Cause - Consequence: from Management System to Results
Below is a simplified
model showing the relation between the management system and the (unwanted) event. Simplified but including
the main phases of the sequence that lead to loss - from the Management System on the left to the
Consequences on the right.
model" shows the cause - consequence sequence and can be used in a positive way - going
"downstream"- to indicate the important role of the management system to
control loss via basic and direct causes. The model can also be used starting from the other end to
indicate the process to learn from what went wrong, taking the loss or unwanted event as a starting point and
The model was
originally developed by W.H. Heinrich during the thirties of last century. At that time "Management System"
was labelled "Ancestry - Social Environment" while "Basic Causes" was called "Fault of Person". Obviously not
something you could manage very well in an industrial environment.
In the sixties,
Frank E. Bird Jr. renamed the domino's to suggest the relation between the unwanted event
and its consequences on the right and the Management System on the left via Direct- and Basic or "root"
Causes. It was Mr. Bird who showed the way by making the sequence a manageable - and controllable -
The model above is a
simplified reflection of the real life situation but powerful for communication purposes: it relates the
management system to the event and the results thereof, either good or bad, depending on the quality of each
link in the system. It indicates three cause levels: direct
causes, basic causes and the management system. This model is widely accepted in business including such
areas as safety, quality, environment.
The 3 dimensional
cause - consequence model below is an extension I made to show the complexity that can not be seen in the 2
dimensional model above. The 3 D model may appeal more to professional people.
The text on the
domino's is a little different compared with the 2-D model but, without any further explanation, I think you
get the idea about the complexity that unwanted event causation models can have. I included the "barrier
concept" between the event and the initial loss. I also realized that the final loss depends on the actions
to reduce loss and added the emergency services as well as Post Event Planning (PEP) intended to get the
operation back to normal as soon as possible. Please note that I only have one management system at the far
left end. Obviously there could be more than one - not preferable but often practice following various
certification processes and legislative requirements.
Different losses -
In our day to day work
we see the results of unwanted events as errors, mistakes, damage, injuries, complaints, liability claims,
etc. All different losses, yes. But look at the basis causes and they may not be so different anymore.
Unwanted events are caused! By people! Because they do not know how to do their work properly, they cannot do
it as they should do it, they grew into the habit to do it different, they are not motivated, they are not
allowed, they are encouraged to cut corners, they do not have the right tools or they not proper equipment,
Different losses - but the same causes!
Look at the table above and you may conclude that the losses we see all come from the first phase
or domino of the Cause - consequence model.
Loss Control - a
matter of Top-Down AND Bottom-up
"management system" will be initiated by (top) management, it should be clear that various organizational
levels and functions have to work together to make the management system a success. This involves all
management levels, staff and operational personnel. Remember the "Principle of Point of Control".
The principle of point of control
The greatest potential for control tends to exist at the point
where the action takes place
There are more
causation models ranging from simple to complex. If too simple, you can do little with it, if too complex it
may be difficult to explain. What is important is that the model has communication value: to explain the
model to management, employees and others. Also important is that the model has broad international
acceptance. The 5-domino Heinrich/Bird model has both.
In 1990 I did a study
for the Dutch Ministry of Social Affairs covering about 20 different causation models and investigation
methods to include: Heinrich, Bird, Mort, Swain, De Reamer, Adams, Kjellen, Hudson/Reason and others but
concluded that the 5-domino model (Heinrich/Bird) was most suitable. The Bird model relating the management
system to the unwanted event is the one that provides opportunities for managing accidents, incidents and
other unwanted events and associated losses; it is my preferred model to communicate the importance of the
management system and the roles of both management and operational personnel in controlling
The study, by the way,
produced a Dutch government publication S137. You will not find my name connected with it as I did not agree
with the 4 phase model that is introduced in the publication and in which management system and basic causes
are put in one phase. While they are closely related to each other they represented a different level: it is
the management system and related procedures that produce the basic causes in hardware, software and human