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716 Safety Management System Evaluation
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716 Safety Management System Evaluation

Example of a Fish-Bone Diagram

To illustrate the findings of the fish-bone diagram, refer to the example below of an accident where a worker cuts their hand with a knife. The list covers not only the immediate surface causes (conditions and actions) but also the underlying root causes (SMS weaknesses).

The Accident: Worker cuts hand with knife.

  1. People
    • Inadequate knowledge, skills, abilities (KSAs)
      • Inadequate task instruction
      • Insufficient training programs
    • Lack of attention or distraction
      • Excessive noise or interruptions
      • Inadequate lighting
      • Poor work environment
    • Fatigue or overworking
      • Long working hours
      • Inadequate rest breaks
      • Inadequate work scheduling policies
  2. Methods
    • Improper cutting technique
      • Lack of standardized procedures
      • Insufficient supervision and oversight
    • Not following safety procedures
      • Lack of written safety rules
      • Inadequate enforcement of rules
      • No "safety value" culture
    • Rushing to complete tasks
      • Unrealistic deadlines set
      • High workload pressure from operations
      • Safety prioritized rather than valued
  3. Equipment
    • Dull or damaged knife
      • Lack of regular maintenance checks
      • Inadequate equipment replacement policy
    • Inadequate safety guards on the knife
      • Poor design standards
      • Failure to update equipment
    • Lack of personal protective equipment (PPE) such as cut-resistant gloves
      • Insufficient PPE availability
      • Poor enforcement of PPE use
      • Inadequate PPE purchasing policies
  4. Environment
    • Poor lighting in the work area
      • Inadequate facility maintenance
      • Failure to address known hazards
    • Cluttered or cramped workspace
      • Poor workplace organization
      • Lack of regular housekeeping
    • Slippery or unstable surface
      • Failure to maintain floors and walkways
      • Inadequate spill management procedures
  5. Materials
    • Improper material handling techniques
      • Lack of training on material handling
      • Inadequate handling equipment
    • Using the wrong type of knife for the task
      • Insufficient task-specific training
      • Poor tool selection guidelines
    • Handling materials that are difficult to cut
      • Failure to assess material hazards
      • Inadequate risk assessment procedures

This example is for illustration only and does not include all possible surface and root causes. An actual list could be much longer. It also helps managers and employees understand that, ultimately, the causes of most accidents are weaknesses in the Safety Management System (SMS), not personal failings. This also illustrates why management is rarely justified in disciplining employees when workplace accidents occur.

Knowledge Check Choose the best answer for the question.

3-6. What do the findings of a Fish-Bone Diagram help managers understand?

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