Safety and Weed Control

How often is your green lawn or beautiful garden spoiled by the appearance of weeds. You can pull them, poison them, dig them up, and try everything in the book to get rid of those weeds but until you get right down to the root of it and deal with all of that root the weeds continue to return. Incident investigation is very much like gardening. The goal of the investigation should be to identify the root causes that resulted in that incident occurring and make the changes that prevent that root cause from resulting in a similar incident.

Wikipedia defines root cause as “an initiating cause of either a condition or a causal chain that leads to an outcome or effect of interest.” The definition goes on to state that “commonly, root cause is used to describe the depth in the causal chain where an intervention could reasonably be implemented to improve performance or prevent an undesirable outcome.” This second part of the definition is key to making effective use of incident investigations to reduce and hopefully prevent a repeat of the incident.

There are factors for which controls cannot reasonably be implemented such as weather, but all to often the use of general terms such as “operator error” or “equipment failure” are used to identify root causes. These types of conclusions are not specific enough to identify effective changes to prevent recurrences. There are also root causes that investigators fail to get to because they are not conducting their investigation independently. There are times that root cause analyses lead to decisions and directions provided by management and supervisors but identifying these can create difficult situations. An effective root cause analysis identifies root cause(s) that management can address and make effective changes. Their own decisions and directions may well be a root cause that can be addressed.

Investigations are conducted for a variety of reasons. There are times investigations are being conducted to determine fault. There are times investigations are being conducted to locate lost or missing products. From a health and safety standpoint the ultimate purpose of an incident investigation is to prevent a recurrence. The crucial factor to a successful incident investigation is not identifying the root cause(s) but having management and supervisors making use of that root cause analysis to make effective changes.