EPHM7320 Chap.4 Incidents, Near Misses and Root Causes
Incidents, Near Misses and Root Causes
An event is evidence about a control system
A near miss exposes a real pathway without producing harm on that occasion. Investigation should distinguish the outcome, direct causes, surface conditions and deeper management-system causes.
The chapter shows why worker error is a starting point rather than a conclusion, how several causal levels can coexist, and why correction of the immediate condition differs from corrective action that reduces recurrence across future work. Outcome severity may depend on timing or position, so learning should follow credible potential rather than injury alone.
A defensible causal account links facts across levels and then selects actions that alter those connections. Reporting remains useful when workers receive feedback and can see that evidence changes conditions without turning the process into blame.
What this chapter covers
- 01
Incidents and near misses
- 02
Potential harm and timing
- 03
Direct and surface causes
- 04
Root and basic causes
- 05
Correction and corrective action
- 06
Effectiveness review
Worked example · free
Analyse a dropped-load near miss
- 3Define event potential and direct conditions.
- 3Trace inspection and storage system causes.
- 3Match actions to causal levels.
Key terms
- Incident
- A work-related event that caused or could have caused injury, ill health or damage.
- Near Miss
- An incident where a small change in time or distance could have produced harm.
- Direct Cause
- The immediate contact, energy transfer, action or condition closely connected to the outcome.
- Surface Cause
- An enabling task-level action or condition visible near the event.
- Root Cause
- A deeper system weakness that allowed surface and direct causes to arise or persist.
- Corrective Action
- Action addressing a cause so the same or a similar event becomes less likely to recur.
Incidents, Near Misses and Root Causes FAQ
Why investigate a near miss when nobody was injured?
The event shows that a hazardous pathway was active and that the missing injury may have depended on timing or distance. Investigation can identify failed controls and system causes while the organisation still has an opportunity to prevent recurrence.
Is worker error a root cause?
Usually it is an observation that needs explanation. Ask whether procedure, design, workload, training, supervision, production pressure, maintenance or change made the action understandable or likely. The deeper answer reveals more durable intervention points.
What is the difference between correction and corrective action?
Correction removes the immediate problem, such as clearing an aisle or replacing a leaking hose. Corrective action examines why the condition arose, changes the enabling system and later tests whether recurrence or the targeted risk has actually decreased.
Exam move
Take a short event description and draw four levels: outcome, direct cause, surface condition and system cause. Add one action at each supported level, then cross out any action that does not change the causal chain or produce effectiveness evidence. Begin by writing a neutral event statement that says what happened, where and under what task conditions without assigning blame.
Add a timeline of normal work, deviations, triggering events, responses and consequences. For each item, mark whether it is an observed fact, a record, an interview account or an inference. This prevents a plausible story from being mistaken for established evidence. Practise distinguishing immediate causes from contributing and underlying conditions.
A slip may be immediate; contamination, drainage, cleaning schedules, procurement choices and supervisory priorities may explain why the exposure existed and persisted. Ask ‘why’ only while the answer remains supported and actionable. Do not force every case to a predetermined number of layers or end with a vague label such as poor culture.
Near misses deserve the same disciplined analysis because outcome severity may have depended on chance, position or timing rather than system strength. Compare actual and potential consequence, then decide the investigation depth from credible risk and learning value. For each recommendation, map the action back to a supported causal factor.
Prefer controls that alter equipment, environment, process or organisational conditions before reminders and retraining. Assign ownership and a completion criterion, then specify an effectiveness test based on future work: observation, measurement, repeat inspection, worker feedback or trend review. Completion evidence and effectiveness evidence are different.
In assessment practice, challenge hindsight bias by asking what information was available before the event and why the risky state seemed acceptable or invisible at the time. Also consider changes, contractor interfaces, workload and conflicting goals. End each case with three products: a concise causal statement, a prioritised action set and a learning message that workers can use without exposing personal details or blame.
Revisit the case after studying investigation and ISO 45001, adding evidence preservation, nonconformity handling and management review connections. The repeated analysis should become more precise, not merely longer.
