While accident investigation is a basic function of EHS management, it is by no means routine or predictable. If not managed appropriately, the investigation process can produce tunnel vision as the investigator searches for the accident cause – and too often produces a singular finding when the real cause is more complex.
To conduct a successful accident investigation, investigators must look beyond what meets the eye in the form of the immediate cause and instead examine the root cause(s) of an accident, which often is more multifaceted than a single cause.
The Multiple Factor Theory
Investigators can avoid the pitfall of tunnel vision by employing the Multiple Cause Theory, popularized by V.L. Grose. This theory holds the belief that accidents are rarely, if ever, caused by a single event. Rather, multiple factors work together and culminate into a singular accident event.
These factors can vary but are typically divided into four groups: man, machine, media and management.
Despite the fact that the human factor is sometimes overlooked, it is a vital consideration during accident investigation. More often than not, people are a composite component in the creation of an accident.
Factors such as worker age, experience, skill level, education, fatigue level and attitude, as well as many other human factors, can influence the development of an accident.
The majority of accidents experienced in industry involve exterior forces such as mechanized equipment, vehicles, stationary industrial equipment and a plethora of other types of equipment that feature moving parts or the ability to produce energy. The machine factor is integral to any accident investigation.
Media includes the method and/or atmosphere in which the accident took place. It is important to consider the atmospheric conditions (weather, environment, pollution, etc.) as they often play a role in accidents. Equally important is the method in which the accident came about -- this provides valuable causal insight.
Company or organization management represents a commonly overlooked accident factor. The lack of management buy-in to company safety programs is a systemic problem that likely will lead to accidents. Company/organization policies, organization structure, mission statements and production objectives should include EHS endeavors. The absence of EHS in these elements is a definite consideration to be made during an accident investigation.
Although not all of the aforementioned factors will always come into play during accident investigations, it is likely that several will. Be sure to include them in your protocol. After all, while most EHS managers understand that accident investigations are not implemented to place blame, properly executed investigations are vital to the health and well-being of an organization’s work force.
EHS Today guest blogger Jason Townsell was named the 2010 Future Leader in EHS. He works as an assistant safety manager/trainer for LA World Airports (LAWA) Airport Development Group.