Kevin Ian Schmidt

Category: Incident Investigation

  • Root Cause Worksheet

    Root Cause Worksheet

    Conducting a full and proper root cause analysis is important to completing an accident investigation. This worksheet will aid in a full root cause analysis.

    Including this form in your accident investigation toolkit, will aid those conducting an investigation after a safety incident.

     

    Using the Root Cause Investigation Worksheet

    Example Accident: “An employee comes into the lobby, with uncovered marble flooring during a rain storm, and slips on water puddled near door; spraining their wrist.”

    Even if this specific accident didn’t result in a serious injury, they can result in broken bones or head injuries. No matter the level of injury, each accident should be investigated equally to prevent future accidents that may result in a more serious injury.

    Using the root cause worksheet, you read the environmental section and see multiple applicable items.

     

     

     

    So, applying this to the above example, you can identify:

    • adverse weather: raining outside;
    • walking/working surface: uncovered marble floor;
    • poor housekeeping: water puddled at entrance on floor;

    as causes of this instance. So which is a root cause and which is a causal factor of the incident? You can find that by applying some simple questions:

    • If it were raining outside, and the floor was covered with an anti-slip rug, would this have occurred?
    • If housekeeping had cleaned up the water pooled, would the person have slipped?
    • If there was no puddled water, but the person’s shoes were slick with rain could they have slipped on the marble floor?

    Applying those questions, you will realize that the adverse weather and the poor housekeeping were contributing factors, while the walking/working surface was the root cause. Because a simple anti-slip rug could have stopped this, even if there wasn’t a puddle and it was raining outside, or if there was a puddle and it wasn’t raining outside.

     

     

     

    If you follow through with this root cause analysis, and take action and place an anti-slip mat at the lobby entrance, you have negated the possibility for further accidents.

    You can see how this root cause worksheet is a good tool to have as part of an accident investigation program.

    Ensure you give your team the tools and training required to fully implement a quality accident investigation program, which includes ensuring they are aware of their roles in the program, that they have been trained on their responsibilities, and they know how to follow-up to create change.

    I have also published a book for Root Cause Analysis, available in softcover and hardcover.

    Check out my book on Amazon.

     

    Check out the following related program components available for free:

     

    View the Root Cause Worksheet here

    Root Cause Worksheet

    Download the Root Cause Worksheet here

  • The 5 Why Method of Root Cause Analysis

    The 5 Why Method of Root Cause Analysis

    root cause 5 why trainingKnowing how to properly conduct a 5 why root cause analysis is imperative when handling a safety incident investigation.

    It isn’t just OSHA that encourages the use of root cause during an incident investigation, but also the EPA under their Risk Management Program(RMP).

    Concerning Root Cause Analysis OSHA says:

    During an incident investigation, an employer must determine which factors contributed to the incident, and both OSHA and the EPA encourage employers to go beyond the minimum investigation required and conduct a root cause analysis. A root cause analysis allows an employer to discover the underlying or systemic, rather than the generalized or immediate, causes of an incident. Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself. – Source
    While this is not an official order to conduct a root cause analysis, and it may not result in an OSHA fine for not complying, it can potentially result in a violation of OSHA’s General Duty Clause:

    a) Each employer —

    (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees;
    That is because the occurrence of a safety incident is a clear indication of a workplace hazard, and a failure to abate this hazard potentially means your company is no longer furnishing employees with a workplace with recognized hazards, as a full and proper root cause investigation would have uncovered the direct cause of this hazard.
    So while OSHA doesn’t require it, they may cite you over not investigating properly. Anyone with an understanding of OSHA rules, regulations, and interpretations, will understand this is often the case, as OSHA will always err on the site of caution for employee protection.
    Check Out: How to Improve Your Safety Culture

    The 5 Why Method as a Root Cause Analysis Method for Workplace Incidents

    The 5 Whys technique can also be used as a method for determining root causes of workplace incidents. What would 5 Whys look like in the context of a workplace incident investigation? Here’s the application of 5 Whys to an example mentioned in an OSHA fact sheet:

    The Problem: A worker slips and falls, and suffers an injury.
    1st Why: There was a puddle of oil on the plant floor.
    2nd Why: Oil spilled from a compressor.
    3rd Why: An oil leak from the compressor was not detected.
    4th Why: The compressor was not inspected on a regular basis and repaired (if required).
    5th Why and the Root Cause: The compressor was not in the maintenance system.

