Key Takeaways

  • Incidents and their systemic causal factors are indicators of management system flaws. When identified and understood, these indicators can be used to address deeply rooted deficiencies and prevent recurrence of similar events.

  • While many methods are available, OSH professionals should select, design and apply a causal analysis process that effectively identifies causes at all levels, from direct causes down to the management system elements and organizational factors. For some situations, a simple five-why process is appropriate, while complex incidents may require more in-depth methods.

  • This article presents a causal factors analysis model using a sequence of modified methods that can be used to analyze more complex incidents and uncover deeply embedded causal factors.

As the OSH profession continues to evolve, a major concern remains: the number of workplace fatalities and serious injury events each year. As incident rates have declined over the years, fatality rates have not significantly changed; they have plateaued and risen slightly. Recent data from Bureau of Labor Statistics (BLS, 2017) indicate 5,190 workers died from an occupational injury in 2016. This number increased by 7% over 2015 and is the highest count since 2008.

In the authors' view, the persistence of serious injuries and fatalities suggests that many organizations have flaws within their management systems in the way they plan, organize, implement, execute, monitor, communicate and improve. One way that OSH professionals can help organizations improve their management systems is through more effective analyses of incidents.

An incident is an unplanned, unwanted event that results in injury or damage (an accident) or an event that could have resulted in harm or loss (a near-hit). All incidents should be investigated, regardless of the extent of injury or property damage. In the authors' experience, most organizations perform some degree of investigation and analyses for incidents resulting in injury, damage or those with significant severity potential. However, the driving forces for conducting incident investigations and analyses can vary for organizations ranging from the need to file insurance claims; complete regulatory compliance records; track lagging indicators; or meet contract requirements from customers. All of these are important, but they do not represent the real purpose of incident causal analysis.

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