Root Cause Analysis

as applied to
Incident Investigations
Trainer:
DAY 5 – HSE 3 Asad Ullah
free learning for all. Launching by 1st Dec. 2021
 Why We Investigate Accidents

1. To find out what happened

2. To prevent it from happening again.
Root Cause Analysis (RCA) is an excellent tool
to allow accidents to be investigated in an
effective and timely manner.
What is Root Cause Analysis (RCA)

RCA does the following:

• Examines the cause of an incident
• Analyzes the factors that contributed
to the incident
• Allows the development of measures
to help prevent future reoccurrences
 Differences between
Direct Cause and Root Cause
Problem: My car will not start.
 Q1. Why?
A1. The battery is dead (this is the ‘direct cause’)
Q2. Why is the battery dead?
A2. The lights were left on (a root cause)
Q3. Why were the lights left switched on?
A3. I forgot to turn them off (another root cause)
Q4. Why did you forget?
A4. I was taking shopping bags out of the car (another root cause)
Q5. Did you forget anything else?
A5. I didn’t lock the car and I left the keys in the ignition (a notable item, but
not a root cause of the incident)
 Ask “The 5-Whys”

Ask the question ‘why’ five times and it will

reveal the direct cause of the incident, the
associated root causes and, sometimes,
items not related to the incident, but
problems that still need to be corrected.
 Why Discovering Root Causes is
so Important
Finding the root causes is essential to
developing appropriate corrective actions
and prevention because, if you don’t identify
the root causes, the same incidents will likely
reappear in the future.
Root Cause Analysis Procedure

1. Define the Incident

2. Gather Data / Evidence
3. Ask the 5 “Whys”
4. Identify Corrective
Actions
 1) Define the Incident

Determine what actually happened.

For example, ‘a person fell to the ground when
the ladder broke’.

The actual incident is the

‘broken ladder’, not the
‘person falling to the ground’.
 2) Gather Data / Evidence
Gather physical evidence from the
scene such as photographs &
sketches, interview eyewitnesses,
maintenance & repair records,
history of previous incidents, safety
inspections and follow ups, etc.
 3) Ask the 5 “Whys”

Use the ‘5-whys’ technique to identify the true

root causes associated with the incident.
Then you can identify and categorize the
root causes into root cause types.
Why,
why,
why,
why, why
 Identify Corrective Actions

Identify corrective actions that will prevent

recurrence of the incident, by using
S.M.A.R.T. (Specific, Measurable,
Attainable, Realistic, and Timely)
recommendations.
 Examples of S.M.A.R.T.
• Specific – “Improve ladder safety” (not specific)
“Replace defective ladders” (specific)
• Measurable – “Replace all defective ladders” (no end-point and not measurable
“Conduct job site inspection, replace all defective ladders, and report total
number replaced” (has end-point & is measurable)
• Attainable – “Replace all ladders within one day” (not attainable)
“Replace all defective ladders within one month” (achievable)
• Realistic – “Replace all ladders” (not realistic)
“Replace all defective ladders” (realistic)
• Timely– “Replace all defective ladders” (no time constraint and repeat incidents
could occur)
“Replace all defective ladders within one month” (time-bound)
 Recommendations

It is important that the recommendations do

not solve one problem but create another.
Recommendations should also be feasible,
sensible and within budget.
There is no use in proposing recommendations
that will never be put into place because
they are too expensive.
Implement the recommendations
This means making manpower, materials and
other resources available to ensure the issues
are resolved within the allotted time period.

Methods Materials

Machines Management
Equipment Systems

Supervisor Environment
Manpower
 Observe the recommendations
for effectiveness
Monitor and track the
Contractors Employees Management
completed
recommendations to
make sure safety has
improved. Safety Safety Safety Safety Safety

If not, revise the

recommendations
until they work Recommendation Recommendation Recommendation

effectively.
 Categorizing Root Causes
Putting root causes into categories helps you
target the corrective actions and
recommendations, so you can fix the actual
problem first time.

