Accident Analysis - finding causes of unwanted events
Analysis of accidents, incidents and other type of unwanted events is directed at finding the causes that have
lead to the event and its consequences.
Accident analysis would normally be directed at three levels:
Basis causes and management system aspects can be considered the "root causes" of unwanted events. Root causes
are at the practical end of the causes analyses; "practical" meaning that the causes can (still) be controlled
through efforts and resources that are in proportion to the expected or desired results.
When considering cause analysis consider two routes:
The investigation protocol shall determine when a cause analysis
shall be carried out, depending on the level of risk classification. When
establishing the risk level, consider circumstances that are (slightly) different from those of the actual
accident, incident or event. Could the consequences of the event be much greater under different
circumstances? Consider issues like: if the fire would have occurred during another time of the year, would the
loss have been much greater? Or if the fire brigade could not reach your plant in time because there was an
accident blocking the road, what would have been the consequences? Or: if for, whatever reason, there
would not be enough water to extinguish the fire, what then?
Preferably these analyses should be done using a team approach under the guidance of a "facilitator" with
sufficient knowledge and expertise of the analysis method being used. The role of this person is of particular
importance if the analysis data will be put in a data base for future use and retrieval of information.
Event Cause Analysis
Systems used for cause analyses may include: SCAT (Systematic Cause Analysis Technique) or BSCAT; MORT (Management
Oversight and Risk Tree); Causal tree ("Arbre des Causes") or others. Systems and related software can be found
using the Internet and appropriate search key words.
Unwanted event analysis can
be an important source of information to improve the management system and all related aspects influencing on
the culture of the organization.
Extent of Loss Analysis ("downstream analysis")
The extent of loss analysis should consider:
- presence and efficiency of barriers between the event and the resulting
- the availability of private and public emergency means
- the presence of an up-to-date post event plan (PEP) to limit commercial
Remedial actions ("upstream analysis")
Cause related remedial actions should be developed through a team approach. The following people should be
included when selecting team participants :
- relevant management and supervision
- people from department where the event took place
- people carrying out the activities that took place prior to or during the event
- staff people from maintenance, human resources and other relevant departments
- people involved in emergency actions
- facilitator to guide the process of remedial action development
Consider evaluation of effectiveness of remedial actions, before carrying them out as well as after.
To make sure that remedial actions will be carried our properly and in time, consider the following
- event coordinator - person responsible for everything that is related to the accident, incident or
event, including the actions to be taken
- action owner - person responsible to assure that the action is carried out properly an in time.
This could be the person who actually carries out the action or a person who makes sure that somebody else,
possibly outside the company or organization, carries out the work.