Advanced Safety Management, 3rd Edition

CHAPTER 20INCIDENT CAUSATION MODELS

Incident investigation is one of the most important elements in an operational risk management system. Nevertheless, research has shown that in many organizations what is done for incident investigation results in missed opportunities to reduce risks. Thus, they do not learn from their histories, and the causal factors remain dormant, with potential.

One of the reasons that incident investigations are not done well is that many safety practitioners have convinced management, based on their adopted causation model, that the principal causal factors for incidents are the unsafe acts of employees. This chapter pleads with safety practitioners that they:

• Do a self-analysis concerning how they think incidents happen.
• Adopt a causation model that encourages inquiry into the reality of causal factors.
• Initiate an educational activity in the organizations for which they give advice to have the causation model they have adopted to become the base for incident investigations.

If incident investigations are done properly, an organization identifies the relative hazards, risks, and possible deficiencies in management systems and can take corrective action to reduce the probability of similar incidents occurring in the future.

REQUIREMENTS FOR CAUSATION MODELS

This author concludes from his research that an incident causation model must be inclusive of the following premises.

• An organization's culture is the primary determiner with respect to the ...