Three Phases of Cause Analysis
During the three phases of accident analysis, important questions must be asked: What is the direct cause of the injury? What are the surface causes? What are the root causes of the accident?
Phase 1: Injury Analysis
This phase of the analysis determines what directly caused the injury to the employee involved in the accident. The focus is on trying to determine how a harmful form of energy transfer resulted in the injury. Remember, the outcome of the accident process is an injury.
Phase 2: Surface Cause Analysis
Surface cause analysis determines the unique conditions, behaviors, and actions that interact in each event to produce the accident. The analysis focuses on identifying and correcting the specific factors that directly caused or contributed to the accident.
Phase 3: Root Cause Analysis
Root cause analysis, also called system analysis, focuses on the safety management system weaknesses that contribute to the unique surface causes for accidents. Therefore, root causes always pre-exist surface causes. They include inadequate safety management system performance, principles, policies, programs, plans, processes, procedures, and practices that contribute to the accident. Below are examples of each of the root cause categories.
- Performance: The measurable outcomes of the safety management system, which in an inadequate system may reflect poor safety records, frequent accidents, or non-compliance with safety standards.
- Principles: The foundational beliefs or values guiding the safety management system. In an inadequate system, these principles might be poorly defined, inconsistently applied, or not prioritized.
- Policies: The formal rules or guidelines governing safety practices. In an inadequate system, safety policies may be outdated, incomplete, or not enforced, leading to gaps in safety coverage.
- Programs: Specific initiatives or efforts designed to promote safety. In an inadequate system, these programs may be poorly planned, under-resourced, or ineffective in achieving their safety objectives.
- Plans: Detailed strategies for implementing safety measures. In an inadequate system, safety plans might be vague, unrealistic, or not aligned with actual workplace risks.
- Processes: The series of operational and administrative procedures taken to manage safety. In an inadequate system, these processes may be inefficient, unstructured, or fail to address key safety concerns.
- Procedures: The specific, step-by-step instructions for performing tasks safely. In an inadequate system, procedures may be unclear, incomplete, or not consistently followed.
- Practices: The actual behaviors and actions of employees and management regarding safety. In an inadequate system, unsafe practices may be common, and there may be a lack of adherence to established safety procedures.
Only by thoroughly conducting injury, surface-cause, and root-cause analysis can effective safety management system improvements be made.
Knowledge Check Choose the best answer for the question.
6-2. Which phase of cause analysis focuses on the unique conditions and behaviors that interact in each event to produce the accident?
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