Safe Work Procedure: Root Cause Analysis

Document Number: [SWP-NUMBER] Revision Date: [DATE] Next Review Date: [NEXT REVIEW DATE] Department: [DEPARTMENT NAME]

1. Scope

This Safe Work Procedure (SWP) outlines the steps for conducting a root cause analysis (RCA) to identify the underlying causes of incidents, equipment failures, or other undesirable events. It applies to all personnel involved in incident investigation, problem-solving, and continuous improvement activities. This procedure aims to provide a systematic approach to prevent recurrence by addressing the fundamental issues.

2. Definitions

Root Cause: The fundamental reason for the occurrence of an event that, if corrected, would prevent a recurrence of the same or similar events.

Incident: An unplanned event that resulted in or had the potential to result in injury, illness, damage, or loss.

Corrective Action: An action taken to eliminate the cause of a detected non-conformity or other undesirable situation.

3. Responsibilities

3.1 Supervisors

Ensure that all incidents and near-misses are reported promptly.
Initiate and support the root cause analysis process for significant events.
Provide necessary resources and training for conducting effective RCAs.
Implement and monitor corrective actions identified through the RCA process.

3.2 Workers

Report all incidents, near-misses, and hazards immediately to their supervisor.
Participate in root cause analysis teams as required.
Provide accurate and detailed information during the investigation process.
Implement corrective actions as directed and provide feedback on their effectiveness.

3.3 Health and Safety Representative

Provide guidance and support in conducting root cause analyses.
Monitor the effectiveness of the RCA process and recommend improvements.
Ensure that RCA findings and corrective actions are communicated to relevant stakeholders.

4. Potential Hazards and Risks

Hazard	Risk	Control Measures
Incomplete or inaccurate information	Incorrect identification of root causes	- Gather data from multiple sources and verify its accuracy. - Interview all relevant personnel to obtain a comprehensive understanding of the event.
Bias in the investigation process	Failure to identify the true root causes	- Use a structured RCA methodology to minimize bias. - Involve a diverse team with different perspectives in the analysis.
Implementation of ineffective corrective actions	Recurrence of the incident or similar events	- Ensure that corrective actions address the identified root causes. - Monitor the effectiveness of corrective actions and make adjustments as needed.
Failure to communicate RCA findings and corrective actions	Lack of awareness and potential for similar incidents to occur	- Communicate RCA findings and corrective actions to all relevant personnel. - Use multiple communication channels to ensure that the information reaches everyone.

5. Personal Protective Equipment (PPE)

Always use the appropriate PPE for the environment where the root cause analysis is being conducted. This may include:

Safety glasses - To protect eyes from potential hazards during site inspections.
Hard hat - To protect the head from falling objects.
Safety shoes - To protect feet from impact and puncture hazards.
High-visibility vest - To ensure visibility in areas with vehicle or equipment traffic.
Gloves - To protect hands from contact with hazardous materials or sharp objects.

Inspect all PPE before use and replace any damaged or worn items.

6. Equipment and Tools

Investigation tools (camera, measuring tape, etc.) - [Description and proper use]
Computer with internet access - [Description and proper use]
Communication devices (phone, radio) - [Description and proper use]

Ensure all equipment is in good working order before use.

7. Pre-Job Requirements

7.1 Training and Competency

All personnel involved in root cause analysis must be trained in the chosen RCA methodology (e.g., 5 Whys, Fishbone Diagram, etc.).
Ensure that team members have a clear understanding of their roles and responsibilities.

7.2 Pre-Job Briefing

Conduct a pre-job briefing with the RCA team to discuss the scope of the investigation, the chosen methodology, and any potential hazards.
Review the incident report and any other relevant information.
Establish clear communication protocols for the investigation process.

7.3 Work Area Preparation

Ensure that the investigation site is safe and secure.
Control traffic and access to the area as needed.
Provide adequate lighting and ventilation.
Ensure that all necessary equipment and tools are available.

8. Safe Work Procedure Steps

Step 1: Define the Problem

Clearly define the incident or problem that needs to be investigated. [1], [2], [3], [4], [5], [6]

Gather all available information about the event, including incident reports, witness statements, and photographs.
Define the scope of the investigation and set clear objectives.
Establish a timeline of events leading up to the incident.

Safety considerations for this step: Ensure that the problem is clearly defined to avoid wasting time and resources on investigating the wrong issues.

