Incident investigation multiple causal factors

Analysis, that can assist with the identihcation of causal factors. The concepts of incident causation encompassed in these tools are fundamental to the majority of investigation methodologies. (See Chapter 3 for information about the Domino Theory, System Theory, and HBT Theory.) The simplest approach involves reviewing each unplanned, unintended, or adverse item (negative event or undesirable condition) on the timeline and asking, Would the incident have been prevented or mitigated if the item had not existed If the answer is yes, then the item is a causal factor. Generally, process safety incidents involve multiple causal factors. 

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 ... 

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. 

The tool helps the investigator to understand and focus on the failed harriers, which are normally identified as causal factors. These failed harriers may need to he strengthened, replaced, or supplemented, especially where weak administrative controls are highlighted. Even successful barriers that prevented more serious consequences may require reinforcement. Therefore, barrier analysis can give the investigator valuable insights into how the incident happened and some of the multiple causes that need corrective action to prevent recurrence. 

In some entities, it is required that an incident investigation team be selected and gathered if the results of the incident were serious or could have been serious under other circumstances. Reports prepared by investigation teams (12 of them were received) were a pleasure to read. Every one reflected an understanding of multiple causation and pursued several routes in causal factors determination and in selecting corrective actions. 

Monitor leading indicators using the Safety Scorecard Identify and report incidents, near misses, and unsafe conditions Track accident investigations and store causal factor data Assign and manage corrective actions / Collaborate with multiple departments for incident resolution Monitor the status of tasks and projects Manage OSHA-recordable and other injury records... 

Setting the above knowledge and proposals together leads to integrated incident investigation procedure which is stUl based on the timeline development, causal factor identification and causal factor chart development, but which allows the determination of different Incident Cause Level for each of multiple causes. If the Incident Cause Level of specific cause is outside the internal safety management, the apph-cation of non-hnear analysis method is recommended. 

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