NEBOSH IGC 2 February 2022 Scenario

A car showroom for an international car sales organisation is situated on an industrial

estate on the outskirts of a town. The showroom mainly sells new cars but
occasionally sells used ones. Car sales are driven by ambitious targets. If these
targets are met, the sales force receive large financial bonuses. The Managing
Director (MD) reports to the regional, national, and international Boards and delegates
the responsibility for meeting sales targets to the Head of Sales (HoS).

The indoor showroom is a single storey building, with an open plan design. The centre
of the showroom displays four examples of the new cars for sale. Towards the back of
the showroom are three desks where the sales team talk with customers. To the right
of the desk areas are two separate offices. One office is occupied by the HoS, and
one by the MD. Next to these offices is a waiting area that includes a drinks
dispensing machine, a few tables and chairs (for information displays, customer
seating, etc) and a television. Various new and used cars are parked in neat rows
around most of the outside of the showroom building. Also outside, near the entrance,
there are twelve dedicated parking bays for visiting customers, vehicles for test driving
and vehicles being prepared for handover to customers.

The HoS has 10 years’ service at the showroom. They are driven by car sales, usually
at the expense of safety. This attitude is shared by the leadership team and the Sales
Supervisor. The Sales Supervisor has 5 years’ service and has a strong influence on
those reporting to them, including a very impressionable 17-year-old sales apprentice.
The sales team all get along very well and are given a great deal of freedom to do
what they like; what matters most is getting the job done and achieving the sales
targets. As a result, most of the sales team take chances for the greater good of the
team and to maximise bonuses. The sales apprentice, in an attempt to ‘fit in’, thinks it
is humorous to use the fire extinguisher to wake up the Sales Supervisor who is
sleeping during their break. The Sales Supervisor sees the comical side and puts the
fire extinguisher back.

The remaining member of the sales team is a senior salesperson. They have worked
at the showroom for a long time. They are more cautious than the others and have
safety concerns.

One of these concerns is about the lack of attention paid during the movement of
vehicles. Although there are signs saying, ‘do not use mobile phones while in
vehicles’, the senior salesperson has observed near misses due to ‘rushing’ the job,
the apprentice using their phone while driving, and speeding in the car park in an
attempt to ‘show off’. They think some of this is due to a lack of training and
supervision, having witnessed a very short induction with the apprentice. There have
been other, similar, events in the past, some involving minor injuries. But there is no
record of any of these near misses or injuries.

In the last 12 years, only one fire-related incident has been recorded. This was a false
alarm, where a child had read the instructions on one of numerous fire call points that
read ‘Break glass, press here’, so that is exactly what the child did! The Sales
Supervisor had assumed the role of fire marshal, and although untrained, escorted
visitors and workers to the assigned assembly point nominated in the written
emergency procedure. Not even the workers really knew what they were doing, as
such events do not happen very often, and no one can remember ever practicing the
emergency procedure.

The senior salesperson talks, in confidence, to the Sales Supervisor about these
safety concerns. Surprisingly, the Sales Supervisor replies that management feel that
overall fire risk is low and there is no need for frequent fire drills. The senior
salesperson is confused and highlights that petrol vehicles are in the showroom, and
emphasises the compliance obligations to inform, check, learn and improve through
such drills. They finish the conversation by pointing out that all the fire action notices
around the building are not just there for the benefit of visitors, but to help protect
people and to satisfy insurers too. Despite these personal concerns, the senior
salesperson still feels a lot of pressure to fit in with the rest of the group, and not worry
about the unsafe working that has become common practice.

The MD is somewhat detached from the day-to-day practical operations because of

attendance at various off-site exhibitions, national and international conferences, and
frequent online meetings. As

a result, they delegate the daily ‘running’ of showroom to the sales team and any
health and safety responsibilities to the HoS. However, the HoS has not had any
specific health and safety training to fulfil this role. Although the senior salesperson
has bravely raised the fire evacuation testing safety issue with the MD in the past, the
MD sees no reason to challenge unsafe behaviours and interfere with a successful
team if it is meeting the sales targets. However, they do accept that there have been
some lucky escapes from incidents that could have been more serious. But nothing
bad has happened so far, so why worry? The senior salesperson respectfully
suggests a different view that profits and bonuses can be wiped out easily by the large
costs associated with even one workplace accident. In addition, the unwelcome
attention of enforcement agencies and the media. The senior salesperson’s view is
that is just a matter of time before a serious accident happens.

