Cause and control

Accident theory places such an emphasis on the idea of ’cause’ that it is often hard for people to understand the relative insignificance of this concept.  Heinrich understood that while one thing may ’cause’ an ‘accident’ something else altogether might be needed to control the potential for the damage, but few who rely on accident theory have bothered to read or understand what Heinrich said or recognise the significance of the difference.

A recent tragic case illustrates that the distinction is important and that it may well be recognised by people whose thinking process, one may reasonably assume, have not been affected by accident theory as it is promulgated.

On 13th July, 2016 two trains collided head-on in Southern Italy. According to the report in Telegraph newspaper (UK) (see viewed 27th July, 2016).

These two reports come from the web article:

Cause ideas predominate in some minds…

“Investigators have told AFP it is possible the collision was caused by human error.”

“There is yet to be any official confirmation of what caused the crash.”

“… a committee of inquiry would also be held into the cause of the accident.”

And more enlightened ideas in others…

“It is unacceptable that such incidents can still occur in 2016, and even more unacceptable that to speak about ‘human error’,” said Carlo Rienzi, president of the consumer group, Codacons.

“All the railway lines in the world benefit from the most advanced technology available to avoid collisions, derailments and errors.

“Today’s tragedy demonstrates how the railway transport in southern Italy is still at an intolerable level.”

Eleonora Forenza, a European MP from Bari, said it was “incomprehensible” that such a popular railway line was on a single track.

Control measures such as signalling system upgrades and track duplication are regarded as important, and indeed the need for them had been recognised for a long time on this line but bureaucracy is reported to have significantly delayed the works.  According to some reports the line relied on a 1960s phone system with one station master phoning the other.



    Alexander Leaving by Leonard Cohen contains the following phrase…………..Do not choose a coward’s explanation that hides behind the cause and the effect. Cause effect thinking is lazy and mechanistic and does not account for the complexity of human activity systems

    All too often following major disasters there is an investigation which searches for an elusive cause, usually human error, which is the simple solution.

    The term cause must be used sparingly during investigations because it often implies blame and retribution and it is hardly surprising that truth becomes the next victim. Ironically, the two most popular investigation tools have the word cause in their title.
    Human error is often the consequence, not the cause.

    The late Trevor Kletz stated attributing cause to human error is akin to saying falls are due to gravity. When conducting any investigation always begin with how can we prevent this from happening again?

  2. Derek Viner (Post author)

    Thanks Bernard, our task is to make these observations about the futility of cause-effect language more evident to the world in general and to the world of safety practitioners in particular.


    This aligns with David Snowden’s Cynefin framework covering evidence-based management and pattern-based leadership and contextual decision making. Moreover, cause and effect are only obvious in hindsight with unpredictable emergent outcomes:


    The following table compares and summarises the attributes of accident theory and risk and energy damage theory:


    Subjective speculation Objective evaluation
    Hierarchical Organic
    Adversarial Collaborative
    Downstream human focus Upstream technological focus
    General risk General & operational risk
    Descriptive Process and evidence based
    Linear and mechanistic cause-effect Systemic
    Intuitive Scientific
    Counting Measuring
    Pejorative Constructive
    Reactive hindsight Predictive and preventive foresight
    Blameworthy Virtuous
    Qualitative Quantitative
    Change the person Change the situation
    Receiver focus Source focus

    Moreover, risk and energy damage theory aligns with the key principles of operational excellence and the unique attributes of high reliability organizations.

    However, many organizations and safety professionals persist with antediluvian accident theory and remain puzzled when there is no transformational change and safety performance stagnates.

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