ASSE: A Weak Link in Accident Theory?

June 26, 2003
Using a model of a linear chain of events to describe accidents and their causes is common in the safety profession, said Allan Goldberg, a safety consultant with International Risk Control America, but is misleading and can result in accident investigations that fail to uncover the root causes of incidents.

Goldberg spoke at the 2003 American Society of Safety Engineers' Professional Development Conference in Denver.

Goldberg cited three problems with the chain of events analogy:

1.) Incidents are not linear but multivariable, said Goldberg. Various factors that interact in a variety of ways can lead to an accident. He said it was unrealistic to "look at any one action by the worker in one particular incident and declare that preventing this one action will always preclude the incident from happening."

2.) The "weakest link" view of accident causation fails to address multiple causes and tends to focus on direct or immediate causes. The direct causes of accidents are symptoms, not the root cause, Goldberg stressed, "Human error is not a root cause." He said a problem with behavior-based safety is that it tends to focus on workers' actions. In accident investigations, this may lead to a failure to identify the root cause of an accident.

3.) Corrective actions tend to focus on the "point of failure," often perceived as a worker's error. "If we think all problems are caused by human error, that is the only place we will look," Goldberg told attendees. Instead, he said safety professionals should look for the most effective "point of control," which may involve supervision, work process controls, training and inspection procedures, in order to prevent a similar incident from occurring.

"Investigation leads you to the point of failure," said Goldberg. "Analysis leads you to the point of control."

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