Strategies for Comprehensive Root Cause Analysis of Workplace Incidents

When a workplace incident occurs, you need to understand the root cause before you can properly address the issue. Otherwise, you may be vulnerable to encountering the same problem again in the future. 

Questions are integral to the root cause analysis process. By asking questions of yourself, those involved, and your company as a whole, you can get to the bottom of any issue. This list of who, what, when, where, why, and how questions should help you determine what caused an incident so you can make meaningful, positive changes to prevent future problems.

Find Out Who Was Involved

First, consider who was involved in the incident and whether they potentially contributed to the issue or were negatively impacted. Ask these questions:

• Who was injured/affected? In the case of injuries, these employees should receive medical attention right away and may be entitled to time off and workers’ compensation. 

• Who else was involved? Be sure to interview witnesses and create a detailed workplace incident report, which you may need to present to your workers’ compensation insurance carrier or in the case of an OSHA investigation or litigation. 

• Who may be fully or partially to blame for the incident? Keep in mind that the person who may immediately appear to be to blame isn’t always the person who should bear all or even most of the responsibility. Consider who may have contributed to the root cause of the problem. Also keep in mind that, sometimes, causes go beyond individual people and involve a company’s culture as a whole.

Understand What Happened

To understand why something occurred, you first need to understand what exactly happened. Ask anyone who was involved or who witnessed the incident these questions, or use your own observations:

• What was the series of events? Break down what happened as much as you can to capture every detail. You may want to put the series of events into a timeline to make the sequence clear.

• What equipment or processes were involved? If the incident involved a particular type of equipment on the job or a certain task, make note of this. You may find that there are some inherent safety risks involved with that equipment or workplace process.

• What damage resulted from the incident? Recording the damage that occured is important for both your company and any insurance companies involved. Taking photos can also help you record this damage, whether it’s a personal injury, broken equipment, or damaged products. Store this information in an incident management software program.

Note When the Incident Occurred

You should also take note of exactly when an incident occurred. Ideally, you should learn about incidents as soon as they happen, but this isn’t always the case. Especially when it comes to root cause analysis, you may find that the real problem started much earlier than the incident itself. Ask:

• When did the incident take place? Start simple. Find out exactly what day and time the episode occurred. 

• Were there past indications of a problem? Now take a step back to see if there were any earlier problems or signs that led up to the incident. For example, you may find that a piece of machinery was already showing signs of a maintenance problem before it failed.

• Were there any unusual circumstances occurring at the time of the incident that may have contributed to the problem? It’s worth considering whether any extenuating circumstances may have played a role. For instance, maybe workers took shortcuts that led to an injury because they were short-staffed that day. 

Record Where the Incident Occurred

Another basic factor to include is where the incident occurred and how location could have played a role in the incident. Ask these questions:

• Where did the incident occur? Did the incident occur inside or outside? On or off company property? What was the exact location? 

• Were there any hazardous environmental conditions that contributed to the incident? In some cases, the conditions of an area may contribute to a mishap. For example, severe weather may play a role in an auto accident, or freshly mopped floors may lead to a slip and fall.

Delve Into Why the Incident Occurred

“Why” questions are a top priority during root cause analysis. One approach is known as the “five whys.” In root cause analysis, the five whys involve asking why an incident occurred repeatedly to go several levels deep until you make it to the actual root cause. 

Here is an example progression of the five whys in root cause analysis:

1. An employee was injured because they were not taking the right precautions according to company policy. 
2. Asking why the employee didn’t take the right precautions, you may find that the employee knew the proper procedures but was taking shortcuts. 
3. Asking why they were taking shortcuts, you may discover the employee was rushing because they were trying to meet a quota. 
4. Asking why the employee had to rush to meet a quota, you may find that managers have set unrealistic expectations. 
5. That final “why” may reveal that management is placing a higher priority on output than on safety. 

In addition to the “five whys” approach, you can also ask these more specific questions to help you understand what contributed to an incident:

• Did the employee(s) or manager(s) disregard any safety or other procedures? In some cases, it is individuals’ poor choices that lead to incidents. Consider whether those involved may have contributed to the issue by disregarding company policies.

• Did employees have the training necessary for the task involved in the incident? As in our example above, you may find that an employee did not have the proper training needed to safely perform a task. 

• Did workers have access to and use the right tools and personal protective equipment (PPE) needed for the job? First, employees must have access to the tools and PPE they need to perform their jobs effectively and safely. But what if they have access and still don’t use the appropriate PPE? Dig into the cause. One study found, for example, that top determiners in whether construction workers wore proper PPE included their perception of risk, safety training and education, on-site supervision, and employment status.

Determine How to Proceed

Finally, plan your path forward, considering how you can properly address the incident. Ask these critical questions:

• How can we correct this issue to prevent future incidents? Once you understand the root cause (or causes; there is often more than one) of the issue, you should be able to come up with a plan that addresses underlying issues, not just the immediate problem.

• How can we track corrective actions? Just as you should record the information you learn throughout your root cause analysis, you also need to keep careful track of the corrective actions you take. Work smart by using incident response case management software to systematically move through the process and keep your whole team informed. 

Manage Incidents and Conduct Root Cause Analysis Like a Pro with Help from Pulpstream

Root cause analysis is essential if you want to effectively address and prevent workplace incidents. Pulpstream’s incident management solution can empower you to conduct comprehensive root cause analyses. Specifically, Pulpsteam will help you stay organized, document information, track corrective actions, and visualize data so you can spot any noteworthy trends. 

We do all this in a way that streamlines your incident management processes so you can spend less time on manual tasks and more time helping your business thrive. Schedule a demo today to see how we can help you conduct streamlined root cause analyses!