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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