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"Root Cause" Accident Investigation - Not a Band-Aid, but a Solution

In route to repair a water main leak, a newly hired backhoe operator drifts to the edge of the road and slams into the back of a car, injuring a mother waiting for her kids to get out of school. 

The young operator is near tears, the supervisor overflows with accusations, another worker slams their hand in a door. Everything is confusion.

Eventually, when the mess is sorted out, the safety coordinator will investigate the accident. He learns the steering and brakes on the backhoe were bad. Someone will get blamed, and the equipment issues will be repaired.  The safety coordinator, overwhelmed by the demands on his time, will go off to fight the next fire. 

This is not an extreme case.  Accidents are handled like this every day. At best, this type of approach deals with symptoms and not the actual or root cause.  In a few days, another piece of equipment, perhaps a manifold at the water plant, will fail.  Someone else will be injured or maybe killed.  The plant will shut down for a while and the damage will be repaired, but the risks will remain.

To identify and control risk, an accident investigation must get to root causes. Why was a new employee operating the backhoe?  How much training had they received?  Why wasn’t the faulty equipment taken out of service immediately?  Why wasn’t it clearly tagged out of service? Reported? Was the equipment regularly inspected?  Is there a preventative maintenance program? What must be changed in maintenance, training or safety to keep this from happening again?

Accident investigation should be a critical part of overall safety program strategy. Done correctly, it can enhance safety and reduce costs.  All accident investigations should be conducted in a professional manner and should always focus on causes: the whys. Using the 5 “Whys” of a typical Root Cause Analysis allows the employer to discover the underlying or systemic, rather than the generalized or immediate, causes of an accident.  Correcting only immediate cause may eliminate a symptom of the problem, but not the problem itself. The more incidents that are reported, the more problems that can be investigated and resolved. The more problems solved, the safer and more cost effective the operation will be.

The fact is that the only difference between a near miss and a catastrophe may be chance. That's why every potential problem should be resolved. 

For more information on conducting accident investigations, and developing a Root Cause Analysis please view “Incident [Accident] Investigations: A Guide for Employers” https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf

Accidents and injuries are not a cost of doing business; all are preventable!

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