EXTERNAL PUBLICATIONS

SUMMARY

Typically an incident report will place emphasis on developing a description of the consequences rather than causes of the incident, explaining what happened, but not why it happened. It is only by adopting investigation techniques that explicitly identify root causes, ie the reasons why an incident occurred, that organisations may learn from past failures and avoid similar incidents in the future. Root causes analysis is simply a tool designed to help incident investigators determine what, how and most importantly, why an incident occurred.

Based on this literature review it is apparent that there are three key components that need to be applied to ensure effective root causes analysis incident investigation. These are a method of describing and schematically representing the incident sequence and its contributing conditions; a method of identifying the critical events or active failures and conditions in the incident sequence, and based on this identification; a method for systematically investigating the management and organisational factors that allowed the active failures to occur, ie a method for root causes analysis. In selecting or developing a root causes analysis method, the analyst needs to consider whether the method specifically facilitates the identification of safety management and organisational inadequacies and oversights which relate to their own operations. The method needs to identify those factors that exert control over the design, development, maintenance and review of their risk control systems and procedures.

This report and the work it describes were funded by the Health and Safety Executive (HSE) Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.