Investigation of Incidents: Finding The Underlying Causes

Certificate IV in Occupational Health and SafetyThe determination of the underlying causes of a workplace incident will be dependent on the immediate causes supported by information provided by witnesses and established by undertaking appropriate research. The immediate causes have told us how the incident happened, whilst the underlying causes will tell us why the incident happened.

To establish the underlying causes, the investigators will need to ask probing questions to witnesses, primarily to establish their understanding of the health and safety practices and procedures in place at this site, and whether they are being implemented and adhered to. Some of the witnesses the investigator will need to interview will not have first-hand knowledge of the incident that is being investigated, but should be fully aware of the health and safety practices and procedures of the enterprise.

Major writers on incident investigation such as Trevor Kletz, quoted at the start of this section, all agree that the responsibility for the basic underlying causes of incidents rests with management. DuPont, one of the world’s largest enterprises and manufacturers, espouses, amongst other things, the theory that: “…all injuries are preventable and are ultimately caused by management failure.”

This does not mean that management have deliberately created situations where a person will be injured, but, usually they have not fulfilled their duty of care. For example: to provide sufficient safe working procedures or policies that will identify the hazard before the risk associated with that hazard becomes unacceptable; or to provide and enforce sufficient maintenance and replacement policies to prevent a piece of equipment becoming distorted or failing.

Take an example of a person being injured because a rope or cable used to lift or restrain some load or item fails, causing the person to be struck by the load or item. The immediate cause of the incident is that a rope or cable failed. It broke! The important thing to establish is – why did it break? Was there a procedure in place to regularly check the rope or cable for wear? Was there a procedure in place to replace the rope or cable after a pre-described period of time or usage? If not, management have failed in their duty of care! We all know that ropes and cables are disposable or consumable items that are subject to “wear and tear,” and there should have been inspection, maintenance and replacement procedures in place.

If our research reveals that the inspection, maintenance and replacement procedures were in place, what do we do? The next step is to establish: were these procedures observed? Did the person who was responsible for implementing these procedures know about the procedures and their role? Have they been trained to assess the conditions of the rope or cable? If not, management have failed to provide adequate training to ensure that their workers work in a safe environment!

Our further research indicates the procedures were in place, the person responsible for implementing the procedures was fully aware of their responsibilities, had received adequate training, and were competent to carry out the tasks. Ah-ha! The careless worker! WRONG! Management failure again! Lack of supervision. It is fine to delegate a responsibility after ascertaining the delegated person is adequately trained and skilled. However, it is essential that adequate follow up is maintained to ensure these delegated responsibilities are implemented and continued.

Once again, our research has ruled out all of these factors. The cable was inspected, maintained and was not due for replacement. What next? Was the rope or cable adequate for the purpose it was being used? Was the rope or cable for industrial use? Was the rope or cable quality tested? Was the load excessive? These are the type of questions that have to be asked, the type of research that has to be undertaken, in a methodical structured format, eliminating potential for failure as you go…until you find the root cause of the incident.

Hopefully, by now, you will see a trend. All of the scenarios outlined in the example all ultimately pointed to a management failure. Failure to have safe working procedures! Failure to have adequate training for workers! Failure to have adequate instructions for workers! Failure to have adequate supervision for workers!

Whilst in some incidents, the worker may have done the wrong thing, and admits it, it still does not absolve management from having sufficient systems, training, instruction and supervision in place that should have detected and prevented the worker doing the wrong thing.

Could the system have been changed to avoid using the rope or cable? Could the rope or cable be substituted with another method of restraint or lifting? Was it necessary to restrain or shift this item or load? Was it necessary for the injured person to be in a position where they could be struck by the load if the rope or cable failed? Could a barrier be placed between the load and the location of the injured person?

Whilst undertaking the research and analysis of the immediate and underlying causal factors of this scenario, the investigator should have been cognisant that they have to make recommendations and provide preventative strategies as part of their investigations and reporting, as well as being mindful of the hierarchy of control.