That same day, in the late afternoon, the Sales Supervisor asks the apprentice to
move a car from the car park to a hardstanding location right in front of the entrance,
ready for customer collection. The apprentice locates the car, as instructed. As they
move the car to the required location, they answer a call on their mobile phone, and
 stop the car in front of the showroom. While simultaneously raising the mobile phone
to their ear with one hand and exiting the vehicle, they trip over the seatbelt which has
not quite fully retracted. They stretch out their other arm to cushion the fall onto the
concrete hardstanding. The apprentice hastily gets up, looks around in
embarrassment to see if anyone is looking, and acts as if nothing has happened.
However, the Sales Supervisor witnessed the seemingly harmless-looking incident.
Later, the two of them have a conversation in the rest area about the incident. The
Sales Supervisor promises to spare the apprentice embarrassment by saying “It is a
matter for you, and you alone; as long as you don’t say a word to anyone else, neither
will I”.

The following day, the apprentice arrives at work with a plaster cast on their wrist.
Their wrist had swollen and become tender and painful. They had gone to hospital
and had an X-ray that confirmed a small fracture of the wrist. The plaster cast allows
limited movement of the fingers. The Sales Supervisor talks to the apprentice and
advises them to say that they fell off a bike at home should anyone ask. The
apprentice agrees and does not see this as a problem. They are put on light duties
until further notice. The senior salesperson is suspicious, and later takes the
apprentice aside and informs them about the implications of accidents at work.

Task 1: The influence of peers

When people get together into groups, they interact with each other, and Workers are
often influenced by their peers (Companions, group members, colleagues) at the
workplace.

1 Comment on the influence of peers on health and safety at the car showroom. (10).

Note: You should support your answer, where applicable, using relevant information
from the scenario.
The base of the scenario below mentions the influences of peers on health and
safety at the car showroom.

 Peer group influenced the safety culture of the showroom as sales apprentice
in an attempt to fit in thinks it is humorous. At the same time, the supervisor
keeps the fire extinguisher back without any instruction; thus, the behavior of
both indicates a negative culture.
 Competition because of peer group resulting incident or accident, as
near-miss accoutred in the showroom because of rushing the job which
indicates unsafe behavior because of peer group competitions.
 Work-related violence is in place because of peers as apprentice using his
mobile while driving, which indicates the negative safety culture.
  Misusing the assets results from peer groups on the showroom as an
apprentice speeding the cars.
 Supporting culture is a form of negative culture that creates peer relations as
the MD sees no reasons to challenge unsafe behavior and interfere with the
success team if it meets targets.
 Poor Practice as MD and supervisor evacuated the workers and visitors during
an emergency, but they both don’t have a proper fire marshal.
 Showroom workers did not report previous near misses and accidents
because of peer competition or might because of embarrassment, which is also
poor safety management system been placed by Peer.
 Unsafe working has become common practice because of the peer group as
young and new workers don’t care about safety which indicates poor behavior
about safety.
 Work-related violence by pretending workplace accidents as normal. The bike
accident also resulted in the peer group as the sales supervisor witnessed the
accident but did not report it.
Task 2: Emergency procedures

Answer (a)

Positive points about fire safety arrangements at the car showroom

(a) What are the positive points about fire safety arrangements at the
2 (5)
car showroom?

(b) What are the negative points about fire safety arrangements at the
(10)
car showroom?

(c) Why is it important to practice emergency procedures? (5)

Fire safety plans define arrangements for implementations, controlling, monitoring,
and reviewing fire safety standards. Following are the positive points of fire safety
management arrangements:

 Proper fire fighting equipment and fire/emergency detection/emergency alarm

points (MCPs) are in place to detect the emergency situation in the showroom.
 A proper emergency procedure is in place for following in case of an
emergency.
 Proper actions were notified in case of fire around the building because the
existing fire hazard was highlighted “as patrol vehicles are in place and petrol is
a highly flammable liquid,” which is beneficial for workers and visitors. Also,
 plan to comply with the obligations to inform, check, learn, and promote the
emergency drills system.
 Proper written instructions have been provided with fire fighting and
emergency alarm points by graphic communications (safety signs); as
mentioned in the scenario, the child had read the instructions posted on/close
to MCP.
 A properly designed assembly point has been nominated as mentioned in the
scenario for escorting the worker & visitors to that point in case of any
emergency condition.

