Get to the Root Causes
An incident or accident in the workplace can often stem from a combination of various interacting factors.
When conducting a proactive incident/accident investigation, you must include each of the following levels of analysis: injury analysis, surface cause analysis, and root cause analysis.
Injury analysis - How did the injury occur? The focus here is on identifying the direct cause of the injury, whether it actually happened or had the potential to occur. Examples of direct causes of injury are provided below.
- strain due to lifting heavy objects
- concussion from impact forces due to a fall
- tissue damage from contact with with a toxic chemical
- burns from exposure to flammable materials
Surface Cause Analysis - Why did the accident occur? The emphasis of this stage is to determine the unique hazardous conditions and unsafe behaviors that interacted to produce the accident. Each of the hazardous conditions and unsafe behaviors uncovered are the surface causes for the accident. They give clues that point to possible root causes/system weaknesses. Examples of surface causes are listed below.
- a broken ladder
- a worker removes a machine guard
- a supervisor fails to conduct a safety inspection
- a defective tool
Root cause analysis - Why did the surface causes occur? At this level, you're analyzing the weaknesses in the safety management system that indirectly contributed to the accident. Examples include missing or inadequate safety principles, policies, programs, plans, processes procedures, or practices.
This level of investigation is also called "common cause" analysis (in quality terms). It focuses on identifying a system component that may contribute to common conditions and behaviors that exist or occur throughout the company. Examples of root causes are provided below.
- Lack of a safety training program
- Inadequate or missing safety procedures
- Lack of enforcement of safety violations
- Failure to conduct safety inspections
Knowledge Check Choose the best answer for the question.
2-8. At what level of analysis are you trying to determine safety management system weaknesses?
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