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.

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.

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!

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

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.

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.