Phase 2: Surface Cause Analysis
In the last module, you learned that each event in our sequence will include an actor and an action that may have contributed to the accident. Once we have identified the actors and actions in the sequence of steps, our next job is to analyze each event to determine the surface causes for the accident.
What are Surface Causes?
The surface causes of accidents are those hazardous conditions and unsafe or inappropriate behaviors within the sequence of events that have directly caused or contributed in some way to the accident. It's important to understand that surface causes describe unique conditions or individual behaviors.
A hazardous condition is characterized by the following:
- a unique tool, piece of equipment, or machinery, etc., that is not properly guarded or somehow defective
- an employee's "state of being" such as fatigue or being distracted
- may also be a unique defect in a process, procedure or practice
- may exist at any level of the organization
- is the result of deeper root causes
Unsafe or Inappropriate Behaviors are characterized by:
- taking an intentional/unintentional action that is unsafe or failure to take an action that is safe
- a unique performance error in a process, procedure or practice
- may exist at any level of the organization
- are the result of deeper root causes
It's important to know most hazardous conditions in the workplace are the result of the unsafe or inappropriate behaviors that produced them.
Knowledge Check Choose the best answer for the question.
2-3. Which of the following would be considered a surface cause for an accident?
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