112 Introduction to Safety Supervision

Get To the Root Causes

A hazard, unsafe behavior, near-miss, or injury may be the result of many factors that have interacted in some dynamic way. When conducting hazard analyses or incident/accident investigations, be sure to include questions for each of the following levels of analysis to make sure you uncover the root causes:

Injury analysis - Ask what did or could cause injury or illness? Usually, that's going to be the harmful transfer of some form of energy. Below are examples of the direct causes of injury.

• Overexertion from lifting a heavy object causes muscle strain
• The sudden impact of a fall causes a concussion
• Tissue is damaged when exposed to a toxic chemical

Surface Cause Analysis - Ask what did or could cause the accident event? There's rarely only one condition or behavior that causes an accident. You need to discover each unique hazardous condition and/or unsafe behavior that could or did interact to cause the accident event. Below are examples of surface causes of accidents.

• A worker removes a machine guard
• A supervisor fails to conduct a safety inspection
• A defective tool

Root cause analysis - Ask what did or could cause or contribute to each hazardous condition and/or behavior? Analyze the weaknesses in the safety management system that contributed to the accident. These weaknesses are inadequate or missing safety components such as policies, programs, plans, processes, procedures, or practices. Below are examples of root causes of accidents.

• Inadequate or missing safety management system components.
• Inadequate performance or failure to carry out system components such as: failure to train, failure to provide PPE, and inadequate implementation of safe procedures.
• Failure to enforce safety rules, discipline for safety infractions or recognize safe performance.
• Failure to conduct safety inspections, JHAs, and incident/accident investigations

Knowledge Check Choose the best answer for the question.