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This material is for training purposes only. Its purpose is to inform employers and employees of best practices in occupational safety and health and general OSHA compliance requirements. This material is not a substitute for any provision of the Occupational Safety and Health Act or any standards issued by OSHA.

MODULE SIX: SOLVING PROBLEMS

Solving safety problems

Solving safety problems centers around two key strategies:

  • Eliminating or reducing the surface causess. It's important to eliminate or at least reduce the inappropriate employee thoughts, unsafe behaviors, and hazardous workplace conditions that directly cause or contribute to the accident. Employee thoughts, behaviors, and workplace conditions represent the most direct observable and measurable indicators of the effectiveness of the occupational health and safety management system (OHSMS). If OHSMS design or performance is flawed, the most direct internal effect is the change that occurs in what employees think. Thoughts, then, affect how employees behave in the workplace. Behaviors are the most direct observable effect (leading indicator) of OHSMS effectiveness. Inappropriate or unsafe employee behaviors, then, result in hazardous workplace conditions. To improve employee thoughts and behaviors, and workplace conditions, conduct employee surveys, employee interviews, observations, and workplace inspections.

  • Eliminating or reducing the root cause problems. To most effectively eliminate or reduce surface causes, you must dig up and treat their root causes. Improving OHSMS programs, plans, policies, purchasing, processes, and procedures (the Six-P's) will positively affect how employees think and behave in the workplace. To improve the OHSMS conduct formal program audits and performance evaluations.


Fix the system, not the blame!

Understanding the problems

It's very important that management take action to correct OHSMS problems to reduce the risk of injuries and illnesses in the workplace. Most accidents, by far, are caused by inappropriate or unsafe employee thoughts/behaviors. Problems with the physical work environment can also cause injury or illness. Unsafe behaviors indicate that the nature of the problem may reflect employee/manager personal behaviors and performance that increases the probability of injury or illness. Tools that we have previously discussed in the course to identify and understand hazardous conditions and unsafe work procedures include:

  • Informal and formal observation
  • Safety inspection
  • Job Hazard Analysis
  • Accident investigation
  • Records/Reports review

Root cause problems includes corporate behavior and performance that leads to increased probability of injury or illness. Unsafe corporate behavior and performance is reflected in poor management vision, attitude, decision-making, and policy direction regarding workplace safety and health. Tools to help identify and understand the root cause problems associated with surface causes include:

  • Interviews
  • Surveys
  • Records/Reports review
  • Brainstorming
  • Pareto Chart
  • Fishbone Diagram

To better understand the problem you are trying to solve, you need to answer some very basic questions.

What is the nature of the problem?

  • Leadership - Are supervisors or managers failing to demonstrate necessary leadership skills.

  • Management - Do managers lack the ability to design and/or carry out management processes?

  • Relationships - Are there unproductive or harmful working relationship between employees?

  • Process - Is there a failure to design or carry out safety processes and procedures?

  • Environment - Is the physical or psychosocial environment healthful to employees? Is some form of distress (due to factors outside the control of the employee) causing injury or illness?

  • Equipment - Are tools, equipment, machinery reliable is there a high rate of failure?

  • Material - Are materials used in production or service processes hazardous in some way?

What is the scope of the problem?

Personal. Affects/within yourself, or between yourself and another Interpersonal. Affects/within another or between two persons Group. Affects/within a group or between groups Corporate. Affects/within the company Industry. Affects/within another company (supplier, distributor)
  • Personal. Affects/within yourself, or between yourself and another
  • Interpersonal. Affects/within another or between two persons?
  • Group. Affects/within a group or between groups?
  • Corporate. Affects/within the company?
  • Industry. Affects/within another company (supplier, distributor)?

Is there REALLY a problem?

  • Is there a gap between what we want and what we’ve got? You need to be able to communicate what that gap is.

  • Get agreement - is everyone sold on the problem? It's important that everyone involved in solving the problem can agree with the problem and solution, or can at least live with it: That's called "consensus."

Getting to the facts with Cause-Effect Analysis

One technique used in conducting root cause analysis when hazards are identified or when incidents/accidents occur is called Cause-Effect Analysis. For every effect there is a cause. Starting with the accident, we analyze each event leading up to the accident to identify "effects." Then we attempt to uncover the cause for each event. It's important to understand that each effect can generate a completely new cause-effect branch. The table below represents only one branch of many possible branches.

