Conducting an Accident Investigation
Course 102
Safety Certified Supervisor Series

MODULE 5: DETERMINING SURFACE AND ROOT CAUSES

System Analysis to determine the root causes of accidents

Once you start identifying inadequate policies, programs, plans, processes, and procedures in the diagram above. You're getting to the real root causes!

The root causes for accidents are the underlying safety system weaknesses that have somehow contributed to the existence of hazardous conditions and unsafe behaviors that represent surfaces causes of accidents.

These weaknesses can take two forms:

• Design root causes. Inadequate planning and design of the system. The development of formal (written) safety management system policies, plans, processes, procedures is very important to make sure appropriate conditions, activities, behaviors, and practices occur.
• Implementation root causes. Inadequate implementation of the system. Failure to effectively carry out the safety management system is critical to the success of the system. You can develop a wonderfully designed system, yet if it's not implemented correctly, it won't work.

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