the sources of hazards. This author builds a case in support of what he proposes for a systemic sociotechnical causation model for hazards-related incidents. 

It is evident and convincing that several observers recognize the impact that management decisions have on what become causal factors for hazards-related incidents in the sociotechnical work environment— in the system in which work is done. Similarly, this author s review of over 1700 incident investigation reports results in the conclusion that decisions made at a board of directors and at senior management level must be given prominence in a causation model. Figure 13.1 depicts such a causation model. Comments in support of the model follow. 

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