Root cause analysis for safety incidents in the workplace

Best practices when conducting root cause analysis for safety incidents

Employers are strongly encouraged to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called “near misses”), in which a worker might have been hurt if the circumstances had been slightly different.

Investigating a worksite incident allows employers and workers to identify hazards in their operations and shortcomings in their safety and health programs.

Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

A supervisor often conducts incident investigations, but it is more effective to have investigations that include a team of both managers and workers since both bring different levels of knowledge, understanding, and perspectives to the investigation.

With an effective safety and health management program in place, all involved in the team are aware of their roles during the investigation. Being aware of roles helps the transition from emergency response and site safety to preserving the scene and documenting the incident.

Before investigating, all emergency response needs must be addressed (caring for the injured worker), and the incident site must be safe and secure for entry and investigation.

Incident investigations should not focus on finding fault or blame. Rather, they should instead focus on identifying and correcting root causes, as this approach demonstrates the employer’s commitment to a safe and healthful workplace.

The investigation team should look beyond the immediate causes of an incident. It is far too easy and often misleading to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents.

Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself. When a shortcoming is identified, it is essential to ask why it existed and why it was not previously addressed.

Now that the background on root cause investigations has been covered, an example of an incident will be used to show how potential investigation questions could be created.

Examples of questions to ask in a root cause analysis

Now that the background on root cause investigations has been covered, an example of an incident will be used to show how potential investigation questions could be created.

For example, a worker slips on a puddle of oil on the facility floor and falls, the investigation conclusion should not be limited to “oil was spilled on the floor—worker was instructed to be more careful of workplace surroundings.”

A proper root cause analyses would instead look for fundamental problems in the workplace, such as:

  • Why was the oil on the floor in the first place?
  • Were there changes in conditions, processes, or the environment?
  • What is the source of the oil?
  • What tasks were underway when the oil was spilled?
  • Why did the oil remain on the floor?
  • Why was it not cleaned up?
  • How long had it been there?
  • Was the spill reported?

Note that most of the questions start with “what,” “why,” or “how.” It is essential to consider all “what,” “why,” and “how” questions to discover the root cause(s) of an incident. Successful root cause analyses identify all possible root causes as there are often more than one.

Properly framing and conducting a root cause investigation is vital for employers following process safety management and risk management programs.

Not all incident analyses or root cause analyses will be the same. Still, there are ways to help structure and conduct investigations using a general template to make incident response time quicker.

Programs such as safety management software are a great way to keep investigations organized and up to date.

What are the 4 steps in a root cause analysis?

Four steps that should be used to create an analysis template are:

1. Preserve/Document Scene

Preserve the incident scene by preventing evidence from being removed or altered. Document essential incident facts such as the date, location, investigator, injured employee’s name, and injury description. Documentation could also include videos or photos of the scene.

2. Collect Information
Investigators should attempt to answer as many questions about the scene as possible by asking the injured employee and any witnesses. Some examples are: who was injured, who saw the incident, what was the worker doing, what precautions or protective equipment should have been used, The location of other workers at the time, or why and what did the worker do before the incident occurred.

3. Determine Root Causes
Finding root causes goes beyond the collection of information. It requires persistent digging into the incident, typically by asking “why” repeatedly to avoid incomplete conclusions. The more profound “why” questions asked, the more contributing factors are discovered and the closer the investigator gets to the root causes.

If a procedure or safety rule was not followed, why was the procedure or rule not followed? Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety? Was the safety procedure out of date, or training inadequate for the situation? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?

4. Implement Corrective Actions
The investigation is not complete until corrective actions have been implemented that address the root causes of the incident. Implementation should entail program-level improvements.

Addressing underlying or root causes is necessary to truly understand why an incident occurred, develop effective corrective actions, and minimize or eliminate severe consequences from similar future hazardous situations.

Using root cause analysis tools is a quick and effective way to document incidents and answer questions. Not all incidents will have the same questions, but it can help create a general template using guidelines from the steps laid out above.