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Akinsamol  
#1 Posted : 27 September 2021 12:04:07(UTC)
Rank: New forum user
Akinsamol

There was an underground utility damage (150mm portabe water pipeline) on my project where an excavator operator had operated outside safe work zone. The supervisor was at another work area and from investigation, some inspections that should have been done by the engineer prior to work commencement were not properly carried out; required signages were not adequately installed.

I have concluded in my report after my investigations that the root cause was due to inadequate work supervision and the underlying casue was failure to adhere to the SSOW. However, my consultant Safety engineer informed the panel that I was wrong, stating that the root casue should have been the operator working outside the safe zone.

I will appericiate further discussions and opinions about this.

Thanks.

peter gotch  
#2 Posted : 27 September 2021 12:12:49(UTC)
Rank: Super forum user
peter gotch

Akinsamol

May be the Consultant thinks that there is only ever one "The Cause".

I think however that most modern practitioners recognise that for most incidents there is usually more than one cause - as you have identified.

But if someone decides to pin an incident on a worker doing what they shouldn't it might make it easier not to address the more important UNDERLYING conditions that you have identified.

Good luck, Peter

thanks 1 user thanked peter gotch for this useful post.
Akinsamol on 27/09/2021(UTC)
A Kurdziel  
#3 Posted : 27 September 2021 12:18:19(UTC)
Rank: Super forum user
A Kurdziel

As far as  I am concerned the root cause is always a failure of management. Simply pinning the blame on operatives means that you are not really interested in actually making the situation better. An operative makes a mistake for what ever reason  and I assume you sack the operative because it is their fault; you then hire a new operative who then repeats the mistake. The problem won’t go away until you have changed the way things are managed; so it’s a management issue not an employee issue.

So why did the employee do what he did?

Was he trained to work near services?

Were the services properly surveyed?

Was the operative properly informed of the issues?

Was he under pressure  to complete the job?

Thus and lots of other questions all lead back to the way the job was being managed. To be honest I would not stop at the supervisor but take it all the way up the line. It could be a poor H&S culture issue.

 

thanks 3 users thanked A Kurdziel for this useful post.
HSSnail on 27/09/2021(UTC), CptBeaky on 27/09/2021(UTC), Akinsamol on 27/09/2021(UTC)
Kate  
#4 Posted : 27 September 2021 12:28:16(UTC)
Rank: Super forum user
Kate

The operator working outside the safe area may have been a cause but cannot possibly have been the root cause.

That is because it gives rise to the answerable question "Why did the operator work outside the safe area?"

The answer to that question is either the root cause or at least closer to the root cause than the operator working outside the safe area is.

thanks 3 users thanked Kate for this useful post.
Akinsamol on 27/09/2021(UTC), A Kurdziel on 27/09/2021(UTC), Andrew McLean on 05/10/2021(UTC)
CptBeaky  
#5 Posted : 27 September 2021 12:29:48(UTC)
Rank: Super forum user
CptBeaky

I was always under the impression that the root cause can only be confirmed once you can't ask "why?" anymore. For example, if the root cause was the worker working outside the safe zone, then there would have to be no valid reason as why this was the case. I would suggest that being "unsupervised" is a valid reason why, and therefore the worker cannot be the the root cause, by definition.

Furthermore, I would suggest there is probably a reason "why?" there was no supervision. Was it down to time pressures? Lack of understanding of responsibilities? Or even a lack of leadership from the top level in ensuring that work was properly supervised?

I find that, when the dust settles, it is usually a management failing that leads to a root cause. Management bear the responsibility of health and safety (and welfare), but they also have the power to ensure work is carried out in a safe manner. Unfortunately, the same people that want you to carry out an investigation don't often like being told they are the root cause of the accident. Did management ensure those carrying out their respective roles were competent? Did they ensure the dangers were known (if if only by delegating to competent people). Do top level management ensure there is a positive health and saftey culture in the workplace?

Proper root cause analysis should help an organisation make a change that would result in a safer working place for everyone, not just stop a repeat of one incident. By blaming the individual you run the risk of the replacement worker also making exactly the same mistake.

dammit, just noticed A Kurdziel has beaten me to the punch, so I will stop here!

thanks 2 users thanked CptBeaky for this useful post.
Akinsamol on 27/09/2021(UTC), Kate on 27/09/2021(UTC)
HSSnail  
#6 Posted : 27 September 2021 12:31:14(UTC)
Rank: Super forum user
HSSnail

Without knowing the full details its difficult to know for sure but "operator working outside the safe zone" sounds more like an imediate cause to me.

"Inspections that should have been done by the engineer prior to work commencement were not properly carried out; required signages were not adequately installed" sound like underlying and then as A says the root causes would be the management practacies (or lack of) that allowed the above to happen.

thanks 3 users thanked HSSnail for this useful post.
Akinsamol on 27/09/2021(UTC), CptBeaky on 27/09/2021(UTC), A Kurdziel on 27/09/2021(UTC)
peter gotch  
#7 Posted : 27 September 2021 18:19:22(UTC)
Rank: Super forum user
peter gotch

Hi Akinsamol

Now wouldn' it be interesting if this consultant safety engineer would come here and explain why they are right and you (+ some readers here) are wrong?!?!

P

Akinsamol  
#8 Posted : 28 September 2021 05:04:02(UTC)
Rank: New forum user
Akinsamol

Originally Posted by: peter gotch Go to Quoted Post

Hi Akinsamol

Now wouldn' it be interesting if this consultant safety engineer would come here and explain why they are right and you (+ some readers here) are wrong?!?!

P

Really, I was disaponted that a the safety engineer - a chartered member of IOSH could have said that. I actually knew that the Root Cause was management failure but in the part of the country where I work, that could have landed me in serious trouble, unfortunately however, to say the obvious immediate casue was the root casue was unexplainable to me and that's why I brought it up to this forum. 

I really appreciate all the repsonses to the question.

thanks 1 user thanked Akinsamol for this useful post.
CptBeaky on 28/09/2021(UTC)
MrBrightside  
#9 Posted : 28 September 2021 09:05:06(UTC)
Rank: Forum user
MrBrightside

I had a rather similiar discussion with my MD who belived the route cause of an incident was the Operator. The only way I managed to get my point across was; "if we take that Operator out of the equation (i.e. sack them) what do we have in place to make sure that another Operator would not make the same mistake" or to put it another way "if someone had died, who would of the HSE found at fault us or the Operator". He still wouldn't have it that I was right.

Imediate: Excavator operator operated outside safe work zone

Underlying: Failure to adhere to the SSOW (and a few others I would imagine)

Root cause:  Inadequate work supervision / management failure

A lot (and I mean a lot) of people with H&S experience still get this mixed up.

thanks 5 users thanked MrBrightside for this useful post.
CptBeaky on 28/09/2021(UTC), A Kurdziel on 28/09/2021(UTC), RVThompson on 28/09/2021(UTC), mihai_qa on 29/09/2021(UTC), Andrew McLean on 05/10/2021(UTC)
peter gotch  
#10 Posted : 28 September 2021 16:49:20(UTC)
Rank: Super forum user
peter gotch

Mr Brightside

Nice explanation but my guess is that the actual root cause (or even causes) even deeper.

Gerry Knowles  
#11 Posted : 05 October 2021 08:53:29(UTC)
Rank: Forum user
Gerry Knowles

Where there might many factors relating to the causation of an incident or injury, if you drill down deep enough it will nearly always come down to a failure to manage the people, equipment and the enviroment in which the incident happened. 

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