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MODULE 4 LESSON: Successful Root Cause Analysis Copy

June 1, 2021

[vc_row][vc_column][vc_single_image image=”11138″ img_size=”full”][vc_column_text]A successful root cause analysis relies on detail and will help investigators understand the safety practices that are used in the work area where the accident occurred. And, do not worry about giving investigators to much information. They will sort it all out. You never know when some fact will be the key to determining what really happened and why. Let’s take a look at some examples.


A worker is standing on the top step of a ladder and falls off.  It may appear to be an easy investigation. Obviously the worker ignored the rule about not standing on the top rung of a ladder, he lost his balance and then he fell. But, there may be other factors.

Why was he on the top rung of the ladder?

The worker’s actions are certainly a factor, but there are other reasons why the accident occurred as well. To prevent the same type of accident from happening again, we need to look deeper.

What if the ladder he was on was the tallest one in the warehouse? We know a person fell off a ladder. We also know he was standing on the top step.

By continuing the investigation, we eventually discover that he that he was using the tallest ladder in the warehouse.

The worker’s carelessness was a factor, but the lack of proper equipment is the root cause of this accident.

The warehouse needs a taller ladder so that workers can reach the highest materials without standing on the top step.

Remember, the goal of an accident investigation is to prevent this incident from happening again. Let us look at another real life example of a root cause analysis.


A worker fixing a piece of equipment is suddenly shocked. We might conclude that because electricity was involved, the task was inherently hazardous and there wasn’t much to be done to make this situation safer.

But it takes electricity to run the machine and there are procedures that allow electrically powered machines to be worked on safely. So there are probably other factors to consider.

Should the system have been locked out? And, if so, why wasn’t it?

We need to look at whether the worker who was repairing the machine had been given training on lock-out tag-out procedures.

Had he?

And if he’d been given lock out tag out training, we would also need to determine if the worker was following the procedures he was taught.

In this instance, the investigator determined the root cause of the accident was because of lack of training. The worker never attended the lock-out tag-out class that he was scheduled for. And therefore, he never knew the danger that he was putting himself into.

Now let’s apply a root cause analysis to a third situation, one that involves personal protection equipment.


Falls are accidents that people do not always investigate fully. If a person falls we usually figure they lost their grip or their footing. But, when we take a closer look, we discover that the worker did not follow procedure by wearing his fall protection gear.

We will then need to find out why.

There are several reasons why the employee might skip proper safety procedures, and all of them are bad.

Attempting to increase their output and being in a hurry can sometimes lead to forgetting safety procedures. There are times when an accident has nothing to do with equipment, training, or procedures.

Often investigators find that miscommunication is the root cause of an accident. Workers need to clearly hear and understand any instructions they receive about the job they are. If communication isn’t clear or, if there was a question that went unanswered, this could be a serious problem. Instructions should be repeated so that everyone understands the proper procedure.

So far we’ve only looked at the first goal of an accident investigation. Determining the cause. In the next module, we’ll dig deeper into learning from accidents. A short quiz is coming up! Go ahead and take it, come back here and then we’ll move on.[/vc_column_text][/vc_column][/vc_row]