HUMAN

factors no15
Institute of Petroleum Human Factors Briefing Note No. 15
briefing notes
For background information on this series of publications, please see Briefing Note 1 – Introduction.
For background information on this series of publications, please see Briefing Note 1 - Introduction

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

root cause
Purpose of This Briefing Note
analysis
This Briefing Note introduces root cause analysis
methods. These are used as a means of tracing the
Purpose of origin
thisof accidents
briefingand incidents (near misses). They
note
This briefinghelp organisations
note introducestoroot
learn from these
cause experiences
analysis methods.
These are used as a means
and indicate of tracing
what steps to takethe origin offuture
to prevent accidents Management
and incidents (near misses). They help organisations to learn
occurrences. decisions
from these A experiences
large numberand indicate what
of techniques exist.steps to take
You are to
advised
prevent future occurrences.
to read further or A
tolarge
attendnumber of course
a training techniques
before
exist. You are advised to read further or to attend a training
using any of them.
course before using any of them.
CompaniesCompanies should develop a policy for when to
should develop a policy for when to conduct root
conduct
cause analysis; rootbe
it may cause analysis;
applied it may
to all be applied
incidents to allthose
or only Unsafe acts
incidents or
with major accident only those with major accident potential.
potential. Accidents

Case study and and

Case Study analysis
Analysis Why rootWhy
causeRoot
analysis?
Cause Analysis?
Sparks fromSparks
a weldingfrom torch fell torch
a welding onto solvent
fell ontoand paint-
solvent and paint-soakedThe ragsHealth and Safety Commission issued a consultative
The Health and Safety Commission issued a Consultative
soaked ragsleft leftininthe
thework
work area
area causing
causing a small
a small fire. This
fire. This was quickly document on the subject of accident investigation, but rather
Document on the subject of accident investigation and are
was quickly extinguished
extinguishedbyby thethe welder.
welder Paintwork
himself. andand
Paintwork cable
cable ducting
than introduce a legal duty, it plans to develop guidance to
likely to make it a legal duty under the RIDDOR or MHSWR
ducting werewere damaged
damagedwithwithrepair
repaircosts
costs of around
around £2 £2500.
500. help employers to conduct investigations.
Regulations to conduct investigations.
Many companies would review
Many companies wouldthis information
review the above and look and look no
information
no further than the than
further immediate causes:causes:
the immediate litter was left in
someone the
left litter in the Many accidents are blamed on the actions or omissions
“Many accidents are blamed on the actions or omissions of an
workplace and adequate
workplace firewelder
and the blanketing
did not was not used.
remove this orThe
put adequate of fire
an individual who who
waswasdirectly involved
individual directly involvedininoperational or
operational or
result wouldblanketing in place.the
be to discipline The result and
welder wouldpainting
be to discipline
crew the welder and
maintenance work. Thiswork.
typical
maintenance Thisbut short-sighted
typical response
but short-sighted response
and perhapspainting
issue acrew and to
notice perhaps issue a to
all workers notice
pay to all workers to pay more
more ignores the ignores
fundamental failures which
the fundamental failuresled to the
which ledaccident.
to the accident.
attention to attention
housekeeping.to housekeeping. These are usually rooted deeper in the organisation’s
These are usually rooted deeper in the organisation’s design,
Such a basic Such an analysis
analysis doesdoesnot not explore
explore thethe true
true underlying causes of
underlying this management and decision-making functions.
design, management and decision-making functions”.
event: root cause analysis methods
causes of this event provided by the three root cause do. Source: Reducing errorHSE,
and Influencing behaviour HSE Error
HSG48 HSE
[Source: (1999) HSG48, ‘Reducing and
This Briefing
analysis methods whichNote Providesto
are applied examples
the aboveof 3accident
root cause analysis Books
tools (1999) ISBN 0 7176 2452 8
Influencing Behaviour’]
applied
in this briefing note.to the above accident.
HSG65 Approach
HSG65 approach HSE’s Document, ‘Successful Health and Safety Management’ provides good practical advice on accident
