Teams solve problems best.
Solving safety problems centers around two key strategies: Correcting surface-cause conditions and behaviors, and improving root-cause safety management system weaknesses.
- Correcting surface-cause problems. It's important to eliminate or at least reduce unsafe behaviors and hazardous workplace conditions that cause or contribute to accidents.
- Employee, supervisor, and manager behaviors are the most direct observable effects (leading indicators) of safety management system effectiveness. Inappropriate or unsafe employee behaviors, in turn, create hazardous workplace conditions.
- To understand and correct employee surface-cause behaviors and hazardous conditions, it's important to conduct employee surveys, interviews, observations, and workplace inspections.
- Improving root-cause problems. To most effectively eliminate or reduce surface causes, you must dig up and correct their underlying root-cause safety management system weaknesses.
- To correct the root causes you need to design, develop and deploy an effective safety management system.
- Improving safety management system policies, programs, plans, processes, procedures, and practices (the 6-Ps) will positively affect what employees think and how they behave in the workplace.
Understanding the Problems
It's important that management take action to correct Safety Management System (SMS) 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.
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Tools to identify, analyze, and understand surface-cause behaviors and conditions
- Informal and formal observation
- Safety inspection
- Job Hazard Analysis
- Accident investigation
- Records/Reports review
Root cause problems include corporate behavior and performance that lead 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:
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Tools to identify, analyze, and understand root-cause system weaknesses
- Records/Reports review
- 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)?
Is There Really a Problem?
- Gap Analysis - Is there a gap between what we want and what we have? You need to be able to communicate what that gap is.
- Consensus - 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."
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.
Every "effect" is the result of a "cause". It's important to understand that each effect is, at the same time, the cause for another effect. A single effect by itself can generate a completely new cause-effect branch.
Click on the image to the right. It represents only one branch of many possible branches.
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.
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Something's Fishy Here
One of the primary tools in cause-effect analysis is 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.
Mind Mapping - Another Tool to Identify Problems
Mind Mapping, originated by Tony Buzan, is nothing more than "instantaneous non-linear cognitive deduction utilizing spatial forms in a two-dimensional plane." (huh?)
Seriously, 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 it takes advantage of the brain's natural ability to categorize ideas in a rapid, but rather unorganized manner.
Look at the mind map below and follow these steps:
- At the center we write the problem.
- Think about the factors that are the 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)
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- 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 will be able to take any topic, project, or problem and quickly determine related categories, processes, procedures, etc. Once the mind map is complete, it is merely
a matter of reorganizing the information into the more common outline format.
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
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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:
- On a piece of scratch paper, each person in the group writes what they consider a major problem.
- Once each person has completed writing the problem statement, they pass it to the person on their right.
- 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.
- Step three is repeated as many times as necessary until each person has received their original problem statement with possible solutions listed.
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 and that's safety's bottom line.