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circumstances indicating that an accident nearly occurred.
4.3.2 The ICAO definitions use the word “occurrence” to indicate an accident or incident. From the
perspective of safety management, there is a danger in concentrating on the difference between accidents
and incidents using definitions that may be arbitrary and limiting. Many incidents occur every day which may
or may not be reported to the investigation authority but which come close to being accidents — often
exposing significant risks. Since there is no injury, or little or no damage, such incidents might not be
investigated. This is unfortunate because the investigation of an incident may yield better results for hazard
identification than the investigation of an accident. The difference between an accident and an incident may
simply be an element of chance. Indeed, an incident may be thought of as an undesired event that under
slightly different circumstances could have resulted in harm to people or damage to property and thus would
have been classified as an accident.
4.4 ACCIDENT CAUSATION
4.4.1 The strongest evidence of a serious breach of a system’s safety is an accident. Since safety
management aims to reduce the probability and consequences of accidents, an understanding of accident
and incident causation is essential to understanding safety management. Because accidents and incidents
are closely related, no attempt is made to differentiate accident causation from incident causation.
Traditional view of causation
4.4.2 Following a major accident, the questions listed below may be asked:
a) How and why did competent personnel make the errors necessary to precipitate the accident?
b) Could something like this happen again?
4.4.3 Traditionally, investigators have examined a chain of events or circumstances that ultimately led
to someone doing something inappropriate, thereby triggering the accident. This inappropriate behaviour
may have been an error in judgement (such as a deviation from SOPs), an error due to inattention, or a
deliberate violation of the rules.
4.4.4 Following the traditional approach, the investigative focus was more often than not on finding
someone to blame (and punish) for the accident. At best, safety management efforts were concentrated on
finding ways to reduce the risk of such unsafe acts being committed in the first place. However, the errors or
4-4 Safety Management Manual (SMM)
violations that trigger accidents seem to occur randomly. With no particular pattern to pursue, such safety
management efforts to reduce or eliminate random events may be ineffective.
4.4.5 Analysis of accident data all too often reveals that the situation prior to the accident was “ripe for
an accident”. Safety-minded persons may even have been saying that it was just a matter of time before
these circumstances led to an accident. When the accident occurs, often healthy, qualified, experienced,
motivated and well-equipped personnel were found to have committed errors that triggered the accident.
They (and their colleagues) may have committed these errors or unsafe practices many times before without
adverse consequences. In addition, some of the unsafe conditions in which they were operating may have
been present for years, again without causing an accident. In other words, an element of chance is present.
4.4.6 Sometimes these unsafe conditions were the consequence of decisions made by management;
it recognized the risks, but other priorities required a trade-off. Indeed, front-line personnel often work in a
context that is defined by organizational and management factors beyond their control. The front-line
employees are merely part of a larger system.
4.4.7 To be successful, safety management systems (SMS) require an alternative understanding of
accident causation — one that depends on examining the total context (i.e. the system) in which people
work.
Modern view of causation
4.4.8 According to modern thinking, accidents require the coming together of a number of enabling
factors — each one necessary but in itself not sufficient to breach system defences. Major equipment
failures or operational personnel errors are seldom the sole cause of breaches in safety defences. Often
these breakdowns are the consequence of human failures in decision-making. The breakdowns may involve
active failures at the operational level, or latent conditions conducive to facilitating a breach of the system’s
inherent safety defences. Most accidents include both active and latent conditions.
4.4.9 Figure 4-2 portrays an accident causation model that assists in understanding the interplay of
organizational and management factors (i.e. system factors) in accident causation. Various “defences” are
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Safety Management Manual (SMM) 安全管理手册(25)