HSE’s Successful health and safety that
investigation. It suggests the investigation
management team should:
(reference 5), provides good practical advice on accident investigation. It
1. Collect Evidence
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,
• Visit the site and where
directly the flammable
observe materialswhere
the conditions were, the
theposition
accidentof occurred
safety equipment
noting etc)
the layout (in this case, the location of
• Review documents – procedures
the welder, flammable materials, safety equipment, etc)for the painting work and the welding work, permits, policy documents, risk assessments etc
• Review •documents:
Conductprocedures
interviews with for –the
those involved,
painting andwitnesses
weldingtowork;
the accident
permits;orpolicy
its outcome, those who
documents; riskhad any involvement
assessments, etc.before the
accident
• Interview: those (eg. supervisors,
involved; witnesses to inspectors, maintenance
the accident crew).
or its outcome; and those involved before the accident (e.g. supervisors,
2. Assemble
inspectors, and Consider
maintenance crew). the Evidence
2. Assemble •and consider
Using HSE’s themodel of human factors (See Briefing Note 8) identify the ‘immediate causes’ of an accident (those concerned
evidence
with ‘Personal
• Using HSE’s model of human Factors’ and ‘Job
factors (seeFactors’
briefing– note
ie. behaviour of the
8) identify the:painting crew, the welder and the supervisor who signed off the
- ‘Immediate permit
causes’to of
work, work conditions,
an accident adequacy
i.e. those of guards,
concerned withseparation
‘personaldistances
factors’ etc), Identify
and ‘job the ‘underlying
factors’; e.g. behaviour of(those
causes’ the
concerned with ‘Management and Organisational Factors’ – pressure on paint crew to complete
painting crew, the welder and the supervisor who signed off the permit to work, work conditions, adequacy of guards, too many jobs in a shift, failures
separation in safety policy
distances etc. and risk assessment etc).
3. Compare
- ‘Underlying Findings
causes’ with legal
i.e. those and company
concerned with standards
‘management and organisational factors’ e.g. pressure on paint crew to
• too
complete Were
manythejobs
standards applied
in a shift, (eg. is in
failures there a standard
safety for housekeeping,
policy and risk assessment, is it enforced?)
etc.
•
3. Compare findings Werewith
thelegal and company
standards themselves standards
adequate?
• Were the standards applied (e.g. is there a standard for housekeeping; is it enforced)?
• Were the 4. standards themselves
Draw conclusions based on adequate?
the evidence
5. Make improvements
4. Draw conclusions based on theand track progress against these (are they in place; are they working?) by regular monitoring and checking.
evidence
5. 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’ – workplace problems,
consider if these were significant in the accident. Then consider ‘Plant and Substances’ - was there sufficient guarding of
HSG65 provides further
equipment guidance on
or containment ofhow to conduct
substances? the‘Procedures’
Were investigation logically.
adequate Starting
and used with ‘premises’
correctly? consider
Consider ‘People’ and iftheir
workplace
behaviour etc.
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.
HFBr.0043.211102.Root Cause Analysis BN page 1.rev2.D.W.doc
Copyright © 2003 by The Institute of Petroleum, London: A charitable company limited by guarantee. Registered No. 135273, England
SCAT (Systematic cause analysis technique)
This method is based on the International safety rating system (ISRS), which is extensively used in the petroleum industry.
ISRS measures the safety management system in a plant against a number of control ‘elements’: SCAT helps the user to
interpret accidents and incidents in terms of which of the elements failed. The software version (E-scat), allows the user
to enter:
• A description of the accident (date, time, what happened)
• Details of the ‘loss potential’ which comprises the following factors:
- loss severity potential - i.e. how bad could it have been? In the example - ‘serious’ - the fire could have been worse
- probability of reoccurrence - ‘moderate’ - a similar problem could arise until measures are taken to remove the causes
- frequency of exposure - ‘moderate’ - welding is a common task but not a daily occurrence
• Type of contact - SCAT provides various choices. In the example, the contact is, ‘with heat’ (other choices are with: cold;
radiation; caustics; noise; electricity etc)

