Diving Deeper into Causation

One of the hallmarks of a successful safety culture is a clear understanding of causation of incidents.  As the saying goes, if incidents are caused, they can be prevented…

The challenge is to go deep enough in the investigative process to truly understand the actual cause, or “root” cause of the incident – or at least enough about the “probable cause” to succeed in preventing the next one.  In my experience, the easy path to determine causation often results in blaming the employee and discards the harder, less appealing truths about causation: supervisory shortfalls, failures in systems and processes, mistakes in judgement, lack of accountability, poor communication, inaccurate or incomplete hazard assessments, uncontrolled third parties, etc. 

Employee decision making is frequently the culprit on the surface, but what led up to that decision?  How was the employee’s decision influenced by culture or climate, co-workers or management?  Not shooting flaming arrows at management here, but before we condemn the employee, we need to understand the dynamics of his decisions and where that can be improved.  Even if it leads to some uncomfortable truths.

The bottom line is, if we are serious about understanding causation, there is no substitution for a thorough, revealing investigation that uncovers everything about the incident.  Some deference to reality needs to be paid as it pertains to minor incidents, and companies will do what they will with the findings.  But true improvement will prove to be elusive if surface scratches masquerading as investigations is all an organization is inclined to do.

Do your investigations reveal everything about causation?