The SMIS Causes Form
The Causes form is structured around the human performance factors and the 10 incident factors. Human performance factors include errors or intentional rule breaking by a person. The 10 incident factors include weaknesses or failures in an organisation’s systems such as in the design of equipment or provision of training. This encourages the industry to consider the role of system failures as well as human failures, thus contributing to a fair culture. In addition, if accident and incident causes are well understood, this supports the identification of targeted recommendations that will be more effective to prevent similar events from happening again.
GBRailfreight uses the Causes form data to inform their safety strategy.
“We have been using the cause information from SMIS to feed into our safety strategy. We have been targeting causes of incidents that are linked to our three most common 10 incident factor groups: equipment design, risk management, and competence management. We have also been able to secure buy-in from directors to invest in a non-technical skills programme based on the cause data from our safety events. We want to continue to build on this to enable us to deliver the safest freight working environment for our employees, which has a direct link to their wellbeing and in-turn the sustainability of the business. As we develop the internal common language, this will also increase understanding at all levels of the risks that we seek to mitigate. Data-driven decisions protect employees, the potential impact on other rail users, and enhance customer confidence in rail freight, which supports the UK’s net-zero agenda.’’
Read how GBRailfreight and Greater Anglia have been using the Causes form.
Frequently asked questions
What types of accident and incident should we enter cause information for?
Whilst you can enter cause information for any accident or incident that has received any level of investigation, the Causes form is mostly used for events that have had a local or formal investigation. The form is currently being promoted to industry for capturing detailed causes for SPAD events, but it is also used for events such as railway operating incidents, train derailments, and slips, trips and falls. The System Safety Risk Group agreed that from 1 April 2021 that all SPADs should have a Cause form completed in SMIS within 90 days of occurrence.
Who should use the Causes form?
The Causes form has been made available to all SMIS users. Your organisation will determine who is best placed to enter this information into SMIS. Anyone with a SMIS user account can view the information entered into the form.
Where can I get more information?
The following resources are available to support you in the entry of causal data into SMIS:
- SMIS Causes user guide, which provides information on how to enter cause information into the Causes form, as well as further detail on the human performance and 10 incident factor framework.
- Videos explaining the human performance factors and the 10 incident factors.
- SPAD investigation template, which can be used to structure an investigation report around the human performance and 10 incident factor framework.
- RIS-3119-TOM Iss 2: Accident and Incident investigation and the supporting Accident Investigation Training.
Situational awareness
Situational awareness is the way we perceive, process, and respond to external information. This term is often misused in accident investigations. ‘Losing situational awareness’ is not an accurate or helpful factor to report, as it’s a very broad term. We have a new video and guide to explain situational awareness and offer practical advice.
We look at the three stages of situational awareness from Endsley’s famous model. We show how they should be used to fully understand incidents. We also give examples of better questions investigators can ask to learn more about how and why safety events happened. That vital learning can help prevent similar incidents occurring in the future.