By categorizing your history of Incidents and Near Misses on a common hierarchy and severity matrix, your organization can begin to learn from the past and proactively deal with patterns.
Direct Causes
Incidents are typically caused by a combination of unsafe conditions and acts. Unsafe or hazardous conditions might include:
Confined space
Corrosion (internal and/or external)
Excessive noise
Fire and/or explosion hazard
Hazardous or toxic environmental conditions (e.g., gases, dusts vapors, etc.)
Inadequate guards or barriers
Combine any of the above with unsafe or improper acts such as:
Failure to recognize hazardous conditions
Failure to use personal protective equipment
Horseplay
Improper lifting and carrying
Improper use of a hazardous or toxic substance
Making safety devices inoperative
Root Causes
The direct causes each need to be analyzed to determine a Root Cause. Our methodology involves choosing root cause classifications from a hierarchy configured for your organization. This will likely include a three level tree such as:
Job Factors
Tools, equipment and materials
Defective
Equipment inadequate/improper
Improper tool used
Improper/inadequate material used
Work procedures
Personal protective equipment
Systemic/Management Factors
Poor planning
Inadequate leadership/job supervision
Communication
Personal Factors
Knowledge and skill
Capabilities
Judgment
Natural Factors
Fires
Flood or stream overflow
Extreme weather
Recommendations
Following on each of the determined Root Causes, the investigator or senior investigator can make recommendations to mitigate against or prevent incidents like this one from happening in the future.
