In my earlier days (Late 70’s) as a government OHS Officer, I worked with a fine woman, Eleanor Raub (she was the first female OH&S Officer in the Province of Alberta – a true pioneer in a difficult time). Eleanor described the “most important cause” (it goes by many other names, “immediate” is a popular one) as the one thing that could be changed just seconds before the “incident” happened to create the damage/injury (energy released into someone or something beyond the capacity to withstand the force). In Eleanor’s view all other events and/or conditions were secondary to that one “cause”.
Being there in the early times of Canadian OH&S law and the developing safety management systems positions me to have developed the following opinions based on my observations and experiences.
These secondary “causes” that we struggled with (today some call them events, acts, conditions, basic, root, whys, etc.) all basically supported the events/conditions that allowed the energy to release at that time, in that space. The problem then was explaining how this almost infinite list of nested conditions and events all came together at exactly the correct time for the harmful energy to create a damage or injury. Many at the time wanted to throw up their hands and play the “act of god” card. Others took the position that this was silly and could go all the way back to “in the beginning”. Even others focused on creating causation charts, trees, theories, lists, what-if tests, codes, human factors and complex pictures of cheese.
The concept of multiple events/conditions/causes was hard to comprehend for most since the variables are almost infinite. It’s like contemplating the size of the expanding Universe…you’ll soon tire of it. Even for the simplest of energy releases (example: fatal fall from a poorly maintained ladder) an analysis of the circumstances and potentially inter-related factors create a MORT analysis chart (with and/or gates) that quickly grows into wall sized diagrams. This flew in the face of the new OHS legislation that needed a set of specific violations to “blame” for the injury (usually a fatality in most prosecutions). The legislation is written in a specific way to place blame/causation. Any well written regulation names a responsible party and states the condition that needs to happen or NOT happen. “No worker shall climb a damaged ladder.” “Employers will provide ladders that are in a manufacturer’s recommended condition.” “Employers will ensure ladders are inspected before put into use” are simple examples.
The Crown wanted and needed an easily explained “open and shut” case to show that they were “enforcing the new laws”. Causation needed to be reduced to a charge (or charges) under the OH&S Act. The cause/blame then transformed into a legal concept of causation that historically was much different that this complex thinking safety was creating with our charts, theories, lists, science and associated factors. The elected politicians also needed to be seen as reacting to the human tragedy (even more laws). The pressure was great on the new OH&S legal system to get results. I can assure you that no one in OH&S enforcement was bringing any pictures of cheese into court in the early days. The K.I.S.S. principle was our only approach.
The complex then turned simple…easily explained to the judge, the media and the grieving family. The employer supplied an unsafe ladder, the supervisor failed to ensure inspection and the worker climbed it! We can’t charge the dead worker…so the supervisor and the employer are to blame and are the cause of the fatality. The violation of the legislation was proof enough. Period! Next CASE! It was unfortunate for the organization that had the incident because to create a situation where those factors didn’t repeat themselves causing a repeat energy release (another worker climbing another unsafe, uninspected ladder) usually had nothing to do with the simplistic cause in the “charge”. “Good thing for prevention we had all those pictures of cheese and wall sized MORT charts.” some thought!
The political and legal influences on our thinking about causation, safety, prevention and the way we manage cannot be underestimated or ignored. None of which have anything to do with any of the pure sciences where the test for cause & effect relationships is much different. The physics of gravity seldom needs to be discussed in court because the issue presented and argued (the charge) is based on the legislation not the science. This has, in no small way, driven our profession into much debate (this discussion included).
Having been in the rooms where decisions to prosecute were made I can assure you that multiple causation and the associated logic and science have very little to do with the decisions and fact finding efforts put into prosecutions. Of course my first-hand experience is limited to Alberta…but my career long involvement in teaching OH&S legislation and Incident Investigation courses allows me to assure you that there is overwhelming evidence that this is alive and well in a large variety of jurisdictions. The debate continues…