    In theory it takes five “whys” to get to the root cause, but in practice there will be cases where you may use more or fewer than five “whys”.

    This 5 Why Method Training will explain the basics of how to conduct a root cause analysis using the 5 Why method.
    Adding a 5 Why Method training to your company’s incident investigation training program will improve your accident investigations to best identify hazards in the workplace along with empowering your employees in owning their safety.

    Finally, according to the Washington State Department of Labor & Industries, these are the benefits of asking the 5 Whys:

    • Simplicity: Easy to use and requires no advanced mathematics or tools.
    • Effectiveness: Helps to quickly separate symptoms from causes and identify the root cause.
    • Comprehensiveness: Helps to determine relationships between various problem causes.
    • Flexibility: Works well alone and when combined with other methods.
    • Engaging: Fosters teamwork.
    • Inexpensive: A guided, team-focused exercise with no additional costs.

    Combining this training with the Root Cause Worksheet as part of your total incident investigation program will allow your team to thoroughly investigate every incident.
    Please check out the other components of an Incident Investigation Program, listed below:

     

    To facilitate better root cause analysis in the workplace, I published a Root Cause Analysis workbook available on Amazon.

    Download the 5 Why training

    View the 5 Why training

    5 Whys Training – Kevin Ian

     

     

  • Accident Investigation: Root Cause Analysis

    Accident Investigation: Root Cause Analysis

    Over the years, managers and leaders have written thousands of articles about the very complicated causes of accidents in the workplace. The consensus of opinion is that there is not normally one single cause of an accident or an incident. Instead, there are normally a combination of factors that contribute to the accident. These all come together under just the right circumstances to create an accident. Management thinking has moved on from the proposition that accidents just”happen.” But this has been replaced with a culture of blame.

    The problem of accident causation and prevention appears to be a hugely complex problem. However, some industries have proved beyond doubt that it is possible to prevent or control the causes of accidents. For most industries, it doesn’t require huge resources to be successful in preventing accidents and incidents.

    To better understand the circumstances that give rise to undesirable incidents, it would be wise to consider the four major elements that provide the source of accidents in the workplace.

    Elements of a Root Cause Analysis

    The first element is people. This includes everybody from the workers upwards. Its been well established that people are involved in a high percentage of incident causes. Normally, it’s the staff member that is the human element directly involved in an undesirable incident. What they do or don’t do is seen as one of the most common causal factors.

    The second element is equipment. This includes tools and machinery. Since we have been using tools and machinery, they have been identified as one of the major causes of incidents and accidents. Because of this they have been targeted by legislation that has made provision for machine guarding and training. The improper design of controls on machinery and equipment are frequently found to be the cause of many incidents related to safety quality and output.

    The third element is material. This is the stuff that people work with. Material can be sharp, heavy, hot or even toxic. Coming in contact with such things as explosives, chemicals such as solvents, dusts and noise can be a substantial source of undesirable incidents.

     The fourth element is the environment. This is all parts of the physical surroundings and include such things as the quality of air, lighting, heat, cold, humidity, fumes and even moisture. Increasingly, the environment is being identified as the cause of an ever-increasing number of diseases and health related conditions. It is associated with absenteeism and low work quality.

    Check out additional components of an Accident Investigation Program

    These four elements, to a greater or lesser degree, provide the source of causes that contribute to an undesirable incident. The investigation should include a scrutiny of one or all of these factors to pinpoint the cause of the incident or accident.  

    If you are looking for assistance with completing a root cause investigation, I made a book to help you out, check it out on Amazon here

     

    View & Download the Accident Investigation: Root Cause Analysis Training below

    Accident investigation_Root_Cause_Analysis

  • Incident Report Writing Guide

    Incident Report Writing Guide

    Objectivity is vital when writing a report. A judge or investigator probably won’t dismiss the validity of a report if you’ve made a grammatical mistake. But if your report lacks objectivity, it may be viewed as a document full of opinion over facts.

