Root cause of an incident

What was the root cause?

What was the root cause? – Any top management official who pays a visit to the accident site puts forward this question. This article does not deal with the tools and techniques used for root cause analysis (RCA). This is meant to enhance your understanding and give you a clarity on the three most used phrases in accident investigation.

1.       Root cause

2.       Immediate cause

3.       Contributing cause

Immediate cause is the mostly the cause that has more to do with causing the injury rather than being a reason for the accident. It can mostly be related to unplanned release of energy or of hazardous materials.

To be more clear we may check the following two cases

1.       Person A slips and falls on the same level. Gets cut injury.

2.       Person B slips and falls from the same place where A had fallen from. But this time, the floor had an opening through which B fell down to a floor 20 metres below resulting in fatality.

So the immediate cause for the death of B is fall to a level 20 metres below his working surface. The person due to virtue of his position, had potential energy which was released while falling to a level 20 metres below.

Contributory cause is / are mostly the unsafe acts & conditions that led to the incident.

In the above mentioned example, we can identify the following as contributory causes –

a.       Wet floor / poor housekeeping (Unsafe condition)

b.      Wet floor board missing (Unsafe condition)

c.       Unguarded opening (Unsafe condition)

d.      The person B was talking on mobile phone while working (Unsafe act)

e.      The person did not use any personal fall protection devices (Unsafe act)

f.        The person was new to the area and was not properly briefed regarding the hazards in the area (Unsafe act by the supervisor)

Root cause  includes policies, decisions and procedural framework that allowed the immediate and contributory causes to become effective. Root causes identified should be such that if addressed will prevent the similar incidents from repeating. The most common tool to address the root cause is CAPA. Corrective action & Preventive action.  The organization should have an effective system to track the implementation of corrective action which should be based upon the principle of Verify and Validate. If the system  has loop holes even after the corrective action has been implemented, the condition should be reviewed and a better corrective action will be put forward which will again go through the Verify and Validate stages until satisfactory results are achieved.

Now let’s examine the fatality of B again to find out the root cause.

a.       The number of housekeeping staff has been cut short as part of the cost cutting procedures in the company.

b.      Enough wet floor boards were not available.

c.       The opening through which B fell down was made by workers working in the area for ease of shifting materials between levels. The supervisors were unaware of the practice.

d.      Mobile phones were not restricted in the plant. People talking on mobile while working was a common sight in the plant.

e.      The person was not trained to use fall protection devices or to work at height.

f.        Proper risk analysis was not carried out before the start of the work.

CAPA can be prepared for all the root causes identified.