Its standard practice following any major workplace injury to do a root cause analysis.  You might not be familiar with that term; maybe you call it an investigation.  Or, perhaps, it isn’t a formal process in your workplace.  You just correct the apparent issues when someone gets hurt.

Regardless of what you’re currently doing, the goal is to figure out what happened.  Then make changes so that it doesn’t happen again, or someone else doesn’t get hurt.

There are two phrases I like to keep in mind when doing an accident investigation and root cause analysis.

  • The past predicts the future.
  • This has all happened before, and it will all happen again.

That is unless you intervene and change something.  That’s the ultimate goal of any accident investigation.

Never Let It Happen Again. 

What is a Root Cause Analysis?

In the simplest terms, a root cause is:

Root Cause = The one thing that if it wasn’t present, the accident wouldn’t have happened.

But no investigation is ever that simple.  There could be multiple things that contributed to the accident.  There could be more than one root cause.

That’s why it’s called a Root Cause Analysis.  You look at all the factors, and you analyze what could’ve been done differently.  

Contributing Causes

During your investigation and your root cause analysis, you’ll uncover many things that may have gone wrong.

These are called contributing causes.

Contributing Cause = Things that could’ve caused the accident. But even if they weren’t present, the accident still could’ve happened.

There is never one thing that causes an accident.  If that was the case, we would quickly identify that one thing and eliminate it.

Accident investigations are made more difficult because there are so many contributing causes.

It could be…

  • A piece of machinery
  • A lousy process, procedure, or policy
  • Lack of supervisor or leadership
  • Errors in training
  • Employees not following procedures
  • Debris or housekeeping issues
  • The health or physiology of the employee
  • The environment

…And the list can go on.

Your root cause analysis is not complete until you’ve collected all possible causes, defects, or deficiencies. 

Even though root causes stop the accident from happening.  The contributing causes can create a repeat scenario.

Eliminate Everything in Your Root Cause Analysis

Regardless of the type of cause, the next step is to eliminate them.

And this is where many accident investigations fail.  They don’t completely eliminate the hazard.

If you don’t get rid of it completely, the accident will happen again.  

As you are determining your corrective actions.  The most critical question you need to ask is:

“What can we change, as a company, to completely remove this hazard?”

Too often, the cause of the accident is found to be human error.   Companies rely on their employees not to make the same mistake again.

This is not going far enough in your corrective actions.

Using Your Root Cause Analysis to Define Leading Indicators

In an ideal world with a large safety budget, you would engineer out those risks.  

Retraining or disciplinary action isn’t always going to stop a repeat accident. There are steps you can take to reduce the risk of those errors.  

Your human errors need to become your leading indicators.  See the post on How To Use Leading Indicators.

We use leading indicators to stop accidents from happening in the first place.  Remember, the past predicts the future. You can use your root cause analysis to identify your leading indicators.

A leading indicator is a trend in either unsafe acts, conditions, or behaviors.  It increases the likelihood of an accident happening.  If left uncorrected.

Leading indicators can be hard to identify for even the seasoned Safety Manager.  But using your accident investigations makes this easier.

  1. For each root cause and contributing cause, drill down to the employee or employees’ exact behavior or action.
  2. If you are changing your process to engineer out the cause, will this action or behavior still happen?
  3. What action or behavior should the employee be doing?

The answer to #3 is your new leading indicator.  This is where you’ll focus your efforts to improve safe work behaviors.

What to Do with New Leading Indicators

Now that you have a focus area, you need to take a few extra steps to build your workplace’s safety habits.

  • Update your policies, procedures, JHAs, or SOPs to reflect the behavior change.  See the post  How to Know Which is Best: JHA vs. SOP vs. Policies & Procedures for more information.
  • Create an employee training or toolbox talk around the behavior or action.  Your root cause analysis may identify many leading indicators.  Group them together into one training as a response to the accident.
  • Add the new behavior to your regular coaching and observations.  This will reinforce the new behavior.  See the Secrets to an Effective Safety Observation for some tips.
  • Don’t let it go extinct.  Even when it seems like your employees are following the rules to the letter.  If you don’t reinforce the behavior, they can revert back to their old ways.

Eliminating a hazard through engineering controls is a lot easier.  Especially compared to dealing with the human factors.  But you can’t ignore the human element.  Too many accidents are caused by simple errors that are not ingrained in safety habits.

Although it takes time to build safety habits. These extra steps for every root cause analysis will improve your safety in the long run.

Take Action

Look at your last accident investigation.  What were the human factors that contributed to it?  Create a leading indicator around that and start changing those behaviors.

Now It’s Your Turn

Drop a comment below and tell me what percentage of your accident investigations are caused by human error? I’m guessing it’s pretty high.

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Hi, I'm Brye (rhymes with sky)!  I am a self-proclaimed safety geek with two decades of general industry safety experience.  Specializing in bringing safety programs to a world-class level and building a safety culture, I have trained and coached many safety managers, just like you, on how to effectively manage workplace safety in the real world.   I would love to help you too.

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