COSS Accident Investigation Principles 5 — Questions and Answers
Question 1: Which of the following factors is considered a 'contributing cause' rather than a 'root cause' in accident investigation?
- Absence of a written hazard communication program
- A spilled liquid on the floor that a worker slipped on (Correct answer)
- Failure of management to enforce lockout/tagout procedures
- Inadequate hazard identification during facility planning
Correct answer: A spilled liquid on the floor that a worker slipped on
The spilled liquid is a contributing cause — a condition that enabled the accident — while the root cause is the systemic failure (e.g., inadequate housekeeping procedures) that allowed the spill to remain unaddressed.
Question 2: What is the primary advantage of using a structured investigation methodology (such as TapRooT or RCFA) over an informal review?
- It is faster and requires fewer investigators
- It ensures consistency, thoroughness, and defensibility of findings (Correct answer)
- It eliminates the need to interview witnesses
- It automatically generates corrective actions without analysis
Correct answer: It ensures consistency, thoroughness, and defensibility of findings
Structured methodologies provide systematic, repeatable processes that improve consistency, ensure thoroughness, and produce defensible findings that can withstand external scrutiny.
Question 3: A worker sustains a serious injury while operating a machine that lacked required guarding. The investigation reveals the guard was never installed. What type of cause does this represent?
- Human error (active failure)
- Latent system failure — engineering/design deficiency (Correct answer)
- Environmental cause
- Acute equipment malfunction
Correct answer: Latent system failure — engineering/design deficiency
A guard that was never installed represents a latent system failure originating in engineering, procurement, or installation processes — not an active human error at the time of injury.
Question 4: When determining the scope of an accident investigation, which factor MOST influences how thorough the investigation should be?
- The shift on which the accident occurred
- The actual or potential severity of the outcome (Correct answer)
- The length of service of the injured worker
- The cost of equipment damaged in the accident
Correct answer: The actual or potential severity of the outcome
Investigation thoroughness should be proportional to the actual or potential severity of the outcome, with catastrophic or high-potential incidents warranting the most comprehensive investigations.
Question 5: Which of the following BEST describes the purpose of distributing an accident investigation report beyond the immediate work group?
- To publicly identify workers responsible for the accident
- To satisfy legal discovery requirements proactively
- To share lessons learned and prevent similar incidents across the organization (Correct answer)
- To document the incident for workers' compensation claims
Correct answer: To share lessons learned and prevent similar incidents across the organization
Sharing investigation findings across the organization multiplies the value of each investigation by allowing other work groups to learn from and apply lessons before a similar accident occurs elsewhere.
Question 6: In accident causation theory, Heinrich's Domino Theory proposed that most industrial accidents result from:
- Purely random events without predictable patterns
- A sequence of factors beginning with social environment and culminating in injury (Correct answer)
- Equipment failures unrelated to human behavior
- Single catastrophic failures in engineering design
Correct answer: A sequence of factors beginning with social environment and culminating in injury
Heinrich's Domino Theory described accidents as a sequence of five factors — social environment, personal fault, unsafe act/condition, accident, and injury — each like a falling domino.
Question 7: Which of the following BEST illustrates the concept of 'management system failure' as a root cause category?
- A worker's momentary lapse in attention while performing a task
- A piece of equipment failing due to normal wear after exceeding its service life
- No formal procedure existed for workers to report hazards they observed (Correct answer)
- A chemical reaction that generated unexpected toxic vapors
Correct answer: No formal procedure existed for workers to report hazards they observed
The absence of a hazard reporting procedure is a management system failure — it reflects a breakdown in the organizational systems designed to identify and control workplace hazards.
COSS Accident Investigation Principles 5
Which of the following factors is considered a 'contributing cause' rather than a 'root cause' in accident investigation?