Tag Archives: consequence

Root Cause Analysis – Large or Small Events?

Root Cause Analysis (RCA) can be applied to events of any size or significance. However, it's usually applied to large events, i.e. those with serious consequences. Even so, it can and should be applied to smaller events as well. Statistically, smaller events are more likely to occur than larger events. Thus, application of RCA to small events may identify many significant opportunities for improvement.
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The Fortunate Near-Miss Event

What do you consider to be an event worthy of investigation? Do you look only at events that had serious consequences, or do you consider less serious events as well? What about near-misses?

I've recently been involved in the investigation of a near-miss event. By near-miss (or near-hit?), I mean an event that almost happened -- an event that terminated one step before a serious consequence was experienced. As is often the case, the event sequence was a seeming string of coincidences. It ended without consequence simply because there was nobody at the event location to be injured.
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Event Frequency and Severity

In 1931, HW Heinrich published his findings from a review of hundreds of thousands of safety incidents. His data showed that on average, for every 300 near-miss events without injury, there would be 29 minor to moderate injuries and 1 major injury or fatality. Similar studies done since 1931 have yielded similar results. The data is deceptively, compellingly simple -- the meaning, however, is not. What is implied by a 300:29:1 ratio of near-misses to moderate injuries to major injuries? Why do we care? Is there some deeper, underlying pattern to this data?
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