The basic assumption here is that the events that lead to the consequences that we see are more often than not
triggered by someone doing something in a certain environment. We divide the direct causes in: (1) causes that are
related to a person and an act, and (2) causes that are related to the (work) environment or
Direct causes of accidents, incidents and other unwanted events are divided in two main categories:
We use the term "substandard" to indicate that there must be a right or "standard"
way of doing things when it comes to acts and right or standard situations or environments when it comes to
conditions. "Standard" meaning safe, good, without undue risks implying that the tasks and conditions need to be
adapted to the people doing the work in the particular environment.
The simple 2 D model above seems to indicate that we are mainly concerned with the acts of people carrying out work
directly prior to the unwanted event. But
that is because the model is a simplification and you should keep in mind that the actual situation is more
there is only a thin line between direct causes and basic causes.The
substandard act could have been done by a person at a different level in the organization, further away from
the unwanted event and at a different time. For example: lack of adequate training to carry
out work could be the cause of a substandard act by the person on the job. But, if so, could the “underlying”
act have been committed by the supervisor or HR department not providing proper training? Or by higher
management not requiring proper training through the management system? Or did the purchasing department buy
the cheaper product to create a substandard condition? Or was the substandard condition created by the
person designing the work environment or installation?
Basic causes may exist because (1) there is no "standard way" if doing things, (ii)
the standard way is not being updated, (iii) substandard work practices are being tolerated by supervision and
management, (iv) carrying out work according to the standard way of doing things is considered "for
Not for Sissies:
Substandard conditions or situations may exist because: (i) they are
designed that way, (ii) there is no proper management of change program, (iii) they are not corrected when found,
(iv) there is no proper inspection program to find the substandard conditions, (v) there is no housekeeping
program, (vi) substandard conditions are being tolerated by supervision and management, (vii) they are seen as
"part of the normal work environment", etcetera.
Substandard acts and conditions are closely related. A substandard condition or
situation may be created though a substandard act by a person, operational, managerial or staff. Once the
substandard condition is there, the act of another person may be looked upon as a substandard while in fact it was
the condition that led to the unwanted event.
causes of unwanted events can often be seen at the actual work
site and may be found during execution of procedures such as work permits or Last Minute Risk Assessment (LMRA).
They can be seen during formal inspections/observations and, preferably, should be noted and acted upon during
day-today operations. Since direct causes relate to acts and conditions that may be there only momentarily, they
may also be considered during incident or accident imaging exercises
asking the "what if" questions.
Substandard acts and conditions can be found during investigation of
unwanted events, leading to remedial actions which may include revision of work procedures or changing the work
One of the main functions of management is to control loss
To close the gap between "practice" and "theory"
Between "what and how it is done" and "what and how it should have been done"
Between "substandard" how it is and "standard" how it should be