Incidents- Causes and Investigation

Birds Lost Causation Model (Frank E.Bird, 2012)


            An Incident is any event that could or does result in unintended harm or damage. Incidents occur daily at most workplaces and while most cause no damage or injuries, all have the potential to impact your operation. All incidents need to be investigated and the Root/Basic cause found as well as what management could have done to prevent/avoid the incident from occurring and more importantly re-occurring. The results of the investigation must be communicated to the employees affected by the incident and discussed at the next Safety Meeting and/or Tool Box Meeting. Using Birds Lost Causation model, we can effectively investigate all incidents and determine the cause of the incident and how to prevent similar incidents from occurring in the future. The “How Incidents occur” arrow indicates a breakdown in the Health and Safety system which allowed the incident to occur. The “Why Incidents occur” arrow indicates all the reasons why an incident has occurred and your investigation will address all the “Whys” and come up with a solution to avoid similar incidents from occurring in the future. Lastly all investigations are NOT to ASSIGN BLAME but rather to determine the cause(s) of the incident and correct any defects in the whole system. Finger pointing and blame undermines the whole Health and Safety system and do nothing to prevent incidents from re-occurring.

Loss- This is the result of the incident. It can be injury to workers or the public, damage to equipment and/or property, environmental damage and in the worst case death of worker(s) and/or the public. With Near-Miss incidents, the loss is negligible but the events leading up to the incident will still need to be investigated.

Incident- This is the event that causes the Loss or had the potential to cause loss. It generally involves the transfer of energy from object(s) to the worker(s), public, equipment. This energy transfer can involve kinetic energy, electrical energy, thermal energy, chemical energy and acoustic energy. Falls, Struck by, Release of, Caught in/on/between, and Overstress/Overload are examples of energy transfers which cause loss. Designing your hazard controls around the transfer of energy concept will allow your business to design and implement controls that prevent or minimize the energy transfers. The use of barriers and PPE that absorbs/deflects impacts should be considered. The use of less hazardous chemicals (reduces chemical energy) should also be considered. Any item that reduces or eliminates the energy transfer should be included in the hazard control phase of your Hazard Assessment.

Immediate Causes- These are the circumstances that immediately precede the incident. These causes are broken down into Substandard Acts or Practices and Substandard Conditions. Substandard Acts/Practices are deviations or departures from acceptable standards/norms. Substandard Conditions are any circumstance(s), that left uncorrected could permit or lead to an incident occurring. The Acts/Practices can be either individual acts or company-wide practices. Failure to correct Substandard Acts can cause these “individual” acts to become Substandard Practices. Using “Substandard” to describe these causes indicates that your business has measurable standards/practices and these standards are to be met by all employees. Any deviations will be corrected immediately. Some examples of Substandard Acts/Practices are Failure to follow Company Procedure(s)/Policy/Rules, Failure to Secure, Failure to Warn, Making Safety Devices Inoperable, Horseplay and Improper Lifting/Loading/Placement. Some Substandard Condition examples are Inadequate Guards/Barriers, Inadequate or Improper PPE, Inadequate Procedures/Instructions and Poor Housekeeping. These examples are only a few of the many Substandard Acts/Practices and Conditions that can contribute to an incident. Most if not all incidents will have more than one Immediate Cause and the investigation MUST ensure that ALL CAUSES are identified. Finally Immediate Causes are only “Symptoms” of underlying issues with the Health and Safety system and one cannot cure the disease by only treating the symptoms. A thorough and complete investigation will continue past Immediate Causes and look at Basic Causes and Management Control to get a complete picture on why the system broke down and an incident occurred.

Basic Causes- These are sometimes referred to as the Root Cause or Indirect Cause of an incident. These help explain why people perform Substandard Acts/Practices and Substandard Conditions exist and how to prevent them from occurring/reoccurring.  An example of this is a person who hasn’t been trained in your procedures/rules therefore cannot follow them, this could lead to an incident. Substandard Conditions could exist due to use of equipment that isn’t suitable for the task(s) assigned to it or equipment that isn’t maintained in accordance with manufacturer’s specifications. Basic Causes are broken down into 2 categories. These are Personal Factors and Job/System Factors. Personal Factors are further broken down into 7 sections. These sections are Inadequate Physical/Physiological Capability, Inadequate Mental/Psychological Capability, Physical or Physiological Stress, Mental or Psychological Stress, Lack of Knowledge, Lack of Skill and Improper Motivation. As you can see these factors revolve around the worker and their issue(s). Again these factors are not to blame but rather to explain why the incident occurred. For example, was the worker new on the job and not used to working the night shift? Did they have stress at home? Or perhaps they were ill and did not possess the strength to lift the boxes properly. An effective investigation will address all these Personal Factors and if required adjust or modify the work environment.

            The second category, Job/System Factors, deal with the specifics of the job, work environment and the system as a whole. Job/System Factors are broken into 8 categories. Inadequate Leadership and/or Supervision, Inadequate Engineering, Inadequate Purchasing, Inadequate Maintenance, Inadequate Tools and Equipment, Inadequate Work Standards, Wear and Tear and Abuse and Misuse. We can see that these categories no longer deal with the employee(s) involved and now deal with supervisors and managers. Because of this, some companies are reluctant to investigate this far as it might reflect negatively on their management and the system put in place by the management team. If the system has failed i.e. Caused an Incident, then the only way to prevent the re-occurrence of the incident is to examine the whole system, fix what broke and to do it in a way that doesn’t point fingers and blame people. Basic Causes are the origins or the “WHY” Substandard Acts/Practices and Conditions exist but they are not the beginning of the model. The start is Lack of Control.

Management Control- Lack of Management Control starts the whole Loss process. Your investigation must take the lack of control into account to ensure that whole system has been questioned, and all defects found and fixed. Management Control has 3 sections in it. Inadequate System, Inadequate Standards and Inadequate Compliance with Standards. A company’s system can be considered inadequate when it contains too few or improper system elements. The system itself needs to be changed/upgraded to avoid incidents or a system needs to be implemented as there isn’t one. Inadequate Standards can lead to confusion about what the standards are, they are not specific enough, not high enough or a combination of all of these. Standards need to indicate who is responsible for them, what they are responsible for, and what the standard is. The standard is measurable and when/how often the standard is to be used. Without Compliance the standards your company has are useless. Who ensures that standards are followed and what happens when they are not followed? Are standards taught/demonstrated to all workers upon hire or are they shown while on the job? Do supervisors know the standards and does management support the supervisors in the enforcement of them. All of these need to be addressed as part of the Management Control stage of the investigation.


   A Health and Safety program from Rampart Safety Services will show you and your workers the investigative procedure and the reasons why all incidents need to be reported, investigated and discussed. It will give your employees the tools they need to reduce incidents and maintain a safe and healthy workplace. Contact us today to see how Rampart Safety Services can put your company on the path to safety.

Andrew Melville, CD, NCSO

Work Cited:

Frank E.Bird, G. L. (2012). Practical Loss Control Leadership 3rd Edition. Duluth, Georgia: Det Norske Veritas (USA) .

Posted by: administrator ON Wed, March 8, 2017 at 3:41:54 pm MST    Comments (0)
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