Getting to the Root Causes of Workplace Incidents
Incident investigations are a basic element of most safety programs. After all, when an incident occurs, everyone wants to know what happened and why. However, as ASSE Fellow Fred Manuele observes in his May 2016 Professional Safety article, "Unfortunately, in a huge proportion of investigations, the causal factor determination stops with identifying an employee’s unsafe act." In the article, Manuele tackles the concept of root-casual factors and explores incident causation and incident models, referencing as his base the work of Erik Hollnagel and Sidney Dekker. He also proposes that safety managers seriously consider applying the five-why process to improve their organizations' investigations.
This article builds on Manuele's October 2014 article, "Incident Investigations: Our Methods Are Flawed." In that article, Manuele concludes, "If incident investigations are objective and thorough, the symptoms relating to technical, organizational, methods of operation and cultural causal factors will be revealed. If appropriate action is taken on those causal factors, significant risk reduction can be achieved." Find additional incident investigation resources in ASSE's Body of Knowledge.
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