A Simplistic Elementary approach to Cause Analyzes from the Occupational Health and Safety perspective

A most common error in perception while analyzing causes following any negative event is that the analyzes is often focused on what happened rather than why an undesirable event happened? Analyzing the why question takes us into the domain of human and organizational factors which normally does not form the center of attention in any incident investigation. It is certainly important to know what people did but it is more important to understand why they did it.

It is not enough to learn that people make mistakes but we should find out why these mistakes were made if we intend to prevent the same mistakes from recurring. The decision makers invariably think that they were doing the right thing when in fact their flawed decisions were taking them closer to an occurrence of a negative event. If we are to make sense of flawed decision making, then we need to understand the perception of the decision makers and how they themselves understood the situations they were in.

Generally speaking, it is important for managers, supervisors to understand and analyze the process or system for identifying and eliminating the conditions, behaviors and management system weaknesses that result in accidents, incidents, near misses, and non-conformities.

If the management system fails to identify and eliminate the causes behind the work place accidents, incidents and non-conformities then chances are that we shall have face these undesirable events frequently.

By understanding and analyzing the conditions, behaviors and management system weaknesses we shall be able to dig out the roots behind these undesirable events!

What causes incidents, accidents and non-conformities?

There are three general cause categories for work place incidents

1.Unpreventable acts - Less than 2 % of work place incidents are thought to be

Unpreventable. Heart attacks or other events that could not have been known by the organization are examples of unpreventable acts.

2.Hazardous conditions – Unique situations or objects that are somehow defective or Unsafe that may include employee fatigue, defects in processes, practices and Procedures. Hazardous conditions may exist at any level of the organization and is generally the result of deeper root causes.

3.Unsafe behaviors - It is important to know that most hazardous conditions at the Work place are a result of the unsafe behaviors that produced them.

Hazardous conditions may exist in any of the following categories

1. Materials

2. Machinery

3. Equipment

4. Tools

5. Chemicals

6. Facilities

7. People

8. Workload

Some of the characteristics of Unsafe behaviors are as under

1. Actions that we take or do not take that increases the risk of an incident.

2. Unique performance errors in a process, practice or procedure.

3. May exist at any level of the organization.

4. Are the result of deeper root causes.

Some examples of Unsafe employee / manager behaviors  

1. Failure to comply with rules.

2. Using unsafe methods.

3. Taking short cuts and horseplay.

4. Failure to report incidents.

5. Failure to report hazards.

6. Allowing unsafe behaviors.

7. Failure to train.

8. Failure to supervise.

9. Failure to correct.

10. Scheduling too much work.

11. Ignoring worker stress.

There are three phases of cause analysis following an undesirable event which are

1.Incident Analysis

At this stage we do not try to determine what caused the incident but rather focus on the direct and immediate cause of the incident. E.g. harmful energy Transfer that caused Injury or damage to property.

2.Surface Cause Analysis

 Surface Cause Analysis - At this phase we determine the hazardous conditions and unsafe behaviours described in the sequence of events that dynamically interact to produce the incident. The hazardous conditions and unsafe behaviours uncovered are the surface causes of the incident and gives clues that point to an underlying root cause.

 3. Root Cause Analysis 

 At this stage we analyze the weaknesses in the management system that contributed to the incident. It is usual to uncover system weaknesses related to inadequate policies, programs, plans, processes or procedures. Root causes always pre-exist surface causes and may function through incorrect system design that allows, promotes, encourage and even require compliance to systems that result in hazardous conditions and behaviours. This stage of analysis is also called common cause analysis as we identify system component failures that may contribute to common conditions and behaviours that exist or occur throughout the organization.

 Direct Cause of accident that resulted in Injury

The injury is the result of the transfer of an excessive amount of harmful energy from an outside source to the body. This is called the direct cause of the injury. For example, the direct cause of a broken arm would be the excessive kinetic energy transferred when the arm strikes the floor.

Examples of direct causes of injury:

Kinetic energy is transferred when an employee strikes the ground after a fall causing Multiple injuries.

Chemical energy is transferred when acid splashes into an employee's eyes causing Tissue damage.

Thermal energy is transferred when an employee comes in contact with hot surfaces causing massive burns.

Surface Causes

The leaves of the weed represent the surface causes for accidents. They are the unique hazardous conditions and individual unsafe or inappropriate behaviors. When an unsafe or inappropriate behavior exposes an employee to a hazardous condition, an accident may occur. These surface causes represent the symptoms of the problem.

We place surface causes into two categories: primary and secondary.

Primary surface causes are the immediate unique conditions or individual behaviors That cause accidents.

Secondary surface causes are the conditions and behaviors that indirectly contribute to the accident.

Examples of direct and indirect surface causes of accidents:

Direct surface causes (unsafe conditions) include:

Broken rung on a ladder

Unguarded grinder

Defective eye protection

Indirect surface causes (unsafe behaviors) include:

Employee fails to report a broken ladder

Employee removes the grinder's guard

Employee does not clean eye protection

Root Causes

The roots of the weed represent the pre-existing root causes of accidents. Root causes may feed and nurture hazardous conditions and unsafe work practices. We place root Causes into two categories: performance and design.

Performance root causes are those behaviors and actions that managers and supervisors engage in that somehow contribute to accidents. Performance root causes are influenced by deeper root causes. For example, a performance root cause might be a situation in Which the employer fails to conduct safety inspections.

Design root causes are those Management System Policies, programs, plans, processes, and procedures that are missing or inadequately designed.

Examples of performance and design root causes of accidents:

Performance root causes include:

Ladder safety training is not being conducted

Grinder preventive maintenance is not scheduled

Eye protection is not being replaced as needed

Design root causes include:

Safety training program does not include ladder safety

Corrective and preventive maintenance programs do not exist

Funding for safety equipment is inadequate

Unique hazardous conditions represent only a small percentage of the causes for Accidents in the workplace. On the other hand, individual unsafe behaviors cause many more accidents.

Ultimately though, virtually all workplace accidents (except for “Acts of God") are caused by system root causes, under the control of management, that result in unique hazardous conditions and/or unsafe work practices.