From lists the user then selects the immediate causes (ICs) - substandard acts or substandard conditions. These include:
‘failure to follow procedure/policy/practice’ and ‘failure to check/monitor’. These were both causes of the fire in the example.
The user then selects the basic underlying causes (BCs) which are split into ‘personal factors’ and ‘job factors’. The user can
choose to see only the most probable BCs that apply to the ICs chosen in the last step. BCs include: ‘abuse or misuse’ which
can be described as ‘improper conduct that is not condoned’. Or, ‘improper motivation’ which leads to ‘improper attempt to
save time or effort’. From the ICs and BCs identified, SCAT will suggest a number of ‘control actions needed’ (CANs) based
on ISRS principles, that will help to remove or reduce the impact of the underlying causes of the accident. CANs include,
for this example: ‘task observation’ - the need for a scheme to carry out ‘spot checks’ on tasks; ‘rules and work permits’ -
review of how compliance with rules is achieved; and, ‘general promotion’ (of safety) - promotion of critical task safety and
promotion of housekeeping systems.

MORT (Management oversight risk tree)

The following is a simplified description of MORT, as this technique can be quite complex.
In general, MORT views an accident as occurring because an unwanted ‘energy flow’ reached a ‘target’. So, in the example,
sparks (a form of heat energy) from welding fell onto flammable materials (the target) leading to a fire. The fire, i.e. more
heat energy, then burned paintwork and cable ducting (another ‘target’) causing damage. Energy flows can only be stopped
by some form of ‘barrier’ and ‘barrier analysis’ is a key part of MORT. In the example, there should have been a barrier to
contain the flammable material (e.g. put the rags in containers and take them away). A second barrier, fire blankets, should
have covered a larger area.

MORT provides a ‘tree’ structure that guides the analyst to consider whether:
• similar (worse) events could happen in future
• the accident had been assumed and already considered as an inevitable given the type of operations carried out (MORT
calls this an ‘assumed risk’), or,
• the accident is unacceptable, and the underlying causes need to be investigated
The investigation then proceeds to identify what specifically went wrong and why. The analysis considers:
• what happened
• what elements of the protection system were ‘less than adequate’
- recovery mechanisms (where they failed to reduce the consequences of the event. In the example, they did work as
the fire was extinguished)
- ‘barriers’ that failed to stop the event occurring (flammable materials were not contained; protective blankets badly
positioned)
- management factors that did not protect against the event (permit system and supervision/checking not carried out
effectively).

Summary of main components

According to reference 1, there are three key components of root cause analysis systems:
1. A method of describing and representing the incident sequence and its contributing conditions (e.g. a ‘tree’ diagram)
2. A method of identifying the critical events and conditions in the incident sequence (often a checklist to stimulate ideas)
3. Based on the identification of the critical events or active failures, a method for systematically investigating the management
and organisational factors that allowed the active failures to occur
The three example methods described here show how these components are used in practice.

Useful reference information

1. Root causes analysis: literature review HSE Contract Research Report CRR 325/2001 HSE Books (2001)
ISBN 0 7176 1966 4
2. Accident investigation - the drivers, methods and outcomes HSE Contract Research Report CRR 344/2001
HSE Books (2001) ISBN 0 7176 2022 0
3. MORT User’s Manual: www.nri.eu.com/
4. SCAT demonstration/purchase: www.dnvcert.com/DNV/trainingandconsulting/products/software/e-scat/default.asp
5. Succesful health and safety management HSE HSG65 HSE Books (2000) ISBN 0 7176 1276 7
© Crown copyright material is reprodued with the permission of the Controller of HMSO and Queen’s Printer for Scotland