February 21, 2006 | Mark Paradies

Comments on “The Curse of Apparent Cause Analysis” Article

John Sargaison from Santos sent the following comment on “The Curse of Apparent Cause Analysis” article:


I would like to challenge your third recommendation re: stop analysing near misses.

I should start by saying there are near misses and then there are NEAR MISSES.

There are two broad categories that you can split incidents/near misses into – high frequency, low consequence and low-frequency high consequence events. Of course, with near misses you are working on the likely potential consequence rather than an actual consequence. The latter category (low-frequency high consequence incidents and near misses) is typically rare in comparison to high-frequency, low-consequence events (incidents and near misses).

A low-frequency high consequence near miss should receive the same time and effort that would be afforded to an actual significant incident as they will identify root causes that are likely to be different than those that will be found in actual high-frequency, low-consequence incidents.

Relying on fixes to root causes derived from investigations of high-frequency, low-consequence incidents to prevent low-frequency, high-consequence incidents is folly. True, insight into system weaknesses that could lead to high-consequence events such as loss of process containment in an oil and gas facility will primarily be provided by a thorough analysis of the relatively rare low-frequency, high-consequence near misses and incidents.

I would rewrite point three along the lines:

Stop doing analysis of low potential consequence near misses…………….

Food for thought.

Root Cause Analysis
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