Root (Basic) Cause Analysis

Root causes are those that, if corrected, would eliminate the accident from occurring again or similar accidents from occurring. They may include several contributing causes. They are a higher order of causes that address multiple problems rather than focusing on the single direct cause. An example would be, "Management failed to implement the principles and core functions of a safety and health program. It is management's responsibility to ensure that the workplace has an effective safety and health program and that the workplace is safe for employees to work in."

Root Cause Analysis Methods

The most common root cause analysis methods are as follows:

  • 1. Events and causal factor analysis identifies the time sequence of a series of tasks and actions and the surrounding conditions leading to an occurrence.
  • 2. Change analysis is used when the problem is obscure. It is a systematic process that is generally used for a single occurrence and focuses on elements that have changed.
  • 3. Barrier analysis is a systematic process that can be used to identify physical, administrative, and procedural barriers or controls that should have prevented the occurrence.
  • 4. Management oversight and risk tree (MORT) analysis is used to identify inadequacies in barriers and controls, specific barrier and support functions, and management functions. It identifies specific factors relating to an occurrence and identifies the management factors that permitted these risk factors to exist.
  • 5. Human performance evaluation identifies factors that influence task performance. The focus of this analysis method is on operability, work environment, and management factors. User-system interface studies are frequently done to improve performance. This takes precedence over disciplinary measures. Human performance evaluation is used to identify factors that influence task performance.
  • 6. Kepner-Tregoe (K-T) problem solving and decision making provides a systematic framework for gathering, organizing, and evaluating information and applies to all phases of the occurrence investigation process. Data are needed for those using this method. A further description is not included in this book.

The use of different methods to conduct root cause analysis has been widely accepted over a period of years. There have been many creative adaptations and permutations using the root cause analysis approach, but the foundation for it has stood the test of time. Certain methods are used for different circumstances, such as when they fit well for certain industries, for unique hazards, when engineering becomes a factor, or when complexity is present. The analysis of an accident does not stop with the identification of the direct, indirect, and basic (root) causes of the accident or incident. To make positive gains from the event, changes should be made in the interaction of users, systems, materials, methods, and physical and social environments. These changes should result from the recommendations that are derived from the causes identified during the investigation. The goal of these changes is the prevention of future accidents and incidents similar to the one investigated.

This type of analysis may trigger the need to more closely analyze a job or task that has been identified as presenting a high risk of producing hazards or injuries.

 
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