Analyzing the Facts
Step 5: Cause Analysis
You have completed the initial step of the accident analysis by gathering information and using it to break the accident down into an accurate sequence of events. You have a good mental picture of what happened. Now it is time to continue the analysis process by completing each of the following three phases of analysis to determine what caused those events. This module will introduce us to three phases of analysis:
This shows how the direct cause of injury and surface causes result from deeper root causes.
- Phase 1 - Injury Analysis: It's important to understand, we're not analyzing the accident in this phase: we are analyzing precisely what happened during the accident event to identify the type of harmful energy involved (electrical, mechanical, thermal, etc.) and how the harmful transfer of this energy (an action) caused the injury or illness. Remember, the outcome of the accident process is an injury or illness.
- Phase 2 - Surface Cause Analysis: In this next phase of the analysis process, you determine how the hazardous conditions and unsafe behaviors described in each of the events interact to produce the accident. The hazardous conditions and unsafe behaviors uncovered are the surface causes for the accident and give clues that point to possible system weaknesses.
- Phase 3 - Root Cause Analysis: During this phase of the analysis process, you're analyzing the weaknesses in the SMS that contributed to the accident. You can usually uncover weaknesses related to inadequate safety policies, programs, plans, processes, and procedures. Root causes always pre-exist surface causes and may function through poor component design to allow, promote, encourage, or even require systems that result in hazardous conditions and unsafe behaviors.
We'll cover each of these three phases of analysis in more detail in the next few sections.
Knowledge Check Choose the best answer for the question.
2-1. In which phase of cause analysis, do we want to know what system weaknesses contributed to the accident?
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