Factors to Consider During an Accident or Near Miss Investigation

Immediate Causes

“Immediate causes” are the circumstances that immediately preceded the event. They can usually be seen or sensed and are therefore most readily apparent to the investigator. Some examples of immediate causes are listed below:

defective tools, equipment
inadequate or missing guards
poor housekeeping
high or low temperature exposures
inadequate lighting
hazardous environmental conditions: dust, smoke, fume, gas, vapour
excessive noise levels
using equipment improperly
failing to use personal protective equipment
improper lifting techniques
horseplay
failure to unplug / lockout machine before servicing
failure to secure or warn

Basic Causes

“Basic causes” are the real causes that lead to the event and allow the immediate cause(s) to exist. By taking a closer look at the immediate causes it is often possible to trace back to an underlying cause(s) or reason(s) why the circumstances immediately preceding the event occurred. Some examples of basic causes are listed below:

inadequate engineering
- inadequate - standards or design criteria, assessment of needs - human factors / ergonomics
inadequate maintenance program
- inadequate - prevention: servicing, adjusting, cleaning
- inadequate - repair: part substitution, communication of need to repair
inadequate purchasing standards
- inadequate - specifications, research of needs/requirements, inspection upon receipt
inadequate work standards
- inadequate – development, communication and updating of standards
lack of skill or knowledge
- inadequate – orientation, training, coaching, practice
inadequate leadership or motivation
- inadequate – performance feedback, reinforcement of proper behaviour, incentive
physical or psychological stress
- previous injuries, fatigue, exposure to environmental hazards, work load