Step 5: Cause Analysis
After completing the initial stage of accident analysis—gathering information and breaking down the accident into an accurate sequence of events—you now have a clear understanding of what happened. The next step is to determine why the accident occurred by completing the three phases of cause analysis:
![Accident Weed Graphic: showing accident causes]
This graphic illustrates how direct causes of injury and surface causes stem from deeper root causes.
Phase 1 – Injury Analysis:
In this phase, the focus is not on analyzing the accident itself but on understanding what happened during the event. Identify the type of harmful energy involved (e.g., electrical, mechanical, thermal) and how the transfer of this energy caused the injury or illness. Remember, the final outcome of the accident process is an injury or illness.
Phase 2 – Surface Cause Analysis:
Here, you examine how hazardous conditions and unsafe behaviors interacted to produce the accident. These conditions and behaviors are considered the surface causes, providing insight into potential weaknesses in the system that allowed the accident to occur.
Phase 3 – Root Cause Analysis:
In this phase, you analyze weaknesses in the safety management system (SMS) that contributed to the accident. Root causes often involve inadequate safety policies, programs, plans, processes, or procedures. They pre-exist surface causes and may function through poor system design, allowing or even promoting conditions and behaviors that lead to accidents.