An investigator or team who believe that incidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine all underlying factors in a chain of events that ends in an incident.
The important point is that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an “investigation” which concludes that an incident was due to worker carelessness, and goes no further, fails to find answers to several important questions such as:
– Was the worker distracted? If yes, why was the worker distracted?
– Was a safe work procedure being followed? If not, why not?
– Were safety devices in order? If not, why not?
– Was the worker trained? If not, why not?
– An inquiry that answers these and related questions will probably reveal conditions that are more open to correction.