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Root Cause Incident Investigations

In most organizations the greatest amount of safety effort occurs after a significant accident occurs. At this time there usually is a flurry of reactive activities such as new rules, disciplinary actions, meetings, training, accident investigations, contests, etc. In the short term progress is achieved. However, in the long run the progress experienced is difficult to maintain. The amount of effort spent on safety typically decreases as things seem to be back under control. At this time production pressures once again take precedence with the true root causes of the accident still present. When this occurs, the site is doomed to repeat the cycle once again.

Probably nowhere in your organization are you willing to settle for such temporary and unpredictable results. In order to prevent accidents from reoccurring one must be able to go beyond accident symptoms to the underlying Root Causes.

Example:

An eye injury occurred while an employee was not wearing eye protection. A typical investigation that does not identify root causes often will list the lack of eye protection as the cause. The employee might also be disciplined for not following procedures that require eye protection. … But did we identify the true root causes?

Root causes are the underlying reasons for the employee not wearing the required PPE. In our eye injury example a through investigation into why eye protection was not worn might revel that not only was the injured employee not wearing the PPE but at times, other employees are not wearing it either, indicating at the very least, inconsistent enforcement.

Reasons for noncompliance may be that the glasses furnished don’t fit (only one size was purchased), they fog up, are uncomfortable; I lost mine (current replacement procedures are too difficult to deal with), etc. By addressing each and every concern, you will experience greater compliance with the company policy. In addition, engineering solutions that prevent flying objects or materials also needs to be explored.

You want to avoid the trap of laying sole blame on the injured employee. The employee who has not followed prescribed procedures may have been encouraged directly or indirectly by a supervisor or by production pressures to "cut corners". The prescribed procedures may not be practical, or even safe, in the eyes of the employee. In such cases, management errors -- not employee error -- may be the most important contributing cause.

How can we help?

We can help you establish an effective incident reporting, investigation and root cause analysis system. We also provide comprehensive workshops that teach your staff how to conduct effective investigations and how to analyze the data collected to identify root causes.

The typical problem that most organizations struggle with is that their incident reporting form drives the process. Supervisors without the appropriate level of skills collect a little information; fill in blanks or check boxes on a form. When it comes time to identify causes the only data available places blame on the employees.

Once your staff knows what data to collect, how to establish the event sequence, how to identify causal factors then and only then can root causes be identified.

To help understand the human element we will teach you behavioral analysis so that you can identify the antecedents (triggers) that are causing your employees to place themselves at risk and the consequences that support their continuing to do so. Herein lie the majority of root causes for your incidents.

The SafePath Root Cause system uses a systematic process consisting of:

  • Establishment of a clear and effective reporting and investigation system
  • Good Investigative Skills
  • Event and Casual Factor Charting
  • Cause and Effect Charting
  • Behavioral Analysis

Half day, full day and day and half workshops are available. Contact us for more information.

Let us help you establish a comprehensive system that will allow you to identify the true root causes behind your incidents. Doing so will drive consistent continuous improvement throughout all your systems, lower your injury and illnesses rates and save you money.