ROOT CAUSES
 Root Cause Categories
Root causes can be placed in the following
categories:
Materials
Manpower

Machines & Equipment

ROOT CAUSES
Environment
Supervision
Methods
Management Systems
 Materials
– Defective materials
– Wrong type or design of materials for the job
– Lack of materials
 Manpower

– Inadequate capability
– Lack of Knowledge
– Lack of skill and training
– Stress and fatigue
– Improper motivation
– Uncertified or unqualified
 Machines & Equipment

– Incorrect tool or equipment

selection
– Poor maintenance or design
– Poor equipment or tool
placement
– Defective equipment or tools
 Environment
– Orderly workplace and
housekeeping
– Job design or layout of work
– Surfaces poorly maintained
– Physical demands of the task
– Forces of nature, bad weather
conditions, etc
 Supervision
– Insufficient or poor supervision of work tasks
– Inattention at the workplace, not following safety
rules
– Task hazards not properly guarded or barricaded
– Horseplay
– Overloading too much work on available resources
– Lack of proper procedures and no safe system of
work
– Lack of Communication
 Methods

– Inadequate or poor procedures, no written

procedures
– Work practices differ from written procedures
– Poor communications
 Management System
– Training or lack of education
– Poor employee involvement
– Poor recognition of hazards
– Previously identified hazards
were not eliminated
Applying Root Cause Analysis to
Ladder Scenario
Scenario
“An employee fell to the ground when the
ladder he was using broke”. 
Define the Incident
“A ladder broke in the workplace”
Investigate the ladder incident with
the ‘5-whys’ technique
Q1. Why did the employee fall to the ground?
A1. The ladder broke (this is the ‘direct cause’ or the ‘cause of
the incident’) .
 
Q2. Why did the ladder break?
A2. The ladder was worn out and hadn’t been inspected (a root
cause).
 
Q3. Why wasn’t the ladder inspected?
A3. There are no procedures for inspecting and maintaining
any of our ladders (another root cause).
 
 Investigate the ladder incident with
the ‘5-whys’ technique
Q4. Why are there no procedures for inspecting and
maintaining ladders?
A4. We never had an accident with a ladder before, and so no
one was assigned to inspect or maintain ladders (another
root cause)

Q5. Why aren’t employees trained to inspect the ladders before

each use, and isn’t ladder safety mentioned in daily toolbox
meetings?
A5. We don’t have daily toolbox safety meetings,
we only have one meeting at the beginning
of the job (another root cause)
 Categorizing the causes
Q1: is a Supervision failure because there was inadequate
supervision on the job site about using unsafe ladders

Q2: is a Tools & Equipment failure, since there was no inspection or

maintenance of the ladders

Q3: is a Methods failure, since no procedure was in place for ladder

inspection

Q4: is a Manpower failure, since there was lack of knowledge that

ladders will wear out after continuous use

Q5: is a Management System failure, since there were no daily

toolbox safety meetings held to warn employees about
workplace hazards
Generic RCA diagram – Fishbone Layout
Machines &
Materials Manpower Environment
Equipment

Incident

Management
Supervision Methods
System
 Specific RCA diagram for the Ladder
Scenario – Fishbone Layout
Machines &
Manpower
Materials Equipment Environment
Lack of knowledge
no ladder inspection
about ladders
or maintenance

Incident
Employee fell off
broken ladder

Methods Management
Supervision
Inadequate No ladder inspection
System
supervision on job site No daily toolbox
procedure
meetings
 Recommendations for the Ladder
Scenario
• Recommendations should be S.M.A.R.T. (Specific, Measurable,
Attainable, Realistic, and Timely), sensible and within budget.
• Recommendations must specify the organization or person that
should take action or the recommendations are meaningless.
• Avoid sentences like, “…We all need to be safe”, or “…All
contractors need more safety training”, they are too general to
help prevent reoccurrence of the incident.
• Start recommendations with an action phrase followed by the
subject and a date corrections will be put in place.
 Phrases

Action phrases usually include:

“Shall do…,” (Action must be taken done)

“Should do…,” (something needs to be done but it’s not

essential)

“Recommend…”, (actions need to be considered and

then something done)
Sample phrases

“The contractor/proponent/Dept/Div/Unit
shall…”
“The contractor/proponent/Dept/Div/Unit
should…”
“It is recommended that the
contractor/proponent/Dept/Div/Unit
needs to…”
 Risk Control Strategies
When developing recommendations use one
of the following 3 risk control strategies:

•Remove

•Reduce

•Protect
 Remove
Completely eliminate the
hazard (where practical
and feasible)
Example: fill in an open
road trench.
 Reduce
Reduce the degree of the hazard (if
complete removal is not practical or
feasible)
Example: Use steel plates across a road
trench where the trench needs to stay
open for operational reasons
 Protect
Protect people and property from
the hazard (where reduction or
removal is not possible).
Example: put barricades around
the open road trench.
 Class Activity - RCA
Working in notebook, write out the
recommendations for the Ladder scenario:
“A ladder broke in the workplace”