    Providing specific details is the key to writing an objective report.  When you arrive at a scene or conduct an interview, descriptive words immediately come to mind: suspicious, inebriated, aggressive, disoriented, and similar words.

    But professional report writing practices require you to omit these categories and conclusions. You state only facts and details, leaving it to your reader to draw conclusions.

    These requirements seem to defy common sense–but there are good reasons for them. Facts and details:

    • Facilitate follow-up investigations: Recording exactly what a witness or involved party says can be a huge help to anyone reading the report.
    • Prevent challenges: People can’t argue that you jumped to conclusions if you list the behaviors and actions that preceded the incident.
    • Avoid embarrassment: If you announce in a report a definitive list of actions based upon opinions and witness testimonies, a defense attorney or insurance reviewer might point out errors in your reasoning. Just state the fact: describe the scene(include pictures/video when possible), describe the incident exactly, describe any injuries.
    Check Out: Ten Safety Tips at Work

    Here’s a comparison of generalizations you should avoid and details you could use instead:

    • confused (Better: could not state location or details clearly)
    • afraid (Better: whispered the answers to my questions, hands were shaking)
    • reckless (Better: driving too fast for conditions, crossed into pedestrian walkpath)
    • careless(Better: sign posted for team lift, employee picked it up alone)

    While you’re thinking about objectivity, it’s important to be aware of some myths about reports. Writing in third person instead of “I” does not guarantee objectivity. (If only it were that simple!)

    Similar outdated expressions like “Victim 1” and “Witness 2” are equally useless. They create confusion and waste time, especially if you’re preparing for a court hearing six months after the incident occurred. Use real full names whenever possible.

    What about objectionable language? Insensitive labels like “crazy,” “crippled,” and “lazy” don’t belong in a professional report, with one important exception: If you’re directly quoting an involved party or witness who used them. The same principle applies to obscenities and slang..

    Following these guidelines testifies to your professionalism, and they can provide a valuable service to your companyn as well. Train yourself to observe, remember, and record exactly what you’ve seen and heard: That effort will pay off again and again in your criminal justice career.

     

    Report Writing Checklist

    1. Think about the 5 W’s: who, what, when, where, why. If you’re writing on paper, most of this information will go into your opening sentence. If you’re writing on a laptop or using a template, make sure you’ve filled in the spaces accurately and thoroughly.

    2. Include full names and contact information for witnesses, victims, and suspects (if available). If you interview someone who may be important to the investigation, get a backup phone number, such as a relative, friend, or workplace. Many people change phone numbers frequently, and an alternative number can help solve a case.

    Check Out: The Challenge of Employees to Report All Incidents

    3. Include the results of each investigation you did: temperature measurements, distances, recreations, etc…. Omitting results is one of the most common mistakes that investigators make. Result: Confusion, wasted time, and sometimes a missed opportunity to solve or prosecute a case.

    4. Start each sentence with a person, place, or thing UNLESS you have absolute confidence in your writing ability. Keeping sentences simple prevents a multitude of writing errors.

    5. Avoid outdated report practices. Old-fashioned words like “above mentioned,” “ascertained,” and “respective” waste time and cause confusion when you’re preparing for a court hearing. For example, what did you mean when you said you “ascertained” something? A witness told you? You saw it? You came across a useful piece of evidence? Explain in detail.

    6. Clearly state who did what (in other words, use active voice). Contrary to popular belief, passive voice doesn’t magically make you honest, objective, or professional. Those are qualities you have to commit to and work on. Passive voice can create confusion if several officers are working a scene: Six months later, in court, are you going to remember who did what at the scene?

    7. Make sure the disposition part of your report is complete: If you found useful evidence at the scene, did you thoroughly cover the chain of custody? Did you describe injuries in detail? What was the outcome for victims and suspects?

    8. Avoid generalizations and hunches, which can open you up to challenges in a courtroom later. Statements like “I knew Harris was lying” and “Johnson seemed nervous” don’t belong in a professional report. Stick to factual descriptions: “Harris told me they were heading to Porter City, but his wife told me they were going to Hicksville.” “Johnson’s hands were shaking, and he looked over his shoulder 10 times in less than five minutes.”

