Root cause of incident

Root cause of incident: The work carried out in construction projects is considered high risk due to workplace hazards as it facilitates the occurrence of work accidents that affect the physical, mental and social integrity of employees as well as the productivity of companies. For this reason, the purpose of this article is to analyze the causes and consequences of work accidents. Workplace accidents can be generated by immediate or basic causes (usually called underlying causes or root causes).

According to statistics from the International Labor Organization (ILO), in the World Day for Safety and Health at Work report, "Around 4% of global Gross Domestic Product (GDP) is lost to the cost of casualties, deaths and illnesses in the form of absences from work, treatment and disability and death benefits" (ILO, 2005).

The pyramid theory of accidents developed by Bird in 1969 revealed that for every serious accident, there are 10 minor accidents, 30 accidents with property damage and 600 accidents without visible damage or loss.

The immediate (direct cause of incident) ones are those that produce the accident directly and are made up of unsafe acts (inappropriate behaviours of workers that can cause a work incident) and unsafe conditions (facilities, equipment, machinery and tools that are in poor condition and put workers at risk of suffering an accident).

But to achieve an effective solution to work accidents, it is essential to recognize root cause of incident, which gives rise to the immediate causes made up of personal factors (incorrect work habits, incorrect use of equipment, tools and facilities; defects physical or mental, hearing deficiencies, etc.) and work factors (Poor supervision and leadership; Inadequate policies, procedures, guides or practices; Inadequate planning and/or programming of work.

The direct cause of the incident

We call the causes closest to the accident, which are those that materialize its, Immediate Causes. They are those related to the material and environmental conditions of the workplace (unsafe conditions) and those related to the personal actions of the workers who participated in the accident (unsafe acts).

These are the causes that are found in the sequential process close to the event that triggers the accident. The fundamental thing is to discover at this stage the immediate causes, so that once they are eliminated, the accident cannot materialize or it is very difficult for it to materialize. The immediate causes are classified into two groups, of which one or more than one of each group must be noted. Muniriyathse (safety zone) brought to you some examples of unsafe acts and conditions.

The immediate cause of incident
Unsafe acts	Unsafe conditions
Operate equipment without authorization	Inadequate protections and safeguards
Horse playing	Poor housekeeping
Operating at an inappropriate speed	Lack of planning
Put safety devices out of service	Limited space to move around
Remove safety devices	Slippery surface
Using defective equipment	Explosion or fire hazard
Using equipment incorrectly	Poor order and cleanliness in the workplace
Using inappropriately or not using the indicated personal protective equipment	Inadequate protections and safeguards
Not respect for signs and barricades	Hazardous environmental conditions: gases, dust, fumes, metallic fumes, vapours.
Store incorrectly	Noise exposures
Lifting objects incorrectly	Radiation exposures
Adopting an inappropriate position to do the job	Exposures to high or low temperatures
Perform maintenance on equipment while it is running	Excessive or poor lighting
Make practical jokes	Insufficient ventilation
Working under the influence of alcohol or other drugs.	Hazardous environmental conditions: gases, dust, fumes, metallic fumes, vapours.

Underlying or basic cause or root cause of incident

In this blog, we will deal with the root cause of incident. They are the causes that fundamentally correspond to failures in the application of the prevention system, which may be of a personal nature (personal factors) and work organization (work factors).

They are the reasons that explain why unsafe acts and conditions exist. Its analysis allows for deeper, more extensive and more exhaustive control of the working conditions that can give rise to work accidents. Some authors also call them originating causes, real causes, indirect causes, underlying causes or contributing causes.

Root causes of work accidents

Basic Causes help explain, among other things, why people perform unsafe acts. A worker will not be able to execute an appropriate work procedure if he or she has not been previously taught that procedure; training and information are at the heart of the way we carry out our actions.

Similarly, a worker who handles work equipment that requires precise and specialized handling will not be able to use it efficiently and safely if he or she has not been properly trained in its use. Training and periodic practices are also essential to carry out good practices.

It also influences our way of doing things, and our personal physiological and psychological conditions, in other words, each job has demands for which the worker who performs it must be suitable.

Root or underlying causes also help explain why unsafe conditions exist. The existence of inadequate maintenance of work equipment or wear and tear due to the use of materials can also be cited as factors that lead to the existence of unsafe conditions. 

Classification of the root causes of incident

Three common reasons cause a failure in the prevention system.

Existence of:

1. Inadequate occupational risk prevention system
2. Insufficient or inadequate system procedure
3. Failure to comply with any aspect of the system

As an example and on a generic basis among others, we can find the following root causes of incident:

Personal factors

Within the root causes of incident, we distinguish personal factors, which refer to aspects that concern the attitudes and skills of each worker and job. These factors represent a significant risk of a workplace accident when a worker who performs a dangerous function has little experience, when a working day is especially long or tiring, or when the work environment is psychologically exhausting.

Therefore, a young and inexperienced worker in work fields that include dangerous machinery such as construction sites or certain industries is at greater risk of injury. This fact is observed annually in the statistics of work accidents and their causes. This inexperience includes ignoring certain dangers if they have not received extensive training, poor work safety practices, and poor skills in the profession, which substantially increases the likelihood of suffering a workplace accident.

