Environmental Engineering Reference
In-Depth Information
when.it.facilitates.an.understanding.of.why.the.accident.occurred,.and.it.is.useful.
in.developing.lessons.learned.from.the.accident..The.direct.cause.is.also.used.when.
writing.up.the.accident.report.and.illing.out.an.accident.report.form.
C
ontributing
C
AusEs
Contributing.causes.are.events.or.conditions.that.alone.do.not.cause.the.accident.but.
increase.the.probability.of.the.accident.occurring..In.other.words,.they.are.not.suf-
icient.to.cause.the.accident.to.occur.by.themselves.but.are.needed.for.the.accident.
to. occur.. Contributing. causes. can. be. unsafe. acts. or. unsafe. conditions.. (Examples.
of.unsafe.acts.and.unsafe.conditions.can.be.found.in.Chapter.7.).An.example.of.a.
contributing.cause.statement.would.be:.“The.painter.failed.to.attach.fall.protection.
to.a.solid,.secure.object.able.to.withstand.the.force.of.5,000.pounds.as.required.by.
OSHA.regulations.”
r
oot
(b
AsiC
) C
AusEs
Root.causes.are.those.that,.if.corrected,.would.prevent.the.accident.from.recurring.or.
similar.accidents.from.happening..They.may.surround.or.include.several.contribut-
ing.causes..They.are.a.higher.order.of.causes.that.address.multiple.problems.rather.
than.focusing.on.the.single.direct.cause..An.example.would.be:.“Management.failed.
to.implement.the.principles.and.core.functions.of.a.safety.and.health.program.”.It.is.
management's.responsibility.to.ensure.that.the.workplace.has.an.effective.safety.and.
health.program.and.that.the.workplace.is.safe.for.employees.to.work.(see.Figure 9.2).
event FActor chAIns (chArtIng) And exPlAnAtIon
E
vEnts
Events.are.occurrences.that.take.place.in.order.for.a.task.to.be.completed..In.the.case.
of.causal.factor.analysis,.events.describe.a.single.occurrence,.and.are.short,.to.the.
point,.and.contain.detail..The.level.of.detail.depends.on.the.task.that.is.performed..
For.example,.“The.plane.descended.200.feet,”.not.“The.plane.lost.altitude.and.the.
pilot.went.by.proper.procedures.to.regain.altitude.”.It.is.up.to.you,.as.the.investigator,.
to.establish.that.level.of.detail.
Events. should. be. used. in. a. causal. factor. analysis. only. if. they. pertain. to. the.
accident..If.the.event.is.not.pertinent.to.the.accident,.exclude.it.from.the.analysis..
For.example,.do.not.include:.“The.worker.called.her.husband.on.her.lunch.break.”.
However,.do.include:.“The.worker.lifted.the.100-pound.block.over.her.head,.which.
led.to.her.hurting.her.back.”
Each. event. should. precede. the. last. event. in. an. understandable. sequence;. this.
means.that.they.should.be.chronological..If.something.does.not.appear.to.make.sense.
or.something.is.missing,.then.investigate.those.areas.where.information.is.lacking..
This.provides.a.better.understanding.of.why.the.accident.happened..It.is.important.
because.of.the.need.to.develop.a.detailed.step-by-step.chart.showing.each.event.in.a.
sequential.manner,.when.trying.to.eliminate.the.causal.factors.of.the.accident.