Answer (b)

Negative points about fire safety arrangements at the car showroom

Many substances existing at the workplace are related to fire hazards. As mentioned
in the scenario, the patrol vehicle is placed in which patrol is highly flammable;
therefore, in case of the poor arrangement of fire safety, the organization will get
much more loss than they earn. There are some negative points of health and safety
management system at car showroom which are mention below:

 The untrained Fire Marshal has been nominated to escort the visitors and
workers to the assembly point, indicating a poor fire safety management
system because the fire marshal must be properly trained and have proper fire
marshal certification with familiarity to deal with forcible emergency conditions.
 There is no proper training/practice about the emergency procedure, as what
is the role of workers in case of emergency. What they have to do, how to
escape from the building etc.
 No priority/consideration on fire safety management because, as per the
scenario, the management considers the showroom as a low-risk area;
therefore, as per showroom management, there is no need for the fire drill,
which indicates negative safety culture existing in the organization.
 Misuse of fire fighting equipment “as mentioned in the scenario, apprentice
humorously use the fire extinguisher to wake up the supervisor.” All fire fighting
equipment must be in order and proper working condition 24 hours and free of
obstruction also easily accessible in case of emergency.
 No training has been provided to workers about fire fighting equipment, as
training enables the workers about the using of fire fighting equipment and how
to use it. Therefore proper training wouldn’t let the worker to misuse the fire
extinguisher.
 No competent/certified safety staff for managing health and safety in the
showroom “as mentioned in scenario HOS has not had any specific health and
safety training” who can carry out a proper fire risk assessment to identify the
 hazards and risk associated with that hazards moreover find out the control
measure of it.
 No Organisation chat with proper nominated ERT (Emergency Response
Team), as per the scenario only sales supervisor played the role of fire marshal
with the help of MD to handed past incident while other ERT members also
supposed to be there for the handle that emergency which is indication poor fire
safety arrangements.
 As per the layout mentioned in the scenario,” there is no emergency procedure
for new cars which has been displayed in the center of showroom indicates
poor fire safety management, as to how to bring out the cars from the
showroom and the designed escape routes also the nomination of an
apprentice.
 No reporting about work-related violence or investigation system about
violence, which indicates the negative behavior or poor fire safety management
system. As the sales supervisor sees the comical side and puts the fire
extinguisher back without any instructions to apprentice about the seriousness
of the placement fire extinguisher also did not take any administrative action.
 Poor location of emergency alarm/MCP system indicates poor fire safety
management system because as per the scenario, the child has broken the
glass of MCP easily due to easy access for a small child, while it supposed to
be located on the limited range with proper cover also the instructions which
were mention there, were also incomplete because as per the scenario it was
mention “Break the glass Press here” which is incomplete instructions. The
showroom is a service sector area where the child also can enter with their
guardians, so these things must be considered while planning the design of fire
safety equipment location.

Answer (c)

Importance Of Practicing Emergency Procedures

 An emergency procedure is a written method to deal with major foreseeable

incidents at the workplace. Below are the reasons that define the importance of
the emergency procedure practice.
 Emergency procedure practices promote safety awareness and show the
Organisation’s commitment to workers’ safety.
 Emergency procedure practices will clearly define the future action plans,
responsibilities of the Organisation, duties of response team members, and
responsibilities of workers to avoid confusion in case of an actual incident.
 The practice of emergency procedures will help notify the weakness or
possible changes in the plan that can be corrected before an emergency.
 It will provide clear guidelines about escape routes for workers to get to the
assemble point. It will elaborate the entire process, such as using a staircase
 instead of waiting for the elevator, avoiding the rush, not taking any item with
them, using the nearest emergency exit point for exit instead of the regular
route.
 Emergency practices will identify all necessary sources as to what exact
origins need to be arranged before an emergency occurred like first aid kid with
the first aider need to put because while the evacuation if anyone injures first
aider can provide initial treatment until proper medical help is in place.
Task 3: Accident reporting

3 Within a workplace there are formal procedures for reporting accidents.

(a) Comment on the Sales Supervisor’s approach to reporting the

(5)
apprentice’s accident?

