Cause - Consequence: from Management System to Results

Below is a simplified model showing the relation between the management system and the (unwanted) event. Simplified but including the main phases of the sequence that lead to loss - from the Management System on the left to the Consequences on the right.  

The "domino model" shows the cause - consequence sequence and can be used in a positive way - going "downstream"- to indicate the important role of the management system to control loss via basic and direct causes. The model can also be used starting from the other end to indicate the process to learn from what went wrong, taking the loss or unwanted event as a starting point and going "upstream".

The model was originally developed by W.H. Heinrich during the thirties of last century. At that time "Management System" was labelled "Ancestry - Social Environment" while "Basic Causes" was called "Fault of Person". Obviously not something you could manage very well in an industrial environment.  

In the sixties, Frank E. Bird Jr. renamed the domino's to suggest the relation between the unwanted event and its consequences on the right and the Management System on the left via Direct- and Basic or "root" Causes. It was Mr. Bird who showed the way by making the sequence a manageable - and controllable - matter. 

The model above is a simplified reflection of the real life situation but powerful for communication purposes: it relates the management system to the event and the results thereof, either good or bad, depending on the quality of each link in the system. It indicates three cause levels: direct causes, basic causes and the management system. This model is widely accepted in business including such areas as safety, quality, environment.

The 3 dimensional cause - consequence model below is an extension I made to show the complexity that can not be seen in the 2 dimensional model above. The 3 D model may appeal more to professional people.  

The text on the domino's is a little different compared with the 2-D model but, without any further explanation, I think you get the idea about the complexity that unwanted event causation models can have. I included the "barrier concept" between the event and the initial loss. I also realized that the final loss depends on the actions to reduce loss and added the emergency services as well as Post Event Planning (PEP) intended to get the operation back to normal as soon as possible. Please note that I only have one management system at the far left end. Obviously there could be more than one - not preferable but often practice following various certification processes and legislative requirements.

Different losses - same causes?

In our day to day work we see the results of unwanted events as errors, mistakes, damage, injuries, complaints, liability claims, etc. All different losses, yes. But look at the basis causes and they may not be so different anymore. Unwanted events are caused! By people! Because they do not know how to do their work properly, they cannot do it as they should do it, they grew into the habit to do it different, they are not motivated, they are not allowed, they are encouraged to cut corners, they do not have the right tools or they not proper equipment, etc.   

 Different losses - but the same causes!

Look at the table above and you may conclude that the losses we see all come from the first phase or domino of the Cause - consequence model.

Loss Control - a matter of Top-Down AND Bottom-up

Although the "management system" will be initiated by (top) management, it should be clear that various organizational levels and functions have to work together to make the management system a success. This involves all management levels, staff and operational personnel. Remember the "Principle of Point of Control".

There are more causation models ranging from simple to complex. If too simple, you can do little with it, if too complex it may be difficult to explain. What is important is that the model has communication value: to explain the model to management, employees and others. Also important is that the model has broad international acceptance. The 5-domino Heinrich/Bird model has both.

Causation model study

In 1990 I did a study for the Dutch Ministry of Social Affairs covering about 20 different causation models and investigation methods to include: Heinrich, Bird, Mort, Swain, De Reamer, Adams, Kjellen, Hudson/Reason and others but concluded that the 5-domino model (Heinrich/Bird) was most suitable. The Bird model relating the management system to the unwanted event is the one that provides opportunities for managing accidents, incidents and other unwanted events and associated losses; it is my preferred model to communicate the importance of the management system and the roles of both management and operational personnel in controlling loss. 

The study, by the way, produced a Dutch government publication S137. You will not find my name connected with it as I did not agree with the 4 phase model that is introduced in the publication and in which management system and basic causes are put in one phase. While they are closely related to each other they represented a different level: it is the management system and related procedures that produce the basic causes in hardware, software and human ware.