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Root Cause Analysis

Immediate Causes

This page provides information to support Root Cause Analysis. Expand each Immediate Cause below to view related examples and possible underlying causes.

Immediate Causes

Examples

  • Employee trips & falls over equipment/supplies left in an aisle/walk path;
  • Material poorly piled/stored on a high shelf falls off;
  • Material left on stairs or near fire door blocking fire exit or egress path

Possible Underlying Causes

  • Hazards not recognized;
  • Facilities inadequate for storage;
  • Inadequate training;
  • Not following procedures; lack of procedures; no procedures

Possible Management Failures/Inadequacies

  • Supervisory training;
  • Supervisory safety indoctrination;
  • Planning, layout, SOPs

Examples

  • Using the side of grinding wheel instead of the face and the wheel breaks;
  • Someone using a forklift truck to elevate personnel-they fall off;
  • Someone using compressed air to clean dust off clothes - eye injury occurs

Possible Underlying Causes

  • Lack of skills and/or experience;
  • Lack of proper procedure and/or no procedures provided
  • Not following established guidance or using shortcuts

Possible Management Failures/Inadequacies

  • Employee training;
  • Established operational procedure;
  • Enforcement of proper procedure;
  • Supervisory safety indoctrination;
  • Employee safety

Examples

  • Portable electrical drill without ground wire;
  • Axe or hammer with loose head/handle;
  • Vehicle with defective brakes, steering, horn, light etc.

Possible Underlying Causes

  • Not recognized as unsafe;
  • Poor design or selection;
  • Poor maintenance

Possible Management Failures/Inadequacies

  • Supervisory safety indoctrination;
  • Employee training;
  • Employee safety consciousness;
  • Planning, layout, design, SOP

Examples

  • No requirement to check for gas fumes before starting engine possibly causing an explosion;
  • No definite instructions requiring power to be locked out before maintenance is done (LOTO);
  • No requirement to check for hydraulic leaks prior to using a lift;
  • Not checking PPE prior to usage;
  • Cap left off chemical container causing fumes to plume into the workspace

Possible Underlying Causes

  • Inadequate training;
  • Omissions;
  • Errors in design; and/or set-up;
  • Errors by supervisor;
  • Failure to follow procedures and/or policies;
  • Lack of procedures in place

Possible Management Failures/Inadequacies

  • Operational procedures;
  • Planning, layout, design, SOP;
  • Supervisory proficiency

Examples

  • Taking shortcuts instead of following written guidance;
  • Not using written guidance;
  • Not developing guidance

Possible Underlying Causes

  • Inadequate training;
  • Deliberate action(s)

Possible Management Failures/Inadequacies

  • Established operational procedure;
  • Enforcement of proper procedure;
  • Supervisory safety indoctrination;
  • Employee safety consciousness;
  • Employee selection/placement

Examples

  • Shortcuts bypassing safety precautions;
  • Operation will only be done once;
  • Not communicating intentions

Possible Underlying Causes

  • Enforcement of proper procedures;
  • Supervisor safety indoctrination;
  • Operational procedures;
  • Deliberate action(s)

Possible Management Failures/Inadequacies

  • Enforcement of proper procedure;
  • Supervisory safety indoctrination;
  • Operational procedures

Examples

  • Employee uses wrong method;
  • Doesn't understand or follow instructions, procedures, policies

Possible Underlying Causes

  • Instructions too complex;
  • Inadequate comprehension;
  • Inadequate instructions or training;
  • Lack of training

Possible Management Failures/Inadequacies

  • Planning, layout, design, SOP
  • Operational procedures
  • Employee selection/placement

Examples

  • Not realizing rotating shaft was dangerous;
  • Not realizing fumes were dangerous;
  • Not realizing

Possible Underlying Causes

  • Inadequate instructions;
  • Inadequate warnings;
  • Inadequate training

Possible Management Failures/Inadequacies

  • Supervisory safety indoctrination;
  • Employee training;
  • Employee safety consciousness;
  • Planning, layout, design, SOP
  • Safety rules, measures, equipment;
  • Operational procedures

Examples

  • Cart too small for hauling large items;
  • Auto maintenance done without proper tools;
  • Repair or maintenance at a poor location not suited for the equipment

Possible Underlying Causes

  • Need not recognized;
  • Inadequate supply;
  • Deliberate action(s)

Possible Management Failures/Inadequacies

  • Planning, layout, design, SOP
  • Supervisory safety indoctrination;
  • Equipment, materials, tools;
  • Morale, discipline

Examples

  • Machine has exposed belt and gear possibly with a severe cut;
  • No warning horn on vehicle possibly hitting pedestrians;
  • No guard rail on a scaffold 10 feet high - fall hazard

Possible Underlying Causes

  • Need not recognized;
  • Inadequate equipment available;
  • Deliberate action(s)

Possible Management Failures/Inadequacies

  • Planning, layout, design, SOP
  • Safety rules, measures, equipment;
  • Supervisory safety indoctrination;
  • Employee safety consciousness;
  • Equipment, materials, tools;
  • Operational procedures;
  • Morale, discipline, laziness
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