(b) How should the apprentice’s accident be reported by the employer? (5)

Answer (a)

Reporting of incident and accident will help to find the exact root cause of the accident
and will determine the risk elimination, below mention are the sales supervisor
approach to report about the accident,

The poor reporting system is in place from top management to down; therefore
supervisor did not report the accident even witnessed.

There is no trust to follow up on the accident as many incidents had happened before
in the showroom, but there is no follow-up by the management for corrective action;
thus, this behavior forces him not to report.

Poor safety performance, as apprentice been embarrassment and sales supervisor,

promises to spare the apprentice embarrassment.

Blame culture might trigger the supervisor not to report an accident as he could be
blamed for not providing training or instruction.

Reporting active Investigation systems and investigation often take a long time to
complete. There is already a poor priority in safety in the showroom as targets are a
priority than safety; thus, time-wasting because of investigation had discouraged for
not to report.

Answer (b)
An accident report is a formal document that specifies the details of the facts related
to the workplace. Below mention is the way which employer will use to report the
accident.

The employer will provide immediate response to give by first aid, and medical
assistance will also be called if necessary and hospitalized the victim if necessary.

The employer will organize an investigation team to find out the facts of the accident.

All gathered information will be analyzed and determine the root cause of the accident.
Complete action will be a plan to prevent such accidents in the future.

Employer will take needful action to provide all requirements for corrective action to
prevent accidents in the future.

Task 4: The legal reasons for health and safety management

What are the legal reasons why health and safety should be
4 (10)
managed at the car showroom?
ILO sets out some legislation for the health and safety of the workers. Also, most of
the countries adopted laws on the health and safety of workers. Moreover, some
enforcement agencies exist in every country that enforces organizations to comply
with safety rules.

Some legal reasons are mentioned below for managing health and safety in the
Showroom.

 A severe accident will result in the unwelcome attention of enforcement

agencies that can lead to fines, punishment, or both will be imposed on the
employer, which can be a case of wiped out profit. Thus, Showroom needs to
manage the organization’s proper safety system to avoid enforcement action.
 The proper health and safety management system will help get the
compensation, as no one can stop incidents and accidents. If any accident or
incident occurs, the employer manages even proper safety; the employer will
be entitled to get compensation.
 ILO, Convention C155, has advised the employer for ensuring the workplace
under their control, machinery, equipment, and process under their control; thus,
the Showroom has to manage health and safety to fulfill the requirement of ILO
 The major accident will result in the interference of media in the workplace,
which will spoil the organization’s reputation. Therefore Showroom has
massive business and its public service sector, so they have to manage health
and safety for maintaining their reputation.
  All organizations have their self-regulations or self-polices, which will help
adopt appropriate health and safety standards. It also shows the
management’s commitment regarding health and safety. Therefore, a proper
health and safety management system in the Showroom will reflect
management commitment.
 Most countries have legislation of health and safety for workers that should be
fulfilled to get business licenses, and breaches of the law may result in the
cancelation of licenses.
 The health and safety management system will increase prosperity and
improve the living standard which will attract the workers to work in the
organization and also it will have a great attraction of clients because clients
also want the organization which should be safe and can fulfill their required
works safely without any enforcement action.
 Some of the laws related to health and safety control antisocial behavior.
Therefore, a proper safety management implementation system in the
Showroom will help fulfill these requirements as there are some negative
behavior issues in the Showroom that can be controlled by implementing a
safety management system.
 The health and safety management system will help adopt new technology
that is often legally obliged on the employer to provide a workplace example
that instead of MCP, many new technologies have been launched to detect the
emergency.
Task 5: Workers’ responsibilities in the workplace

It is likely that the injured apprentice may have contravened some of their
responsibilities as a worker within International Labour Organisation
5 Convention C155 – Occupational Safety and Health Convention, 1981
(No.155) Article 19 and associated Recommendation R164 – Occupational
Safety and Health Recommendation, 1981 (No.164) recommendation 16.

Comment on the extent to which Article 19 of C155 and recommendation

(10)
16 of R164 may have been contravened.

Note: You should support your answer, where applicable, using relevant
information from the scenario.

