Root Cause Analysis
After we have identified the unique conditions and behaviors during event analysis, we need to analyze them to determine their related root causes.
As you've learned, the root causes for accidents are the underlying safety management system (SMS) weaknesses that contribute to the conditions and behaviors we have identified. SMS weaknesses may take two forms:
- System Design Root Causes: Inadequate design of one or more components of the safety management system, including principles, policies, plans, programs, processes, procedures, and practices. Proper design is essential to ensure consistent adherence to safe conditions, activities, behaviors, and practices throughout the workplace. Most surface causes ultimately lead to flaws in system design.
- System Performance Root Causes: Inadequate implementation and performance of one or more components of the safety management system. Effective implementation is crucial after designing safety management system components. Designing an effective safety plan that is poorly implemented can lead to failures, just as properly implementing a poorly written safety plan can yield the same results. In both cases, improvements in policies, plans, programs, processes, procedures, or practices may be necessary.
Safety managers should work with safety engineers to eliminate or reduce exposure to hazards through effectively improving safety system components. Because systems design components can be common throughout the workplace, eliminating any single root cause may simultaneously eliminate many hazardous conditions and unsafe behaviors.
Since root causes reside within safety management systems, upper management is most likely going to be involved in making the necessary improvements. When analyzing for system weaknesses, it may be beneficial to coordinate closely with those who will be responsible for implementing system improvements.
Knowledge Check Choose the best answer for the question.
6-7. Which type of root cause describes the inadequate implementation of the safety management system?
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