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Course 716 - Safety Management System Evaluation

Safety guides and audits to make your job as a safety professional easier

Cause Analysis

What is Root Cause Analysis?

There are many tools for SHMS analysis. For example, reviewing documents, making observations, and conducting interviews and walkaround inspections are all important methods that can provide valuable data for analysis. In this module, we'll look at these methods and more.


Every worksite should have, at a minimum, written accident reports and the OSHA 300 Log of injuries and illnesses as required by law. It's a good idea, especially for larger companies, to have written procedures and records of all safety and health programs. A program evaluator should compare the written program with the performance record of the program.

1. A program evaluator should compare the written program with the _____ record of the program.

a. historical
b. performance
c. safety committee
d. tracking

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The interview process can be very helpful in SMS analysis and improvement.

In addition to documentation, interviews can be very helpful in establishing the current status of safety management system design and performance. There are two kinds of interviews, formal and informal.

  • Formal interviews are conducted privately with randomly selected employees who are asked pre-selected questions. 
  • Informal interviews occur at employee work stations and generally follow a list of topics.

To assess how well the worksite safety and health policy is communicated and understood, and how well the disciplinary system is working, ask the employees to explain them.

Interviewing employees and supervisors. To gauge the effectiveness of safety and health training, interview hourly employees and first-line supervisors:

  • Ask employees to describe what hazards they are exposed to, and how they are protected.
  • Ask employees to explain what they are supposed to do in several different types of emergencies.
  • Ask supervisors how they teach, how they reinforce the teaching, how they enforce safety and health rules and safe work practices, and what their responsibilities are during emergency situations.

Interviewing management. Interviews with management should focus on its involvement in and commitment to the safety and health program.

  • Ask how the policy statement was created, and how that statement is communicated to all employees. 
  • Ask what information management receives about the safety and health activities, and what action management takes as a result of that information. 
  • Ask how management's commitment to safety and health is demonstrated to the workforce.

2. Interviews with managers and supervisors should focus on management __________.

a. involvement and commitment
b. enforcement and dedication
c. development and performance
d. perception and relationship

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Review Workplace Conditions

The walkaround inspection is a way to directly determine hazardous conditions.

Conditions in the workplace reveal much about SMS effectiveness. Workplace conditions can be observed indirectly by examining documents such as inspection reports of hazards, employee reports of hazards, and incident/accident investigations.

Inspections or tours may reveal hazards. Tips include:

  • Be careful the inspection does not become routine with emphasis only on hazard correction.
  • When a hazard is found, certainly take steps to make sure it is corrected.
  • Ask what management system(s) should have prevented or controlled the hazard.
  • Determine why system(s) failed, and either change them or take other appropriate corrective measures.

3. Which of the following is a way to directly determine hazardous conditions in the workplace?

a. examining safety committee minutes
b. looking at accident reports
c. analyzing hazard reports
d. conducting walk-around safety inspection

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The 5 Whys Method

The "5 Whys" Technique

The "5 Whys" technique is a brainstorming technique that identifies root causes of problems by asking why behaviors occurred or conditions existed. This produces the most direct cause of the event.

As the illustrations below indicate, each cause is, at the same time, the effect of a deeper cause. For each of these causes, ask why it occurred. Repeat the process for the other events associated with the problem.

Click on the buttons below to see two ways to look at the 5-Whys Technique graphically.

Click on the buttons below for more information on the three categories of participation.


4. The _____ is a brainstorming technique that identifies root causes of problems by asking why behaviors occurred or conditions existed.

a. mind mapping
b. fishbone diagram
c. cause effect diagram
d. 5 Whys technique

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The Cause and Effect "Fishbone" Diagram

Fishbone Diagram
(Click to enlarge)

Within the context of safety, a cause and effect diagram graphically represents the relationships between accidents or problems and their possible causes. The accident or problem is stated in descriptive terms that are observable and measurable. Possible surface and root causes can be expressed in words or data.

One common cause and effect diagram reminds us of a stylized fish. Reference the diagram to the right. The box represents the head of the fish and the arrows represent the various bones. If the diagram is used to analyze why an accident occurred, the following would apply:

  • The Head. A description of the accident is placed in a box which is considered the head of the fish. The direct cause of the injury describes the harmful transfer of energy that caused the injury. In this example, the description might be, "Hand cut by rotating table saw blade." To get to the causes, start asking "why."
  • The Back Bone. The back bone represents the primary surface causes - the hazardous condition and/or unsafe behavior that culminates in the accident. In this example, an employee's gloved hand got caught by and drawn into a rotating table saw blade. To get to the indirect surface causes, again, ask "why."
  • The Ribs. The bones attached to the backbone represent the many indirect surface causes that fit in the various major categories. These are many unique or individual conditions or behaviors that contributed to the primary surface causes listed in the back bone. There may be many of these indirect surface causes within each major cause category. For instance, in the "management" category, a supervisor may have ignored the unguarded table saw. Again, ask "why" to better understand by the supervisor ignored the hazard.
  • The Small bones. Finally, the smaller bones indicated the deeper root causes - the SMS weaknesses. In this case, the supervisor may have ignored the table saw because he was under enormous pressure to meet the work schedule. There likely be many additional levels of root causes (arrows) causing the stress the supervisor was feeling.

5. In a Fishbone Diagram, the back bone and ribs represent _____.

a. the acute or chronic results
b. the accident or problem
c. the surface causes
d. the proximal results

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Cause and Effect Fishbone Diagram Procedures

Cause and Effect Analysis
DHi International

A cause and effect diagram to solve problems is developed in the following manner:

  1. Define the effect as clearly as is possible and place it at the head of the fish. This effect represents the "problem" statement. As data are collected, the effect can be redefined, if necessary.
  2. The group brainstorms the causes and lists them in no particular order. These causes are studied and the causes that affect these causes are identified. This will continue until no new causes are thought of by the group.
  3. Once all causes are identified, list all categories and display the categories on the diagram.
  4. The group next prioritizes the causes by multi-voting. Each member of the group lists the causes in order of significance. Votes are counted, and a final list is written.
  5. The highest prioritized causes are listed on the diagram as the big bones. The next highest prioritized causes will be listed on the diagram as the medium bones. Finally, the least prioritized causes will be listed on the diagram as the small bones.
  6. As categories and causes are included on the diagram, thinking may be stimulated and new causes may be identified.
  7. Teams are then formed to research and report on preventive (i.e., proactive) measures.

6. When solving problems using a cause and effect diagram, a good way to identify the causes is to _____.

a. brainstorm ideas
b. rely on feelings
c. determine who is to blame
d. list approved ideas

Check your Work

Click on the "Check Quiz Answers" button to grade your quiz and see your score. You will receive a message if you forgot to answer one of the questions. After clicking the button, the questions you missed will be listed below. You can correct any missed questions and recheck your answers.


Last Words

Well, I hope you find one or two of these techniques useful in your effort to analyze your safety management system. The really do work! In the next module, we will take a look at taking all of the information and data collected to evaluate the effectiveness and efficiency (quality) of the safety management system. See you there!

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