Conducting an Accident Investigation
Course 102
Safety Certified Supervisor Series

MODULE 5: DETERMINING SURFACE AND ROOT CAUSES

Last Words

One last important point to make is that most accident processes are far more complex than we might originally think. Some experts believe at least 10 or more factors come together to cause a serious injury. Other experts state that, on average, 27 factors directly and indirectly contribute to serious accidents.

Only by thoroughly conducting all three levels of analysis can we design system improvements that effectively eliminate hazardous conditions and unsafe behaviors at all levels of the organization. The accident investigation can not serve as a proactive safety process unless system improvements effectively prevent future accidents.