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HUMANfactors no15
b r i e f i n g n o t e s

For background information on this series of publications, please see Briefing Note 1 - Introduction
ROOT CAUSE: accidents happen at the end of a chain of events. Very often, the immediate cause, just before
the accident, is a human error. But before that, there will be other actions, decisions or events influenced by
various conditions that are part of the overall cause of the accident. By finding the root causes, it may be
possible to prevent future similar accidents.

Case study and analysis
Sparks from a welding torch fell onto solvent and paint-
soaked rags left in the work area causing a small fire. This
was quickly extinguished by the welder. Paintwork and cable
ducting were damaged with repair costs of around £2 500.
Many companies would review this information and look
no further than the immediate causes: litter was left in the
workplace and adequate fire blanketing was not used. The
result would be to discipline the welder and painting crew
and perhaps issue a notice to all workers to pay more
attention to housekeeping.
Such a basic analysis does not explore the true underlying
causes of this event provided by the three root cause
analysis methods which are applied to the above accident
in this briefing note.

Why root cause analysis?
The Health and Safety Commission issued a consultative
document on the subject of accident investigation, but rather
than introduce a legal duty, it plans to develop guidance to
help employers to conduct investigations.

Many accidents are blamed on the actions or omissions
of an individual who was directly involved in operational or
maintenance work. This typical but short-sighted response
ignores the fundamental failures which led to the accident.
These are usually rooted deeper in the organisation’s
design, management and decision-making functions.
Source: Reducing error and Influencing behaviour HSE HSG48 HSE
Books (1999) ISBN 0 7176 2452 8

HSG65 approach
HSE’s Successful health and safety management (reference 5), provides good practical advice on accident investigation. It
suggests that the investigation team should:

Collect evidence
Visit the site and directly observe the conditions where the accident occurred noting the layout (in this case, the location of
the welder, flammable materials, safety equipment, etc)
Review documents: procedures for the painting and welding work; permits; policy documents; risk assessments, etc.
Interview: those involved; witnesses to the accident or its outcome; and those involved before the accident (e.g. supervisors,
inspectors, maintenance crew).

Assemble and consider the evidence
Using HSE’s model of human factors (see briefing note 8) identify the:
- ‘Immediate causes’ of an accident i.e. those concerned with ‘personal factors’ and ‘job factors’; e.g. behaviour of the

painting crew, the welder and the supervisor who signed off the permit to work, work conditions, adequacy of guards,
separation distances etc.

- ‘Underlying causes’ i.e. those concerned with ‘management and organisational factors’ e.g. pressure on paint crew to
complete too many jobs in a shift, failures in safety policy and risk assessment, etc.

Compare findings with legal and company standards
Were the standards applied (e.g. is there a standard for housekeeping; is it enforced)?
Were the standards themselves adequate?

Draw conclusions based on the evidence
Make improvements and track progress against these by regular monitoring and checking (e.g. are they in place; are they
working?)

HSG65 provides further guidance on how to conduct the investigation logically. Starting with ‘premises’ consider if workplace
problems were significant in the accident. Then consider ‘plant and substances;’ was there sufficient guarding of equipment or
containment of substances? Were ‘procedures’ adequate and used correctly? Consider ‘people’ and their behaviour etc.












root cause
analysis

Purpose of this briefing note
This briefing note introduces root cause analysis methods.
These are used as a means of tracing the origin of accidents
and incidents (near misses). They help organisations to learn
from these experiences and indicate what steps to take to
prevent future occurrences. A large number of techniques
exist. You are advised to read further or to attend a training
course before using any of them.
Companies should develop a policy for when to conduct root
cause analysis; it may be applied to all incidents or only those
with major accident potential.

Copyright © 2003 by The Institute of Petroleum, London: A charitable company limited by guarantee. Registered No. 135273, England
HFBr.0043.211102.Root Cause Analysis BN page 1.rev2.D.W.doc


Root Cause

Analysis

Why Root Cause Analysis?
The Health and Safety Commission issued a Consultative
Document on the subject of accident investigation and are
likely to make it a legal duty under the RIDDOR or MHSWR
Regulations to conduct investigations.