INITIAL
CAUSE
 Effect
EFFECT
CAUSE
 Safety management system design factors
EFFECT
CAUSE
 Safety management system performance factors
EFFECT
CAUSE
 Victim's previous experience, education, and training
EFFECT
CAUSE
 Preexisting Beliefs of the Victim
EFFECT
CAUSE
 Immediate thoughts and feelings of the Victim
EFFECT
CAUSE
 Hazardous Condition and Employee Exposure
FINAL
EFFECT
 Accident
  • What directly caused the ?
  • What caused the ? .
  • What caused the behaviors? Thoughts.
  • What caused employees to have thoughts that created the hazard and exposure? Beliefs.
  • What caused those beliefs? Previous education, training and experience.
  • What kind of education, training, and experience did the employees receive?
  • What May be missing or inadequate development or implementation of policies.
  • Why? May be missing or inadequate programs or culture.

As you can see, the first set of questions get at the surface cause(s) related to an actual or potential accident. Once we know what directly caused the injury or illness, we begin to ask why to arrive at root causes. Each time a why question is asked, a deeper root cause is uncovered.

Mind Mapping - Another tool to identify problems

Mind Mapping, or "Instantaneous non-linear cognitive deduction utilizing spatial forms in a two-dimensional plane." (huh?) Mind mapping is merely drawing circles and lines to help you quickly think about and categorize ideas, problems, concepts, subjects, and just about anything else. Mind mapping is successful because takes advantage of the brain’s natural ability to categorize ideas in a rapid, but rather unorganized manner.

Look at the mind map below. At the center we write the problem. Then, try to think of the factors that are more obvious causes for the problem. (This works best by letting your subconscious do the work while you watch TV or work on another project) Next, take a look at each factor listed and ask why that particular cause exists. After a while (minutes to hours) you will build a diagram similar in form (but not content) to the one below.

Using this technique, you’ll be able to take any topic, project, or problem and quickly determine related categories of , processes, procedures, etc. Once the mind map is complete, it is merely a matter of reorganizing the information into the more common “outline” format.

Something's fishy here...

Another tool similar to the mind map is called the Fishbone Diagram or "Cause and Effect Diagram. Basically, it's just a mind map using a different form. The diagram illustrates this. The "Effect" describes the problem. Possible causes are listed under one of several categories that you determine. Generally, these categories might be people, materials, equipment, environment, methods, or procedures.

Brainstorming

You are probably familiar with this problem solving technique. Brainstorming can be used by individuals or groups quite successfully to quickly develop a list of possible solutions to problems. There are six basic and unalterable rules to the group process of brainstorming that set it apart from other problem-solving procedures. They are:

  • Define the issue. Make sure everyone is clear on the problem you are going to brainstorm.

  • Critical non-judgment. Defer judgment on any idea that is expressed.

  • This even includes encouraging comments to others or qualifying phrases attached to your own suggestions.

  • Organized chaos. The session should be as freewheeling as possible, with each person voicing whatever ideas come to mind - - no holds barred. Ideas may be expressed in rapid, machine-gun, fashion. Don’t limit the creativity.

  • Similar originality. Participants are encouraged to hitchhike or piggyback on the ideas of others. When one person’s suggestion sparks an idea by another, it should be instantly expressed. Lots of “ah-ha’s”...

  • Quantity, not quality. The more ideas the better. The goal of brainstorming is to get as many ideas as possible. Evaluation and elimination can be accomplished later.

  • Brief summary statements. Don’t go into great detailed explanations of your idea. You want the recorder to be able to have time to write down all ideas as team members think of them.

Mindmelding

Mindmelding is just another way to gather a large number of ideas by taking advantage of the creative minds of many people. Here's the process:

  1. On a piece of scratch paper, each person in the group writes what they consider a major problem.

  2. Once each person has completed writing the problem statement, they pass it to the person on their right.

  3. Each person then reads the problem statement they have received from the person to their left. As quickly as they can, they write out what they think might be one solution to the problem, and then pass the paper to the person on their right.

  4. Step three is repeated as many times as necessary until each person has received their original problem statement with possible solutions listed.

Last words

Using these techniques to conduct cause analysis will help you uncover those root causes that contributed to an incident or accident. If you improve the system as a result of your analysis, long term benefits will result. You are now saving or making money for your organization...safety's bottom line. Well, I think it's about time for your module quiz, don't you?



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