Accidents investigation by the Cause Tree Analysis methodology

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The most extensive accident research methodology is well known, which consists of cause trees. In short, it consists of determining what were the causes of the accident and to propose measures to correct them.


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However, can we say that it is enough?

If we observe the following scene from a famous film, we can see how many circumstances concur for an accident to happen, very few of which cause the accident:

 

That is, limiting ourselves to analysing incorrect or unsafe actions, we can determine what causes these actions and propose measures to prevent them from happening again. But with all the variables that influence an accident, not only unsafe acts, can we really ensure that it will not happen again?

Moreover, most accident investigations I have carried out (and I admit, the majority from my initial investigations) have included at least one or more causes from distractions, overconfidence, breach of safety regulation, etc; that is to say, perhaps the ill-named “human factor”: How experienced was the captain of   Costa Concordia before making such a mistake?

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Well, the most common solution for the Human Factor is the Work Procedures or, put another way, entrust the protection of the worker to “papers”, which, in my opinion, cannot even provide protection from the rain. I do not intend to say that all work procedures are useless, but I think that it is something to be used sparingly.

Therefore, investigating an accident with the cause tree method limits us to analysing what happened and why at a particular time, and we ignore basic information to act on the Human Factor effectively. To this end, we need to study how the work is usually carried out, the most common unsafe acts, the most common errors, the most common corrections to those errors and, almost without realizing it, in addition to finding which deviation caused the accident, we will have the base information to act on the Human Factor (for example, instead of repeating what the worker should not do, encourage them to do the work as they should) and, therefore, establish the best strategy to prevent a recurrence of the accident and increase safety in a real way.

It is actually a technique that can be used before an accident takes place and that helps us to improve productivity, reduce errors and the consequences that occur and thus advance the continuous improvement of safety and health.

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