Transcription of CONTRACT RESEARCH REPORT 325/2001
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CONTRACT RESEARCH REPORT 325/2001
HSEH ealth & SafetyExecutiveRoot causes analysis:Literature reviewPrepared byWS Atkins Consultants Ltdfor the Health and Safety ExecutiveCONTRACT RESEARCH REPORT325/2001 HSEH ealth & SafetyExecutiveRoot causes analysis:Literature reviewA D Livingston, G Jackson& K PriestleyWS Atkins Consultants LtdScience & TechnologyWS Atkins HouseBirchwood BoulevardBirchwoodWarringtonWA3 7 WATypically an incident REPORT will place emphasis on developing a description of the consequences ratherthan causes of the incident, explaining what happened, but not why it happened. It is only by adoptinginvestigation techniques that explicitly identify root causes, ie the reasons why an incident occurred,that organisations may learn from past failures and avoid similar incidents in the future. Root causesanalysis is simply a tool designed to help incident investigators determine what, how and mostimportantly, why an incident occurred.
iii Foreword In 1991 HSE published Successful Health and Safety Management, HSG65, ISBN 0 7176 1276 7, which described a model for health and safety management. This was followed in1993 by The Costs of Accidents at Work, HSG96, ISBN 0 7176 1343 7, which both analysed the costs of individual accidents at 5 sites over a 3 month period and discussed the
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