This week’s Safetip is about incident investigations, and creating and using a list of standard questions to identify contributing factors that can lead to root causes.
Determine Root Causes as Part of Incident Investigations
OSHA makes available several resources that aim to assist employers and workers in conducting effective incident investigations, and to develop corrective action plans. One of these resources, Incident Investigations: A Guide for Employers, provides employers with a systems approach to identifying and controlling the root causes of all incidents to prevent their recurrence.
The guidance document emphasizes the importance of determining root causes, i.e. the underlying reasons why the incident occurred. Root causes generally reflect management, design, planning, organizational and/or operational failings or weaknesses. OSHA strongly stresses that a successful incident investigation must always focus on discovering root causes. Investigations are not effective if they try to assign fault or blame.
Examples of Questions
To assist with the identification of root causes during incident investigations, create, use and maintain a list of standard questions. To have an idea of the type of questions, here are examples of inquiries that can be pursued to identify contributing factors that can lead to root causes:
- If a procedure or safety rule was not followed, why was the procedure or rule not followed? Was the procedure out of date or safety training inadequate? Was there anything encouraging deviation from job procedures such as incentives or speed of completion? If so, why had the problem not been identified or addressed before?
- Was the machinery or equipment damaged or fail to operate properly? If so, why?
- Was a hazardous condition a contributing factor? If so, why was it present?
- Was the location of equipment/materials/worker(s) a contributing factor? If so, why?
- Was lack of personal protective equipment or emergency equipment a contributing factor? If so why?
- Was a management program defect a contributing factor? If so, why?
In addition, Appendix F of OSHA’s guidance document has a more complete list of sample questions for identifying root causes:
Once your questionnaire is created, remember to review it periodically to make sure it is up-to-date and continues to reflect the circumstances of your organization.
Visit Enablon Insights again next Wednesday for a new Safetip!
View the recording of our webinar with TapRooT® to learn how you can enable a human factors-based incident investigation lifecycle, and how the integration of Enablon and TapRooT® facilitates the tasks of incident investigators: