MODULE 6: EFFECTIVE INCIDENT / ACCIDENT ANALYSIS

Root causes may be separated into two categories.

Design weaknesses. Missing or inadequately designed programs, policies, plans, processes and procedures will naturally affect conditions and behaviors generally throughout the workplace. Defects in system design represent hazardous system conditions.

Root Cause - System Design Weaknesses - Failure to develop:

• Missing or inadequate safety policies/rules
• Training program not in place
• Poorly written plans
• Inadequate process
• No procedures in place

Performance weaknesses. Failure to initiate, carry out, or accomplish safety policies, programs, plans, processes, and procedures. Defects in performance represent ineffective system behavior.

Root Cause - Implementation Weaknesses - Failure to carry out:

• Safety policies/rules are not being enforced
• Safety training is not being conducted
• Adequate safety supervision is not conducted
• Incident/Accident analysis is inconsistent
• Lockout/tagout procedures are not reviewed annually