Incident analysis immediate cause

Task analysis can also be used in a retrospective mode during the detailed investigation of major incidents. The starting point of such an investigation must be the systematic description of the way in which the task was actually carried out when the incident occurred. This may, of course, differ from the prescribed way of performing the operation, and TA provides a means of explicitly identifying such differences. Such comparisons are valuable in identifying the immediate causes of an accident. 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

Each company s management style and safety systems have strengths and weaknesses. These strengths and weakness tend to influence the types and severity of incidents that might occur. An analysis of incident investigation findings in terms of causal factors, immediate causes, contributing causes,... 

The information gathered on transportation incidents has long-term value in addition to the immediate lessons learned. For example, this information may be useful for monitoring performance over time. It can be used to build up a database on transportation incidents. Finally, and most importantly, such information can provide statistical data for transportation risk assessments and improvement efforts. Trend analysis of causes of transportation incidents is vital to a management system that addresses major problems and sets priorities for risk reduction. This element should be part of each supply chain partner s transportation risk management. These risk reduction strategies are discussed in detail in Chapter 7. 

If a full team is formed, it continues the analysis, starting by collecting incident data. The immediate causes and root causes of the incident are based on known facts and an action plan for eliminating the root causes is formulated. 

Determining the cause of an incident is the most important responsibility of the incident analysis team. The immediate cause is the act or condition that directly resulted in a near incident, injury, or property damage. The root cause is the underlying system, actions, or conditions that allow the immediate cause to occur. 

Evidence and Cause Analysis Identification and discussion of the root (primary), contributing, and immediate (secondary) system causes of the incident. 

Cause analysis is usually divided into three types (1) direct causes (2) contributing causes and (3) root causes. The direct cause of an incident is the immediate event or condition that caused the incident. Contributing causes are events or conditions that collectively increase the likelihood of the direct cause but that are not the main factors causing the incident. Root causes are the events or conditions underlying the root cause. Corrective measures for root causes will prevent the recurrence of the incident. In simple cases, root causes include materials or equipment deficiencies or their inappropriate handling. More complex examples are management failures, inadequate competencies, omissions, nonadherence to procedures, and inadequate communication. Root causes can be typically attributed to an action or lack of action by a group or individual. 

Historically, the FMEA technique has been extensively used in the aerospace, automotive, electronics, and defense industries because they aU require analysis of complex mechanical systems and because the failure of an equipment item can have such catastrophic consequences. The FMEA method has not been used much in the process industries because most serious incidents are caused by problems with the chemical and refining processes themselves rather than simple equipment failure. (The same criticism is sometimes made of FTA.) In point of fact, neither the FMEA or FTA methods need take a lot of time it is just that the level of detail that is necessary for the analysis of a say a nuclear reactor or airplane wing is much greater than that needed for a pump in a refinery because the immediate consequences of a failure impact are likely to be so much greater. 

In each incident you should ask yourself (1) What happened (2) How did it happen (3) Why did it happen This series of questions is one form of root cause analysis (RCA), a standard procedure in the investigation of incidents in business and industry. The last question is the most important one and you will find you may have to ask and answer this question several times in sequence before you come close to the real or root causes of an incident. RCA generally recommends asking Why five times to get to a fundamental, rather than superficial, cause. Root causes are the basic causes of an incident that can be reasonably identified, that can be controlled, and for which recommendations or lessons learned can be derived. Many times root causes are not immediately obvious, but can be identified from careful inquiry. Once you know the root causes you should be able to develop recommendations or steps to prevent this from happening again. 

Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to foolproof the condition or activity. Considerations of cost or engineering should not enter in at this stage. The primary purpose of incident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully refiects the recommendations made by an incident report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures [6]. 

The following (example) checklist is intended to serve only as a guide to possible causes of an incident. The list is not complete, but should function as a starting point to help guide the analysis team toward finding both the immediate, and most importantly, the root cause. 

To prevent recurrence, the team must begin the analysis as soon as possible. All circumstances and events that immediately led up to the incident must be discovered and the root cause or causes... 

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