Job factors

Now we are talking about factors that are the direct responsibility of the company and the environment that is imposed on the worker. First of all, we can mention the consequences of inefficient leadership in which the correct instructions are not given or the tasks carried out by workers are not sufficiently supervised as a preventive measure against workplace accidents.

Likewise, among the factors of the work environment, we find the correct maintenance of machinery, means of production and tools used in work processes. At best, a machine failure can inflict a mere scratch on a worker that will not require any time off, and at worst, poor machine maintenance can lead to the death of a worker, either by electrocution, crushing or entrapment.

Furthermore, it is the company's responsibility to train workers in occupational risk prevention with training programs specific to their jobs. This is how the company informs the workers about the risks that surround them, how to protect themselves and how to proceed in the event of a workplace accident.

Root cause of incident
Personal factors	Job factors
Inadequate capacity for work (physical or psychological)	Insufficient leadership and supervision
Lack of knowledge about the execution of the work	Improper engineering
Lack of the necessary skills to perform the job	Incorrect acquisitions
Excess tension (physical stress or psychological stress)	Improper maintenance
Inadequate worker motivation	Inadequate tools, equipment and materials
Lack of awareness	Poor work standards and procedures
lack of respect for instruction/laws	Use and wear of materials
Poor motivation	Abuse and misuse of work equipment
Other person factors	Absence of training and training programs for personnel

 Root cause analysis examples

If you only try to treat the symptoms, they will repeat themselves over and over again. It is important to find the answer to the following questions:

• Why did this unsafe act occur?
• Why did this unsafe condition appear?
• What went wrong in our system that allowed that unsafe act or condition?

To solve or analyze a problem, we will need to perform a root cause analysis and find out exactly what the cause is and how to fix the problem. In this article, muniriyathse (safety zone) will define root cause analysis, outline common techniques, and provide some examples.

What is root cause analysis?

The RCA assumes that it is much more effective to systematically prevent and resolve underlying problems rather than just treating symptoms.

Root cause analysis can be performed with a collection of principles, techniques and methodologies that can be leveraged to identify the root causes of an event or trend. By looking beyond superficial cause and effect. RCA can show where processes or systems failed or caused a problem in the first place.

When we analyze problems and root causes, it is important to take a comprehensive and holistic approach. In addition to uncovering the root cause, we must strive to provide context and information that will result in an action or decision. Remember: a good analysis is an actionable analysis.

The 5 Why?

One of the most common techniques for performing root cause of incident analysis is the 5 why approach. For each answer to a WHY question, follow it with an additional, deeper “Okay, but WHY?”

Example: Let’s remember our concussion example. First, an employee slips and falls in the workplace.

This is our first WHY.

Why 1: Why did the employee slip?

A: Because there was a spill on the floor.

Why 2: Why was there a spill on the floor?

A: Because a container with liquid was not properly sealed.

Why 3: Why was the container not properly sealed?

A: Because the lid was damaged.

Why 4: Why was the lid damaged?

A: Because it wasn't regularly checked during maintenance.

Why 5: Why wasn't it regularly checked during maintenance?

A: Because management decided there was no need to have a maintenance plan in place.

Root cause of incident: Lack of a scheduled maintenance plan for checking equipment for which senior management is accountable.

Tips for Conducting an Effective Root Cause Analysis

Ask questions to clarify the information so we can get closer to the answers. The deeper we can dig and interrogate each potential cause, the more likely we are to find a root cause. Once we believe we have identified the root cause of the problem, we can ask even more questions: Why are we sure this is the root cause rather than this? How can we fix this root cause to prevent the problem from happening again?

Underlying causes of Occupational Health and Safety incidents often involve deeper issues within an organization's systems or practices. Some examples include:

Lack of Training: Insufficient training programs or failure to provide ongoing education can result in employees being unaware of proper safety procedures.

Poor Ergonomics: Workspaces that do not consider ergonomic factors may contribute to musculoskeletal issues and injuries among workers.

Conclusion

The "root cause" of an incident refers to the fundamental, underlying reason why it happened. It's the essential factor or combination of factors that set off the chain of events leading to the incident, as opposed to just the immediate symptoms or trigger points. Understanding the root cause is crucial because it allows you to:

1. Prevent similar incidents in the future: By addressing the root cause, you can eliminate the underlying problem and stop it from triggering future incidents.
2. Implement effective corrective actions: Focusing on the root cause ensures your solutions target the source of the problem, not just superficial fixes that might temporarily mask the issue.
3. Improve overall system reliability: Identifying and addressing root causes strengthens your systems and processes, making them less prone to failures and interruptions.

Here are some additional things to keep in mind about root causes:

• They are often deeper than you might think: Don't settle for the first obvious explanation. Dig deeper and ask "why" questions repeatedly to uncover the underlying factors.
• They can be complex: Multiple factors can contribute to an incident, so be prepared for a nuanced analysis that takes all relevant aspects into account.
• Finding them takes effort: Root cause analysis can be a challenging process, requiring careful investigation, data analysis, and critical thinking.