MODULE 6: EFFECTIVE INCIDENT / ACCIDENT ANALYSIS

More on root causes

The root causes or "system causes" for accidents are the underlying system weaknesses that have somehow contributed to the general presence of hazardous conditions and common occurrence of unsafe behaviors that represent surfaces causes of accidents. If we see trends in conditions or behaviors - more than one unique instance - we should suspect system design or implementation weaknesses exist.

Root causes always pre-exist surface causes. Indeed, inadequately designed system components have the potential to feed and nurture hazardous conditions and unsafe behaviors. If root causes are left unchecked, surface causes will flourish!