HSEHealth&SafetyExecutiveRootcausesanalysis:LiteraturereviewPreparedbyWSAtkinsConsultantsLtdfortheHealthandSafetyExecutiveCONTRACTRESEARCHREPORT325/2001HSEHealth&SafetyExecutiveRootcausesanalysis:LiteraturereviewADLivingston,GJackson&KPriestleyWSAtkinsConsultantsLtdScience&TechnologyWSAtkinsHouseBirchwoodBoulevardBirchwoodWarringtonWA37WATypicallyanincidentreportwillplaceemphasisondevelopingadescriptionoftheconsequencesratherthancausesoftheincident,explainingwhathappened,butnotwhyithappened.Itisonlybyadoptinginvestigationtechniquesthatexplicitlyidentifyrootcauses,iethereasonswhyanincidentoccurred,thatorganisationsmaylearnfrompastfailuresandavoidsimilarincidentsinthefuture.Rootcausesanalysisissimplyatooldesignedtohelpincidentinvestigatorsdeterminewhat,howandmostimportantly,whyanincidentoccurred.Basedonthisliteraturereviewitisapparentthattherearethreekeycomponentsthatneedtobeappliedtoensureeffectiverootcausesanalysisincidentinvestigation.Theseareamethodofdescribingandschematicallyrepresentingtheincidentsequenceanditscontributingconditions;amethodofidentifyingthecriticaleventsoractivefailuresandconditionsintheincidentsequence,andbasedonthisidentification;amethodforsystematicallyinvestigatingthemanagementandorganisationalfactorsthatallowedtheactivefailurestooccur,ieamethodforrootcausesanalysis.Inselectingordevelopingarootcausesanalysismethod,theanalystneedstoconsiderwhetherthemethodspecificallyfacilitatestheidentificationofsafetymanagementandorganisationalinadequaciesandoversightswhichrelatetotheirownoperations.Themethodneedstoidentifythosefactorsthatexertcontroloverthedesign,development,maintenanceandreviewoftheirriskcontrolsystemsandprocedures.ThisreportandtheworkitdescribeswerefundedbytheHealthandSafetyExecutive(HSE)Itscontents,includinganyopinionsand/orconclusionsexpressed,arethoseoftheauthorsaloneanddonotnecessarilyreflectHSEpolicy.HSEBOOKSii©Crowncopyright2001Applicationsforreproductionshouldbemadeinwritingto:CopyrightUnit,HerMajesty’sStationeryOffice,StClementsHouse,2-16Colegate,NorwichNR31BQFirstpublished2001ISBN0717619664Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmittedinanyformorbyanymeans(electronic,mechanical,photocopying,recordingorotherwise)withoutthepriorwrittenpermissionofthecopyrightowner.iiiForewordIn1991HSEpublishedSuccessfulHealthandSafetyManagement,HSG65,ISBN0717612767,whichdescribedamodelforhealthandsafetymanagement.Thiswasfollowedin1993byTheCostsofAccidentsatWork,HSG96,ISBN0717613437,whichbothanalysedthecostsofindividualaccidentsat5sitesovera3monthperiodanddiscussedthebackgroundtotheeconomicargumentforgoodhealthandsafetyusinglosscontrolprinciples.TheanalysisconfirmedearlierworkbyHeinrichandothersonbuildingaccidentpyramids,wherebyasmallnumberoffatal/seriousaccidentsisunderpinnedbyamuchlargernumberofminorinjuriesandnoninjurydamageoccurrences.HSEsubsequentlycommissionedWSAtkinstoinvestigateiftheworkinthesetwopublicationscouldbelinked–couldthecostsofaccidentsbeclearlyidentifiedandlinkedbacktospecificmanagementfailures?Ifitcouldthiswouldenableorganisationstotargetimprovementeffortinacosteffectivewaybyconcentratingonwelldefinedareasoffailure.Thisshouldreducebothoverallcostsandaccidentnumbers.Theworkinvolveddevelopingandtriallingtwomajormethodologies–oneforcapturingdataoncostsofaccidents,whichwassimplerandmor...
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