Systems thinking 101..the root cause of accidents and some unanswered questions

What is the most common “root cause” of accidents? That’s the question I’m most often asked as an accident researcher, regardless of project, stakeholder, organisation, or domain.

No doubt the intention is good. The organisation wants to expend its limited resources in the most efficient manner. It can’t afford to solve everything, so its efforts would be best suited if focussed on the one thing that’s involved in all incidents. Unfortunately this way of thinking is dangerous for many reasons. 

First and foremost there is never one specific contributory factor responsible for an accident. There is no root cause. Accidents are a complex phenomenon. They are caused by multiple interacting factors across the overall system of work, and often even normal, commonly accepted behaviours play a role in the ultimate outcome of events. Root cause thinking is too simple for such a complex beast – it ignores the many factors that contribute to accidents.

This means that it would be dangerous for organisations to think that there was one thing, one silver bullet, which they can focus on when developing accident countermeasures.

For example, imagine a series of incidents involving equipment failures. The organisation, with all good intentions, gets rid of their tired and broken equipment and goes out and acquires the latest state of the art equipment. A significant expenditure, no doubt, and one that would improve the quality of resources available to their workers.

The big problem, of course, is that they have not addressed why their equipment was tired and broken in the first place. The competing financial pressures, the limited allocation of funding for equipment maintenance, that ancient policy around replacing equipment, those equipment maintenance procedures, the absence of lines of communication around broken equipment, the training that doesn’t cover inappropriate usage of equipment etc. They are all left free to continue influencing events, to wreak havoc on the new shiny equipment; which in turn means this equipment will eventually return, gently pushed along by these other factors, to the unsafe state. The equipment alone was a red herring. In systems thinking terms replacing the equipment only would be a waste of time – little would change in the long term.

There is no root cause – avoid the temptation to think that there is and to focus on finding and removing it. This leaves many pertinent questions: how can we develop countermeasures that fully address the system wide factors that contribute to failures? How can we avoid the temptation to focus on root causes? How can we stop trying to eliminate the components of failure one by one, and instead identify effective, holistic, solutions? These remain key questions, not only for practitioners, but for researchers as well.

In our work with UPLOADS, and our projects in road and rail transport, we are trying to come up with some creative methods to address this problem. Stay tuned…




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