How to Identify a Root Cause

A root cause is the underlying reason for why an incident occurred.

When identified, root causes can reveal potential faults with the current safety measures in place designed to protect employees from a hazard.

Determining a root cause of an incident is not to find someone to blame, but to ask “How” and “Why” questions about the safety measures that failed or proved insufficient.

A root cause such as “employee should pay more attention when walking” or “employee did not follow safety procedures” do not offer clear solutions to prevent an incident from happening again and lack the specific instruction for an employee to know what to do. Use the Factors that contributed to incident that are selected on the incident report as a guide and begin asking questions that will identify a root cause.

Example – An employee sustained an arm injury because of a slip and fall while performing floor care.

How did the employee fall?

Slipped on the floor with stripper product applied on the surface.

Why was the employee walking over a wet floor?

Performing routine floor care.

Was the employee wearing appropriate footwear, such as non-slip shoes?

No.

Why was the employee not wearing non-slip shoes?

Employee did not know to wear this type of footwear.

Why didn’t the employee know to wear the proper footwear?

No one informed the employee non-slip footwear was required to be used when performing floor stripping.

Why did no one inform the employee to wear proper footwear?

This requirement was not mentioned in any training.

A root cause is now emerging about training.

Why was the requirement to wear non-slip footwear not mentioned in any training?

Prevention – Training can be updated to include the appropriate footwear to be worn for floor stripping work.

Is this the only possible conclusion in this situation?
No. In most cases, there could be several different responses to each question along the way, and there is very often more than one root cause to a problem, and that is OK.

To include a root cause on the incident report is a valuable contribution to your peers and our safety program that is well-worth the effort.

When root causes are identified, preventive measures and actions are more effective, leading to a continuously improving and safer workplace.