Examine the Safety Management System
During an incident and accident investigation, examine how the safety management system (SMS) was designed and carried out. Ask why hazardous conditions or unsafe actions existed, what controls were expected, and whether those controls worked. Follow the evidence; do not assume that a worker's action is the complete explanation.
Root causes may involve missing or inadequate policies, plans, programs, processes, procedures, or practices. They may also involve a failure to implement an effective component. Investigators should identify supported causes, recommend corrective actions, and assign follow-up so the same hazards do not continue.
Knowledge Check Choose the best answer for the question.
2-5. What should investigators examine when identifying root causes?
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