Causation is multi-dimensional, nonlinear and difficult to predict. Even when using the "5 whys" approach in root cause analysis, we are not able to identify most of the true, underlying factors that influenced the situation. In some cases, designing or engineering out hazards to acceptable levels of risk is considered cost prohibitive. Thus, prevention activities focus on procedures, training, protective equipment, signs and warnings, and other less reliable controls. Because of this trade-off, we have not eliminated the hazard nor reduced the level of risk. However, we are required to conduct the investigation, determine the root cause, and evaluate appropriate corrective actions.
“What we are learning is that most investigators are biased in determining the facts of the case,” says Rick Pollock, CSP, Safety 2017 presenter. “Designing or engineering out hazards to acceptable levels of risk is often considered cost prohibitive. This leads to conclusions that focus on the person and corrective measures such as better training, more procedures, or behavioral observations of the involved individual(s).” Pollock will explain that although human error is often the proximate cause, it should never be the starting point of any investigation, in session 516, “Human Error: There is NO Root Cause.“