Some duties and responsibilities have been imposed on workers by ILO international
labor organization, Convention C155 for workers safety, but showroom apprentice
had contravened these responsibilities. The following contravened are mentioned
below:
 As per Article 19, while performing the job, the apprentice has not safely
fulfilled the job by avoiding safety rules because the vehicle could be hit with
the building or other vehicle while using mobile.
 Workers must cooperate with the employer by following safety and health
rules while the apprentice did not cooperate with the organization, as the seat
belt has not retracted before exit.
 Adequate information and instructions have been given to workers to maintain
health and safety, but the apprentice did not follow as to drive by one hand
while using mobile with other hand. Also, exiting from the vehicle, he did not
switch the phone, and because of his busy hand, he did not retract the seat belt
properly.
 Proper training has been provided to workers about their job, but the
apprentice did not follow the instruction given in training as he used mobile
while driving, which is strictly prohibited.
 Workers should consult with the employer about all safety aspects, but the
apprentice failed in it as he acted that nothing had happened and did not
consult with the employer or top management about this incident.
 As per ILO Article, 19 workers should report to the supervisor immediately
about health and safety issues, but the showroom apprentice did not report to
either supervisor by himself or top management for this incident as to take
control measures for further accident prevention.
 The employer has to take remedial action; the employee is not required to
return to work in severe injury conditions. However, the apprentice reported
working the next day while getting a fracture, affecting the daily operation and
the organization’s reputation.
 Workers should take care of their safety and health and the safety of other
people around them, but as per the scenario, the apprentice neither cares
about his health and safety nor care about others because his unsafe behavior
by using mobile while driving could hit the car in building or to her person, and
no proper retracted seat belt could be dangerous for the other person who is
going to use the vehicle after him.
 Use safety equipment provided by the employer and do not temper it while
showroom apprentice has temper seatbelt.
 Apprentice has breached health and safety rules by hiding the facts of the
incident and pretending that he has fallen from bike to avoid further
investigations.
 Task 6: Near misses

6 It is often a matter of chance that a near miss turns into an accident.

How could investigation of the previous near misses have helped prevent
(10)
this accident?

Note: You should support your answer, where applicable, using relevant
information from the scenario.
An investigation is a thorough search for facts, especially hidden or need to be sorted
out in a complex situation. The aim of near-miss investigations are mentioned below:

 Near miss investigation will permit showroom management to take the proper
action to prevent recurrence because this could be a significant accident.
 Near miss investigation will help improve health and safety management in the
showroom to ensure this kind of incident will never be repeated.
 The investigation will help improve the performance of cars showroom about
health and safety.
 The investigation will help increase showroom apprentices morale as
employees will assure that the organization cares about their workers.
 Near miss investigation will prevent the showroom from direct and indirect
losses that might foreseeably impose if the same kind of near-miss changes
into significant accidents.
 Near miss investigation will inform the experienced workers about a
dangerous occurrence that could happen in the future in necessary action not
being taken and not following the safety.
 Near miss investigation will help to adopt new technology/machinery required
to avoid significant accidents because of machinery technology/machinery.
 Near miss investigation will indicate monitoring as the necessary control
measure before a significant accident happens.
 Current showroom legislation will be reviewed and can be changed or
regulated if necessary by near-miss investigation.
 Near miss investigation will help to highlight where risk assessment need to
review
 Near miss investigation will promote the latest training program in the
showroom on all workers, which is precisely required.
 Task 7: Health and safety culture

What appear to be the negative indicators of health and safety culture at the car
7 (20)
showroom?

Note: You should support your answer, where applicable, using relevant information from
the scenario.

Health and Safety Culture can be defined as beliefs and behaviors of organization
relating to health and safety. The negative indicator indicates negative/poor safety
culture below mention are the negative safety culture indicators

