1. ELEMENT 5 - INCIDENT/ACCIDENT INVESTIGATION 52. ____ Incidents/Accidents are investigated for root causes. When incidents and accidents are investigated (analyzed for cause...not blame) it's important that the investigator uncovers the root causes which represent the underlying system weaknesses. Hazardous conditions and unsafe behaviors are called the surface causes for the accident. How do you know you're addressing root causes? Surface causes. Faulty tools, equipment, machinery, facilities, materials (things) in the workplace, or worker/manager behaviors (things done or not done) you're describing surface causes. Inappropriate/unsafe behaviors accomplished by specific individuals. If you can point to a single person or thing in the workplace, it's probably a surface cause that directly caused or contributed to the accident. System implementation root causes. The general failure of supervisors and managers to carry out policies, plans, procedures, etc. These failures are clues that system design root causes exist. System design root causes. Inadequately written or missing policies, programs, plans, processes, or procedures, you're addressing the system weaknesses that represent root causes. If you identify the following situations, you should first assume that system factors have contributed to the accident. If you are pointing at a group of employees performing inappropriate/unsafe behaviors, assume system weaknesses are contributing factors. If one individual has been performing inappropriate/unsafe behaviors repeatedly for a period of time, assume system weaknesses. If you identify a number of tools, equipment, machines that are unsafe, you should assume system weaknesses exist. Only by addressing and correcting system weaknesses will permanent improvement in the safety system occur. Justification for rating: ___________________________________________________________ _________________________________________________________________________________ Ideas to take back: ______________________________________________________________ _________________________________________________________________________________

2. Your total personal score for this element ________________ |----------------------------| 0 1 3 5 ObjectiveAction ItemsPersons Responsible Date to be completed Action Plan: Element 5. – Accident Investigation Handout: 1. Section 5 Acc IV Sample ESD 113.doc