Originally published 11/18/2015
Accidents and injuries create stress, and people react differently to stress. When accidents occur, a supervisor should take charge, and make sure everyone involved receives medical attention, if needed. They should also evaluate the area, identify potential problems that need to be addressed and limit access to the area to prevent further damage or injury. Once the situation is under control, the supervisor should begin the process of evaluating what happened and why it happened. The goal is to prevent a similar incident from happening again. To do that, you must understand the root cause of the accident.
Root-cause analysis is the process used to determine the cause of an incident, and come up with steps to prevent it from recurring. The process includes collecting information, charting or describing what happened over a fixed timeline, determining the root cause and finally, determining and implementing steps to prevent a similar incident.
Defining root causes:
- Root causes are underlying causes. The more specific an investigator is about why an event occurred, the easier it will be to arrive at a recommendation for prevention.
- Root causes can reasonably be identified. Occurrence investigations must be cost beneficial. It is not practical to keep valuable manpower occupied indefinitely searching for the root cause. Structured root-cause analysis will allow you to get the most out of the time invested in the investigation.
- Root causes can be influenced or controlled by management. Investigators should avoid listing general error classifications, such as operator error, equipment failure or external factors. These are not specific enough to allow management to make effective changes. Instead, identify specifics such as the following: Did this incident involve a new employee? Did he have sufficient training? Was the equipment faulty? Had it been tagged? Was it reported? Had it been regularly inspected and maintained? Were employees fatigued? Stressed?
- Root causes are those for which we can generate effective recommendations. If the investigator suggests a vague recommendation such as, “improve adherence to written policies and procedures,” he probably has not found the root cause of the incident, and needs to expend more effort in the analysis process.
Safety is everyone’s responsibility. Find and understand the root cause of an accident or injury, outline the steps necessary to prevent similar incidents in the future and communicate that information to everyone on the worksite. Give everyone the tools necessary to create and maintain a safe work environment.