Sometimes things don’t go as planned. While most days these unplanned occurrences are little more than an annoyance, some days they can be the cause of big problems. When an unplanned occurrence impacts health and safety, or results in property damage, we refer to those as “incidents.”
The Occupational Safety and Health Administration (OSHA) urges employers, owners and operators to conduct a root cause analysis following an incident or near miss at a facility. A root cause is a fundamental, underlying or system-related reason why an incident occurred that identifies one or more correctable system failures.
By conducting a root cause analysis and addressing root causes, an employer may be able to substantially or completely prevent the same or a similar incident from recurring.
During an incident investigation, an employer must determine which factors contributed to the incident. A root cause analysis allows an employer to discover the underlying or systemic – rather than the generalized or immediate- causes of an incident. Correcting only an immediate cause may eliminate the symptom of a problem, but not the problem itself.
A successful root cause analysis identifies all root causes as there are often more than one.
Consider the following example: A worker slips on a puddle of oil on the floor and falls. A traditional investigation may find the cause to be “oil spilled on the floor,” with the remedy limited to cleaning up the spill and instructing the worker to be more careful. A root cause analysis would reveal that the oil on the floor was merely a symptom of a more basic or fundamental problem in the workplace. An employer conducting a root cause analysis to determine whether there are systemic reasons for an incident should ask the following questions:
- Why was the oil on the floor in the first place?
- Were there changes in conditions, processes or the work 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?
- How long had the oil been there?
- Was the spill reported?
It is important to consider all possible “what,” “why” and “how” questions to discover the root causes of an incident.
In this case, a root cause analysis may have revealed that the root cause of the spill was a failure to have an effective mechanical integrity program in place that would prevent or detect oil leaks. In contrast, an analysis that focused only on the immediate cause (a failure to clean up the spill) would not have prevented future incidents because there was no system to prevent, identify, and correct leaks.
We have a form designed to make root cause analysis easier. If you would like further information about root cause analysis, or how it can benefit your safety program, please contact us.