Incident investigation techniques in all high-hazard industries concentrate primarily on the immediate causes, such as the technical failures and the more frequent human shortcomings that led to the incident. Issues that are identified at these superficial levels of investigation and analysis tend to be local and hard to relate to deeper underlying causes that may be company-wide. Answers to more abstract questions, about organizational and cultural issues, provide much more useful information that organizations can use to implement preventative programs with far-reaching benefits rather than just treat symptoms of the underlying problem that may do little to prevent the next incident.

The ‘statistical’ approach described in this paper relies upon the notion that lower accuracy of assignment to a cause category in any single accident analysis can be compensated by averaging over larger numbers of incidents. Investigators often remain close to the event because the evidence is more concrete and less ambiguous at the level of the immediate causes, resulting in a tendency to reinforce the idea that front-line operators are the primary causes of accidents – if only because no evidence is offered that there was a deeper-lying set of causes within the organization.

This paper describes a method for analyzing incidents that allows for the aggregation of multiple causes, taking different points of view, rather than being based upon an essentially linear approach such as event trees. The different categories chosen can be aligned with the organization's requirements for learning and improvement, as opposed to the primary aim of supplying an accurate description of what happened. The paper shows how it is possible to distinguish local from company-wide influences and demonstrate trends in underlying factors.

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