hsesafetystudy: Root Cause of the Accidents/Incidents

Root causes:

The Root cause is the most fundamental and indirect cause of an accident or incident. (Trace the reasons behind the immediate causes.)

Root causes are generally management, planning or Organisational failings.

Example-

Failure to identify training needs, assess competence;
Failure to use the Risk assessments,
Failing to be proactive ( like no Safety Inspection etc.)
Failure to involve the workforce in health and safety etc.
Poor management Practices( No maintenance provision)

Management Failure (Root causes)

Root causes are the things that lie behind the immediate causes.

For example, with the slip we described above, the Root causes might be a poorly maintained machine that has leaked oil onto the floor, and a poorly inspected and maintained workshop with broken light-fittings and inadequate lighting levels.

Here, the worker might be blameless on the basis that, given those conditions, the accident was bound to happen eventually.

Examples of failures in the management system/ Root cause/ Basic Cause / Management Failure

Failed to provide effective supervision (No supervision) (Inadequate Supervision )- - - - -(only one-way communication)
Failed to provide the specific PPEs (No PPE provided.)
Failed to provide the induction training & Job-specific training (No training/ inadequate Training)
Failed to provide the proper maintenance schedule (No maintenance.) (Inadequate/ insufficient maintenance) (Maintenance errors)
Inadequate Safety monitoring
Failed to implement the Active monitoring
No Reactive monitoring (No provision of Active and Reactive monitoring ) (Inadequate Safety Monitoring)
No checking or inspections arrangement
Failed to develop and implement the effective risk assessment (Inadequate or no risk assessments.) Failure to carry out the risk assessment (inadequate risk assessment, or no review of RA)
Failed to develop the OH&SMS ,
H&S Policy (Lack of system, Policy )
Failed to provide the adequate resources (Lack of resources)
Failed to provide the effective Internal & External Communication (Lack of Communication) , Inadequate Communication issues e.g. between shifts, between personnel and management etc
Failure to develop effective SSW/SWP)Safe Working Procedures)
Failed to develop / implement the SOP (Inadequate procedures)
Failed to prevent the Violations
Non-compliance behaviour ( Management & young worker behaviour)
Inadequate Housekeeping ( Items stored in the FLT pathway / Aisles)
Disciplinary action not developed
Pressure to meet production targets ( busy retail store )
Failure to learn lessons from previous incidents (Lesson learn not shared) ( e.g. Previous collisions)
Modification/ updates to equipment without operator knowledge and/or revised risk assessments
Failed to act/resolve the Worker’s complaints/concerns
Inadequate SOP ( Not developed any SOP)
Failed to hire competent manpower (Lack of competency) ( e.g. Young worker)
Could not provided the right equipment/plant design (Poor workplace layout, poor design of tools and equipment, Poor workstation set-up)
Not planned & developed any H&SMS (Inadequate safety management systems)
Failed to avoid the Excess workloads, ( e.g 12 hours working, Rota system etc.)
Excessive work demands
Excess physical & mental pressure - - - - - (Excessive working hours resulting in mental fatigue)
Failure to monitor actual performance
Failure to provide feedback
Failed to implement the accident reporting procedure / system (Inadequate reporting systems)
Not implemented any accident Investigation System (ineffective accident investigation system)
Poor management practices e.g. inadequate supervision
Production focus instead of Safety Focus