Accident Causation - Accident Direct Causes

Direct causes The basic assumption here is that events that lead to the consequences that we see are more often than not triggered by someone doing something (the act) in a certain environment (the condition). Because of this we divide the direct causes in: (1) Causes that are related to a person and an act, and (2) Causes that are related to the actual (work) environment or conditions. Direct causes of accidents/incidents are divided in two main categories:

Substandard (or unsafe) ACTS Substandard (or unsafe) CONDITIONS

The level of direct causes may have to be by-passed - in case of incidents that have little or no relation to safety in order to arrive at the basic causes that have a much wider area of application. Direct causes exist because of underlying causes: the basic or root causes. SUBSTANDARD CONDITIONS/SITUATIONS, such as: Improper guards or barriers No or inadequate or personal protection Defective tools, equipment or materials Proper tools not available Congestion / restricted action Lack of adequate housekeeping Inadequate warning systems Fire or explosion hazards Excessive noise Inadequate ventilation Substandard lighting Inadequate design of workplace

Exposure to chemicals Exposure to radiation Hazardous atmospheric conditions: fumes, dusts, vapors Other

The level of direct causes may have to be by-passed - in case of incidents that have little or no relation to safety in order to arrive at the basic causes that have a much wider area of application.

Causation Model - Accident Basic causes

While direct causes are normally only there for a short period of time, basic causes are there on a more or less ongoing basis. For example a direct cause could be a substandard act or condition. Somebody did something wrong or misplaced a drum or pallet. The basic cause then could be the lack of proper work procedures. Or the motivation of the person to follow the standard work procedure. Or the basic cause could inadequate housekeeping guidelines or inspection program or the motivation of the person not to follow them. Or the basic cause could be management or supervision tolerating that proper procedures are not being followed. Basic causes are sometimes also called "root causes". However, although the term seen to have been around since early last century, there is - as far as I know - no universally accepted definition.

While typical direct causes may often occur on an incidental basis, root causes are generally present more permanently. As such they are the source, so to speak, from which the direct causes evolve. Because of this, the root causes are often also called the underlying causes. Here too, we recognize two main categories: (1) personal aspects - related to a person (in practice, often the person directly involved in the event), and (2) job factors - related to the organization, work conditions and processes.

Leaving natural induced events aside, root causes of undesired events are divided in two main categories:

Substandard PERSONAL FACTORS Substandard ORGANIZATIONAL or JOB FACTORS

PERSONAL FACTORS, such as:

Inadequate mental of physical capability Stress mental or physical Lack of knowledge Lack of skill/experience Improper motivation Other

ORGANIZATIONAL or JOB FACTORS such as:

Inadequate leadership/supervision Inadequate engineering, design of workplace/facility Inadequate design of work standards/instructions Inadequate purchasing Inadequate maintenance/excessive wear and tear Improper tools and equipment Other

The root causes form the breeding ground from which the direct causes develop that can result in undesired consequence, such as: injury, material damage, quality problems, liability claims and other losses. Root causes in turn can develop from inadequate or improperly functioning management activities. That then brings us to the real root causes of (undesired) events that can be found in the management system.