Hazards-related incident causation models

If we who call ourselves safety professionals are to be tmly perceived as professionals, we must resolve this matter of a generally accepted hazards-related incident causation model. A major study on this subject would be to our advantage. 

Professional safety practice requires that the advice given be based on a sound hazards-related incident causation model so that, through the application of that advice, hazards are effectively avoided, eliminated, or controlled and risks are reduced. 

Certain assumptions were made in the development of this hazards-related incident causation model, which... 

WHY PROMOTE DISCUSSION OF A HAZARDS-RELATED INCIDENT CAUSATION MODEL... 

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. ... 

OBSERVATIONS ON CAUSATION MODELS FOR HAZARDS-RELATED INCIDENTS 3... 

If several safety professionals investigate a given hazards-related incident, they should identify the same causal factors, with minimum variation. That is unlikely if the thought processes they use have greatly different foundations. At least 25 causation models have been published. Since many of them conflict, all of them cannot be valid. A review of some of them is followed by a discussion of principles that should be contained in a causation model. 

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

This chapter addresses the need for safety professionals to adopt an incident causation model, a thought process based on a sound understanding of the hazards-related incident phenomenon and which, when applied, identifies the reality of the causal factors in the incident process. 

As used in this treatise, causation means the act or agency of causing or producing an effect. Causal factors include all of the elements — the events, the characteristics of things, and the actions or inactions of persons— that contribute to the incident process. A model is to represent the theoretical ideal for the process through which hazards-related incidents occur, a process that requires determining when the phenomenon begins and ends. 

Safety professionals give many names to the incidents to which a causation model would apply accidents, incidents, mishaps, near-misses, occurrences, events, illnesses, fires, explosions, windstorms, drownings, electrocutions, and so on. Pat Clemens, a prominent safety consultant, has said that the language used by safety practitioners lacks words to convey precise and understood meanings. It s probable that the people with whom safety professionals try to eommunicate are baffled by the many terms used to describe hazards-related incidents. 

A sound causation model for hazards-related incidents must identify and stress the significance of the design management aspects and the operations management aspects and the task performance aspects... 

It s proposed that safety professionals can benefit from a review of the causation models on which their practices are based. For those who would undertake such an exercise toward the development of an acceptable causation model for hazards-related incidents, the following are recommended as noinimal readings ... 

This causation model for hazards-related incidents recognizes... 

Most causation models have minimized less than adequate design and engineering concepts and outcomes as a source of causal factors for hazards-related incidents, with one significant exception. That exception is MORT—the management oversight and risk tree. Concepts on which MORT is based have influenced my thinking greatly, and I am indebted to all who worked on the creation and betterment of MORT. 

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. 

To assist in deciding on the causation model to be applied, I suggest a review of Chapter 9, Observations on Causation Models for Hazards-Related Incidents, and Chapter 10, A Systematic Causation Model for Hazards-Related Incidents. ... 

Chapter 9, Observations on Causation Models 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. 

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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