Conducting an Accident Investigation
Course 102
Safety Certified Supervisor Series

MODULE 5: DETERMINING SURFACE AND ROOT CAUSES

New Theory - Systems Approach

The systems approach takes into account the dynamics of systems that interact within the overall safety program. It concludes that accidents are considered defects in the system. People are only one part of a complex system composed of many complicated processes (more than we realize). Accidents are the result of multiple causes or defects in the system. It becomes the investigator's job to uncover the root causes (defects) in the system.

Fixing the system, not the employee, is the heart of the investigation. To prevent accidents, the system must work more safely. This thinking results in long-term fixes: Less expensive to implement and maintain.