Contributing Factors and Root Causes of Incidents
General
Root causes for incidents are the underlying system weaknesses that have somehow contributed to the existence of unsafe conditions and unsafe acts that represent surface causes of incidents. Root causes always pre – exist basic causes. Inadequately designed system components have the potential to feed and nurture unsafe conditions and unsafe behaviours. If root causes are left unchecked, basic causes will flourish!
Root causes may be separated in two categories:
1. System Design Weaknesses
2. System Implementations Weaknesses
1. System Design Weaknesses
Missing or inadequately designed Policies, Programs. Plans, Processes and Procedures will affect conditions and practices generally throughout the workplace. Defects in System Design represent unsafe System Conditions.
2. System Implementations Weaknesses
Failures to initiate, carry out, or accomplish Safety Policies, Programs. Plans, Processes and Procedures. Defects in implementation represent ineffective management behavior.
| System Design Weaknesses | System Implementations Weaknesses |
| Missing or inadequate Safety Policies/Rules Training Program not in place Poorly written plans Inadequate Processes | Safety Policies/Rules are enforced Safety training is not conducted No adequate supervision Inconsistent incident analysis |
| No Procedures in place | Lockout/tag-out procedures are not annually reviewed |
Basic Elements of Root Causes
| Elements | Description |
| Materials | Defective raw material Wrong type of job Lack of raw material |
| Machine/ Equipment | Incorrect tool selection Poor maintenance or design Poor equipment or tool placement Defective equipment or tool |
| Environment | Orderly workplace Job design or layout of work Surfaces poorly maintained Physical demands of the task Forces of nature |
| Man | No poor management involvement Inattention to a task Task hazards not guarded properly Horseplay Stress demands |
| Methods | No or poor Procedures Practices are not the same as written Procedures Poor communication |
| Management System | Training or education are lacking Poor Employee involvement Poor recognition of hazards Previously identified hazards were not eliminated |