Incident Root Cause – Tools for Identifying Root Cause, Corrective Actions and Legal Considerations

Incident Root Cause: A Incident Root Cause is the primary cause or causes of an accident that, when identified accurately and corrected, will prevent recurrence.

Identification of  Root Cause(s): Analyze investigation results to uncover Root Cause.

Categorize your notes (job experience, location, site layout, work practices, etc.).
Analyze interview information.
Re-interview if necessary.
Review equipment and operation specs, and safety documents.

Use a systematic problem solving approach to identify the following:

Amount and quality of job training
Type and frequency of job supervision
Was motivation/disciplinary procedures were effective in promoting safety rules and procedures?
History of prior accidents or near-misses with a piece of equipment or procedures involved
Were procedures followed? (and if not, why not?)

Tools for Identifying Root Cause:

7 Step Problem-Solving Methodology
Root Cause Analysis Tree
Guide for Identifying Causal Factors and Corrective Actions

7-Step Problem-Solving Methodology:

Identify the problems.
Prioritize the problem.
Perform a cause analysis.
Generate solutions.
Present solutions for approval
Implement and check results.
Standardize new solutions.

Fish-bone Diagram:

Root Cause Analysis Tree:

Direct Cause: Actual description of the result of an accident. (e.g. employee received acid burn to arm)

Obvious Cause or Secondary contributing factors: Readily observable causes of an accident. (e.g. employee was not wearing proper PPE)

Root Cause or Primary Cause: Primary cause(s) of an accident, that when corrected will prevent reoccurrence. ( e.g. employees not trained properly regarding proper PPE to be worn for handling hazardous chemicals.)

Guide for Identifying Causal Factors and Corrective Actions:

Identifies all of the causal factors of an accident.
Assigns corrective actions to them.
If the causal factors are not eliminated, there may be the possibility of another accident.

The Guide contains 5 parts:

Equipment
Environment
People
Management
Ergonomics

The Guide Ensures 3 Basic Steps:

All major actions are considered.
The analysis does not stop with familiar and favorite corrective actions.
Each corrective action chosen for implementation is carefully thought out

Corrective Action Plans : Formulating solid corrective action plans and executing them is essential for:

Getting results from an investigation, and
Preventing recurrence.

3 Elements of Corrective Actions :

A detailed and comprehensive description of the Corrective Action
An experienced owner who will take responsibility for completing the Corrective Action
An estimated time of completion

Incident Legal Implications: Accident Investigation Report may be used in a court of law.

Any document could be used as evidence.
As an investigator, you could be called as a witness.
All documentation is legally binding.

What are the Legal Considerations?

Since the Accident Investigation Report can be used in legal proceedings:

Be thorough in describing what happened.
State facts and data only and don’t state your opinions.
Do not use language that assigns or implies speculation or legal fault (like the terms negligent or incompetent).
Good investigations are essential to prevent future accidents and protect the corporation from litigation.
List ALL causes (especially Root Causes) uncovered in your investigation.
Make recommendations for corrective actions.
Failure to correct a known hazard places the employer at risk for being held negligent if someone were to sustain an injury in the same manner.

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