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Root Cause Analysis – Not Just for Accident Investigation

- January 8, 2018 by Rick Fineman, CSP, ARM (View all posts by Rick)

Safety professionals have been using root cause analysis for decades to understand and solve a problem. Fault tree analysis, fishbone diagrams, the 5-Whys analysis and other approaches are useful tools for investigating serious losses. These techniques can be just as effective when applied to unsafe acts and conditions observed without an accident or near miss. Root cause analysis can be used to identify opportunities to reduce risk at any given time.

For example, if a machine is found unguarded during an inspection, replacing the guard will rarely fix the problem. Why? There was a reason the guard was off the machine, a reason behind why the guard remained removed from the machine while individuals operated it, reasons for the operator to ignore the removed guard and ultimately reasons the guard will be removed again. If a simple root cause analysis technique like the 5-Whys was applied to this scenario, we may have found the following:

5 Why Question


Why was the guard off the shear? The operator removed it….
Why did the operator remove the guard? The stock would not fit through the guard…
Why would the stock not fit through the guard? New stock was brought in for cost – instead of pre-cut stock, the stock is in a multiple piece form which won’t fit through the shear when guard is on
Why was the stock size issue ignored when it was inspected by engineering? Engineering does not have a formal step of reviewing machinery feed size when selecting stock
Why doesn’t engineering have a formal step to review machinery feed size needs when selecting stock? There is no formal audit of processes and procedures within any of the departments.

By drilling into the root causes of the guard not being on the machine, opportunities for improvement become more meaningful. Addressing the engineering process for identifying machinery feed needs and formalizing process audits can affect far more than just this one shear.

Using root cause analysis to identify the reasons unsafe acts and conditions occur and then addressing those fundamental issues can have a significant impact on overall risk reduction efforts. For another look into this concept, check out Leslie’s blog from October. If you would like to speak with one of ICW Group’s risk management consultants about conducting a root cause analysis and action plan, please contact us here.