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162 Accident Investigation: Basic
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Phase 3: Root Cause Analysis

The root causes for accidents are the underlying safety management system (SMS) weaknesses that consist of thousands of variables, any number of which can somehow contribute to the surface causes of accidents. This level of investigation is also called "common cause" analysis (in quality terms) because you're identifying a system component that may contribute to common conditions and behaviors that exist or occur throughout the company. These weaknesses can take on two forms.

Two categories of root causes: performance and deeper design root causes.
  • SMS Design Root Causes: Inadequate design of one or more components of the safety management system. The design of safety management system policies, plans, programs, processes, procedures and practices is very important to make sure appropriate conditions, activities, behaviors, and practices occur consistently throughout the workplace. Design root causes describe the "condition" of the SMS, and ultimately, they contribute to most accidents.
  • SMS Performance Root Causes: Inadequate implementation of one or more components of the SMS. After each SMS component is designed, it must be effectively carried out or implemented. Performance root causes describe the "behavior" of the SMS. You may design an effective safety plan, yet suffer failure because it wasn't implemented properly. On the other hand, if you effectively implement a poorly designed component, you'll get the same results: inadequate system performance.

Ultimately, for the SMS to be effective, both the design and implementation must be efficient.

Knowledge Check Choose the best answer for the question.

2-4. Which of the following is an example of a safety management system (SMS) design root cause?