It is often said that the only good thing that can come out of a workplace injury is that we learn how not to have a repeat occurrence. This learning is only possible when a thorough analysis is performed to determine the root causes of the incident. Since these root causes are systemic in nature, it’s critical that the operations team work closely with safety staff to ensure a focused analysis identifies the true causes and that workable and effective countermeasures are developed.
We recently explored root-cause analysis and the gaps that often impede improved safety and health performance and creation of a zero-harm work environment. The premise: root cause analysis often reveals that an incident is not the result of a single unsafe act or condition, but rather the culmination of a number of systemic issues.
Managers must be asked to view the business as it relates to the employee, the equipment and the environment, and ask themselves:
- Were the employee(s) involved in the incident affected by contributing factors such as a lack of knowledge, skill, training and experience, or fatigue and distraction, which created an unsafe event?
- Was the equipment right for the task at hand? Was it properly inspected and maintained? The list of possible inquiries may be large or small depending on the event details.
- Did diverse environmental realities affect the outcome? Physical factors, like lighting, weather or road conditions, or other workplace characteristics must be examined. Beyond these factors, the non-physical aspects of the environment can present the broadest element of any inquiry. Is there a rush for production that might encourage workers to take shortcuts, or are cost-containment measures being implemented that may delay maintenance or training? Is there a new manager who has not yet grasped the safety culture and the priority of working incident-free?
The broader implication that often emerges is that everyone across the organization, especially line managers, must understand how safety affects operational processes. They then must drive their root-cause analysis toward creating countermeasures to correct root causes and ensuring such incidents don’t happen again. Success herein requires understanding who actually controls operations, and taking practical steps to ensure the development of actionable responses.
Click here to explore in more depth the essential elements of root cause analysis.
Authored by Randy Tomlinson
Randy Tomlinson is senior manager, safety, health and security at Ryder System, Inc. He has more than 30 years’ experience in transportation safety across a wide range of industries, and currently is responsible for innovative creation and hands-on implementation of safety solutions for the oil and gas industry.