Tuesday, April 7, 2009

Root Cause

I just finished another accident investigation, not too serious. Just prior to doing the investigation, I was reviewing my notes on accident investigation so that I was focused on the investigation and the facts. I came across this illustration of the "Accident Weed."

What this states is that the ultimate cause of all accidents is a system failure. Somewhere the safety program has deficiencies. These deficiencies lead to the accident. Although the deficiencies may not have been the direct cause of the accident, they allowed (or did not prevent) the behavior that lead to the accident.

In my years of investigation accidents I found a couple interesting factors that contribute; It is not the "goof-off" employee that is involved in serious accidents, it is the good employee that cares so much about his work that he forgets about safety practices (complacency).

Another factor is that time pressure is present in almost all of these serious accidents. The last contributing cause is when employees do not FOLLOW or do not UNDERSTAND the instructions given. #-part communication can solve this system weakness.

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