In Brief

  • Identifying incident causal/contributing factors has long been a basic element in safety management systems.

  • Simply stated, the purpose of an incident investigation is to learn from history and to make improvements to overcome the management system deficiencies noted in investigation reports.

  • This article presents a concept for determining root-cause factors that OSH professionals can practicably apply.

This article began after reading some thought-provoking comments about incident causation by authors Erik Hollnagel and Sidney Dekker. Hollnagel is the author of Barriers and Accident Prevention (2004), and Dekker wrote The Field Guide to Understanding Human Error (2006). OSH professionals should read the writings of both. Consider some of their commentary:

  • One can describe and understand an incident in several ways, and the cause-effect assumption is perhaps the least attractive option (Hollnagel, p. 26).

  • The tendency to look for causes rather than explanations is often reinforced by the methods used for incident analysis. The most obvious example of that is the principle of root cause analysis (Hollnagel, p. 26).

  • Root cause is a meaningless concept (Hollnagel, p. 28).

  • There is no root cause (Dekker, p. 77).

  • What you call root cause is simply the place where you stop looking any further (Dekker, p. 77).

  • Where you look for causes depends on how you believe incidents happen. Whether you know it or not, you apply an accident model to your analysis and understanding of failure (Dekker, p. 81).

The positions Hollnagel and Dekker take are educational and promote introspection. Safety professionals should analyze these positions for their possible effects on the practice of safety. The excerpts in this article are intentionally presented like book reviews. This was done to illustrate the breadth of what these noteworthy authors have written about how incidents happen, incident causes, root causes and incident analysis.

In addition to reviewing and commenting on statements made by Hollnagel and Dekker, this article presents a concept that OSH professionals can practicably apply to determine root-causal factors. Identifying incident causal/contributing factors has long been a basic element in safety management systems. Simply stated, the purpose of an incident investigation is to learn from history and to make improvements to overcome the management system deficiencies noted in investigation reports.

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