Step 2: Gather Data

Collect all relevant data related to the incident. [1], [2], [3], [4], [5], [6]

Interview witnesses and other relevant personnel to gather their accounts of the event.
Inspect the site where the incident occurred and document any relevant conditions or factors.
Review relevant documents, such as maintenance records, operating procedures, and training materials.

Safety considerations for this step: Be thorough in data collection to ensure that all potential contributing factors are identified.

Step 3: Identify Possible Causes

Identify all possible causes that could have contributed to the incident. [1], [2], [3], [4], [5], [6]

Use brainstorming techniques to generate a list of potential causes.
Consider all possible factors, including human error, equipment failure, environmental conditions, and organizational issues.
Organize the potential causes into categories using a tool such as a Fishbone Diagram.

Safety considerations for this step: Encourage open and honest discussion to ensure that all potential causes are considered.

Step 4: Determine the Root Cause(s)

Determine the root cause(s) of the incident by analyzing the data and potential causes. [1], [2], [3], [4], [5], [6]

Use a structured RCA methodology, such as the 5 Whys, to drill down to the underlying causes.
Verify the root causes by comparing them to the data and evidence collected.
Ensure that the root causes are specific, measurable, achievable, relevant, and time-bound (SMART).

Safety considerations for this step: Focus on identifying the systemic issues that contributed to the incident, rather than blaming individuals.

Step 5: Develop Corrective Actions

Develop corrective actions to address the root causes and prevent recurrence. [1], [2], [3], [4], [5], [6]

Brainstorm potential corrective actions for each root cause.
Evaluate the feasibility and effectiveness of each corrective action.
Prioritize corrective actions based on their potential impact and ease of implementation.

Safety considerations for this step: Ensure that corrective actions are specific, measurable, achievable, relevant, and time-bound (SMART).

Step 6: Implement Corrective Actions

Implement the corrective actions and monitor their effectiveness. [1], [2], [3], [4], [5], [6]

Assign responsibility for implementing each corrective action.
Establish a timeline for implementation.
Track the progress of each corrective action and address any obstacles or delays.

Safety considerations for this step: Communicate the corrective actions to all relevant personnel and provide training as needed.

Step 7: Evaluate and Follow Up

Evaluate the effectiveness of the corrective actions and follow up to ensure that they are sustained. [1], [2], [3], [4], [5], [6]

Monitor the incident rate and other relevant metrics to assess the impact of the corrective actions.
Conduct follow-up audits or inspections to verify that the corrective actions are being implemented correctly.
Make adjustments to the corrective actions as needed to improve their effectiveness.

Safety considerations for this step: Continuously monitor and evaluate the corrective actions to ensure that they are achieving the desired results.

9. Precautions and Safety Measures

Confidentiality: Maintain confidentiality of information gathered during the investigation process.
Objectivity: Conduct the analysis objectively and avoid blaming individuals.
Collaboration: Encourage collaboration and open communication among team members.
Documentation: Document all steps of the RCA process, including data collection, analysis, and corrective actions.
Training: Ensure that all personnel involved in RCA are properly trained and competent.

10. Emergency Procedures

10.1 General Emergency Response

In the event of an emergency during the root cause analysis process:

Assess the situation and ensure the safety of all personnel.
Activate the emergency response plan as needed.
Provide first aid or medical assistance to injured personnel.
Report the emergency to the appropriate authorities.

10.2 Specific Emergency Scenarios

Injury during site inspection: Provide first aid and seek medical attention if needed. Report the injury to the supervisor and complete an incident report.
Discovery of a new hazard: Immediately notify the supervisor and take steps to control the hazard. Update the hazard assessment and implement appropriate control measures.
Equipment malfunction: Stop using the equipment and report the malfunction to the supervisor. Do not attempt to repair the equipment unless properly trained and authorized.

10.3 Emergency Contact Information

Emergency Services: 911
[Company Security]: [PHONE NUMBER]
[Health and Safety Department]: [PHONE NUMBER]
[Project Manager]: [PHONE NUMBER]

11. Incident Reporting and Investigation

All incidents, near-misses, and hazards must be reported immediately to the supervisor. The supervisor will initiate an investigation to determine the root causes and implement corrective actions. The investigation will be conducted in accordance with the company's incident investigation procedure.

12. References and Related Documents

[Company Health and Safety Policy]
[Incident Reporting Procedure]
[Hazard Assessment Procedure]

Approved by: [NAME AND POSITION] Date: [APPROVAL DATE]