    9. Avoid slang and insensitive language unless you’re quoting someone’s exact words. Sexist language, vulgarities, and other unprofessional terminology can embarrass you if a district attorney, newspaper reporter, judge, or community leader reads your report.

  • Tips for Improving the Reporting of Accidents

    Tips for Improving the Reporting of Accidents

    It is important that all workplaces have an effective method of reporting accidents for a number of reasons – severe accidents will need to be reported by law to the relevant agency such as OSHA; accident reports are usually a key fact in Insurance claims and insurance matters; but most of all to help prevent future accidents by understanding what are the primary drivers of accidents at your workplace and the nature/severity of the accidents you experience.

    It is important that all accidents are reported and recorded not just the most severe accidents – all the research done over the years shows us that the accidents with major injuries were usually predictable if we look at the less serious injuries caused by similar factors – near misses and minor injuries probably account for over 80-90% of all accidents, accidents requiring basic first aid another 8-9%; the more severe accidents where people take time off or are badly injured account for around 1-3% of all accidents – thus if we wait for that tiny percentage to happen we’ll never succeed in reducing accidents at work.

    The subject of accident reporting is quite complex and has many factors; but key reasons for not reporting accidents are:

    • The form takes forever to complete
    • “I don’t want to get into trouble for reporting things”
    • “There’s no point; no one ever does anything about them”
    • “I have no idea where the forms are”
    • “It was only a scratch. I’m not filling a form in for that”

    Simplified Forms & Reporting Systems

    No one will deny that there are times you need a lot of information to understand how an accident occurred and how to prevent future ones – but many can be described in a sentence or two.

    Employees and Managers should be able to report most accidents in a matter of minutes – any form that takes more than this to complete is far too complex and will unintentionally discourage reporting.

    Equally it’s easy to get obsessed with forms – but as more workplaces give access to employees for computers, a simple dynamic form that allows for simpler reporting of minor incidents such as near misses or dangerous conditions, and a growing form for a minor injury, and a larger online form for more severe injuries. These allow employees wishing to report simple incidents to do so in a matter of minutes, and also for data collection to be tracked digitally to build a better system of analysis.

    Check Out: Incident Report Writing Guide

    Understanding Why and Encouraging

    If employees think the forms go in a big pile, that its simply about statistics, that issues aren’t fixed they will not report accidents; equally they will not report minor incidents because they don’t always realize that information can save a bigger accident down the line.

    So it’s important that in safety orientations the need to report accidents is stressed, that accident reports are acted upon if solutions are possible -if there isn’t a solution today at least make sure people know you’re thinking about it and obviously that accident reports don’t lead to reprimands as a matter of course.

    Helping the staff see that reporting low consequence accidents today can save their colleague pain down the line is often enough on its own to help encourage reporting.

    Accessible

    Life changes quickly; 20 years ago this was all about having forms on the wall or on the desk – now it’s often about finding them quickly on the Intranet.

    Recognize how and where your staff work – find a solution that suits – web based answers are perfect for office staff – yet old fashioned paper is probably required in a workshop where they can be grabbed quickly.

    But make them simple to find ideally visible to everyone all the time.

    If you’re opting for an online form, make sure it is accessible to everyone! The more peope that can fill out reports, the better chance for more reports.

    Understand the Information

    Employers need to be careful they understand the reports – not just in terms of what they can physically improve but also what the information tells you in terms of patterns. Accident statistics have a very poor reputation for the simple reason they avoid every statistical technique known – raw numbers shouldn’t be discounted but make sure you understand what it tells you.

    Risk Assessments

    Always review your risk assessments – was the accident in question accepted as a potential risk, are the controls in the risk assessment actually in place, is the risk assessment actually workable – or is the risk assessment idealistic and unworkable – and indeed do we need to review the risk assessment.

    Check Out: How to Complete a Risk Assessment

    Self Review

    To work out how effective your accident reporting is there’s some simple questions to which the correct answer better be obvious:

    • Do you have at least 8 times the number of near misses and minor cuts etc as accidents requiring first aid?
    • Do you have at least 8 times as many first aid and low consequence accidents reported compared to accidents that break bones or require staff to have time off work?
    • Does the form take more than 2 minutes to complete for a simple accident?
    • Has any accident report led to a change in the workplace?