“Many accidents are blamed on the actions or omissions of an
individual who was directly involved in operational or
maintenance work. This typical but short-sighted response
ignores the fundamental failures which led to the accident.
These are usually rooted deeper in the organisation’s design,
management and decision-making functions”.
[Source: HSE, (1999) HSG48, ‘Reducing Error and
Influencing Behaviour’]

Case Study and Analysis
Sparks from a welding torch fell onto solvent and paint-soaked rags
left in the work area causing a small fire. This was quickly
extinguished by the welder himself. Paintwork and cable ducting
were damaged with repair costs of around £2 500.
Many companies would review the above information and look no
further than the immediate causes: someone left litter in the
workplace and the welder did not remove this or put adequate fire
blanketing in place. The result would be to discipline the welder and
painting crew and perhaps issue a notice to all workers to pay more
attention to housekeeping.
Such an analysis does not explore the true underlying causes of this
event: root cause analysis methods do.
This Briefing Note Provides examples of 3 root cause analysis tools
applied to the above accident.

Institute of Petroleum Human Factors Briefing Note No. 15

Root Cause: accidents happen at the end of a chain of events. Very often, the
immediate cause, just before the accident, is a human error. But before that,
there will be other actions, decisions or events influenced by various conditions
that are part of the overall cause of the accident. By finding the root causes, it
may be possible to prevent future similar accidents

HSG65 Approach HSE’s Document, ‘Successful Health and Safety Management’ provides good practical advice on accident
investigation. It suggests that the investigation team should:
1. Collect Evidence
• Visit the site and directly observe the conditions where the accident occurred noting the layout (where the welder was

located, where the flammable materials were, the position of safety equipment etc)
• Review documents – procedures for the painting work and the welding work, permits, policy documents, risk assessments etc
• Conduct interviews with – those involved, witnesses to the accident or its outcome, those who had any involvement before the

accident (eg. supervisors, inspectors, maintenance crew).
2. Assemble and Consider the Evidence
• Using HSE’s model of human factors (See Briefing Note 8) identify the ‘immediate causes’ of an accident (those concerned

with ‘Personal Factors’ and ‘Job Factors’ – ie. behaviour of the painting crew, the welder and the supervisor who signed off the
permit to work, work conditions, adequacy of guards, separation distances etc), Identify the ‘underlying causes’ (those
concerned with ‘Management and Organisational Factors’ – pressure on paint crew to complete too many jobs in a shift, failures
in safety policy and risk assessment etc).

3. Compare Findings with legal and company standards
• Were the standards applied (eg. is there a standard for housekeeping, is it enforced?)
• Were the standards themselves adequate?

4. Draw conclusions based on the evidence
5. Make improvements and track progress against these (are they in place; are they working?) by regular monitoring and checking.

HSG65 provides further guidance on how to conduct the investigation logically. Starting with ‘premises’ – workplace problems,
consider if these were significant in the accident. Then consider ‘Plant and Substances’ - was there sufficient guarding of
equipment or containment of substances? Were ‘Procedures’ adequate and used correctly? Consider ‘People’ and their behaviour etc.

Purpose of This Briefing Note
This Briefing Note introduces root cause analysis
methods. These are used as a means of tracing the
origin of accidents and incidents (near misses). They
help organisations to learn from these experiences
and indicate what steps to take to prevent future
occurrences.
A large number of techniques exist. You are advised
to read further or to attend a training course before
using any of them.
Companies should develop a policy for when to
conduct root cause analysis; it may be applied to all
incidents or only those with major accident potential.

For background information on this series of publications, please see Briefing Note 1 – Introduction.

Management
decisions

Unsafe acts
Accidents

1.

2.

3.

4.
5.

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