An improved accident causation model which demonstrates the relationships among different causal factors was proposed in this study. It provides a pathway for accident analysis from the individual level to the organizational level. Unsafe acts and conditions determined by individuals' poor safety knowledge, low safety awareness, bad safety habits, etc. are the immediate causes of an accident. Deficiencies in safety management systems and safety culture remain the root causes, which can cause consequences at the individual level. Moreover, the weaknesses of an organization's safety culture can have a great impact on the formation of a good safety climate and can further lead to poor decision-making and implementation of procedures in the safety management system. In order to contribute to a better perception and understanding of the accident causation model, one typical case in the process industry, the oil leak and explosion of the Sinopec Donghuang pipelines, was selected for this study. The causality from immediate causes to root causes is demonstrated in sequence and can be shown in this model explicitly and logically. Several important lessons are summarized from the results and targeted measures can be taken to avoid similar mistakes in the future. This model provides a clear and resourceful method for the safety and risk practitioner's toolkit in accident investigation and analysis, and the organization can use it as a tool to conduct staff trainings and thus to keep accidents under control.
Keywords: accident causation model; accident investigation; causes analysis; individual; organization.