Incident investigation causal category

The committee s analysis of the seven chemical events listed in Tables 2-1 and 2-2 showed that there were multiple causal factors for all of the selected events. (Note the committee could detennine causal factors only for incidents for which sufficient investigation data were available.) Rather than being specified for each incident, the causal factors identified by the committee are grouped into the following generic categories ... 

It is probable that supervisors, who make only one, two, or three incident investigations a year, don t fully understand the descriptions of the various causal categories given in investigation forms. 

Usually, there are multiple causal factors for hazard-related incidents. Yet, there seems to be a desire to retain an age-old theme of simplicity. If people who make incident investigations are directed to select one pertinent fact. .. in each of the specific categories, more than likely that is what they will do. And the value of the investigation is diminished. Where incident investigation is done best, multiple causal factors are sought, and it is the exception when only a single causal factor is recorded. 

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