Multiple causation, incident

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. 

Let us look at the same accident in terms of multiple causation. Multiple causation asks what ate some of the contributing factors surrounding this incident We might ask ... 

Objectives need to be understood by all employees. When developing your objectives you must use clear, understandable language that leaves no doubt about what employees are supposed to do. For example Investigate incidents to determine multiple causation (root cause). This will be unclear to almost everyone. A better example could be Investigate incidents to determine all causes, and take corrective action in 24 hours of the incident. This objective is much clearer, more understandable, and more specific. 

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 design of most process plants relies on redundant safety features or layers of protection, such that multiple layers must fail before a serious incident occurs. Barrier analysis ) (also called Hazard-Barrier-Target Analysis, HBTA) can assist the identification of causal factors by identifying which safety feature(s) failed to function as desired and allowed the sequence of events to occur. These safety features or barriers are anything that is used to protect a system or person from a hazard including both physical and administrative layers of protection. The concepts of the hazard-barrier-target theory of incident causation are encompassed in this tool. (See Chapter 3.)... 

The principle of multiple causes states that accidents, near miss incidents, and other problems are seldom, if ever, the result of a single cause. This pertains to near miss incident investigation, which in itself is another vitally important criterion of any safety system. If the investigation system is not structured and does not follow the loss causation sequence and determines both the immediate and root causes of the event, the system is basically worthless. 

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