Which option best describes Level I in the model?

• A. Level I: Direct Causes
• B. Level II: Indirect Causes
• C. Level III: Systemic Causes
• D. Preexisting Conditions

Answer: (A)

Direct causes are the immediate actions, conditions, or events that directly bring about the incident. This level focuses on what happened in the moment—the exact trigger that directly produced the harm or loss, such as a person performing the wrong step, a machine malfunctioning, or a safety safeguard failing. Because it isolates the concrete, observable trigger that occurred just before the incident, it best describes Level I.

Indirect causes involve underlying factors shaped by decisions, policies, or management practices that set the stage for the direct trigger. Systemic causes go even deeper, pointing to fundamental design flaws, organizational culture, or governance issues that affect the whole system. Preexisting conditions are vulnerabilities that existed before the incident, which may contribute to risk but are not the immediate trigger itself.