 Lack of awareness about health and safety legislation and the use of fire
fighting equipment’s indicates negative safety culture in showroom as
apprentice to use fire extinguisher to weak supervisor up because don’t have
knowledge about fire fighting equipment’s.
 Negative Behaviour indicates to negative health and safety culture in
showroom as the apprentice using their phone while driving, and speeding in
the car park in an attempt to ‘show off’ even there are signs for not use mobile
while driving.
 Lack of interest in health and safety is part of negative safety culture, MD sees
no reason to challenge unsafe behaviours and interfere with a successful team
if it is meeting the sales targets because they have interest only in targets not
safety.
 No recordkeeping system is in place in showroom which indicates the
negative health and safety culture as there have been other events occurred in
the past, some involving minor injuries. But there is no record of any of these
near misses or injuries.
 No health and safety management structure defines negative safety culture in
showroom as the Sales Supervisor had assumed the role of fire marshal and
escorted visitors and workers to assembly point while there is no any other ERT
member involved in this evacuation process also no organisation chart which
shows the roles and responsibilities in case of emergency of ERT.
 Lack of training and Knowledge is in place in showroom as untrained fire
marshal and uncertified safety representative indicates the negative safety
culture because untrained fire marshals escorted visitors and workers while
himself don’t have any training about fire marshal also safety representative
don’t have specific don’t have specific health and safety training certification to
fulfil the role.
 Poor Administrative control defines negative in showroom, because the
emergency procedure is in place but workers don’t have any knowledge they
don’t know what’s they are doing in case of emergency thus this administrative
controls are not properly effective.
 No priority of health and safety indicates negative safety culture because
management feels that overall fire risk is low and there is no need of frequent fir
drill.
 Reactive monitoring system is in placed which is part of negative safety culture,
as management thinks that nothing has happen so far in showroom therefore
no worry as they are waiting to happen something then they will find out the
measures so such acts indicates negative culture.
 Lack of health and safety communication indicates negative safety culture
because cars showroom workers don’t communicate with management about
safety issues and top management also don’t take it seriously.
 No reporting system in place which is the part of negative safety culture as
many incident did not report to management even as per scenario the
apprentice trip over the seatbelt which has not quite fully retracted and because
of this apprentice stretch out their other arm to cushion the fall onto the
concrete hard standing and got fracture but did not report.
 Poor and Untrained supervision related to health and safety in showroom, as
per the scenario the Supervisor sees the comical side and puts the fire
extinguisher back but did not instruct the apprentice or report to management
for arrange proper training for apprentice and brief them the seriousness of fire
fighting equipment and the exact use of it. In additional supervisor witnessed
the seemingly harmless-looking incident but did not take any further action
even stop apprentice not disclose it to someone.
 Lack of health and safety compliance defines negative safety culture in
showroom because they apprentice answer a call on their mobile phone while
driving even its strictly prohibited to use mobile while driving also raising the
mobile phone to their ear with one hand and exiting the vehicle which is also
unsafe and noncompliance of safety rules.
 Poor Performance of showroom management about health and safety
indicates negative safety culture because as per the scenario showroom top
management don’t focus on safety to think that no think will happen is the
weakness of their performance on health and safety management system.
 Human errors identify in scenario which is the part of negative safety culture
as supervisor witness the incident but ignore it and ask apprentice to pretend
that it was bike accident which is the big human error.
 Lack of Clear direction and leadership indicates negative safety culture as no
competent health and safety leadership been provide to apprentice to motivate
them about safety.
 No proper resources in place for fire safety management system because
there are some essential sources like certified fire marshals, first aider and
 some other resources are required to emergency but as per the scenario no
resources are placed in showroom for fire safety.
 High incident and rates indicate negative safety culture which has no
investigation and no record as well.
 Ill-health rate of showroom is part of negative safety culture as many minor
injuries occurred before even one is mention in the scenario whose wrist had
been swollen Minority of workers conscious about health and safety because of
negative safety culture as only senior salesperson are cautious about safety
and health
Task 8: Health and safety management roles and responsibilities

It is important that everyone in the organisation knows their health

8
and safety roles and responsibilities.

Comment on the effectiveness of roles and responsibilities in relation

(10)
to health and safety management in the car showroom.

Note: You should focus on roles and responsibilities and not the
health and safety management system.

Note: You should support your answer, where applicable, using

relevant information from the scenario.

There is a good practice for organizations to Organising proper organization chat with
effective roles and responsibilities to achieve their targets regarding health and safety,
below mentioned are the effective roles and responsibilities for cars showroom:

Proper health and safety policy should be made and provide proper direction
(appoint Director) to employees as director will ensure good communication is in
place in between showroom employees and management, also will ensure that
adequate welfare and safety-related requirement been fulfilled

There should be properly certified safety manager in the showroom who have
knowledge about safety principles and how to implement the safety to ensure that all
necessary risk assessment have been done and control measure are in place

Competent safety manager should carry out an investigation of all accidents and
incident to find out the root cause of the incident in order for preventing accidents in
future