The “root cause” of an incident is the fundamental reason why an incident occurred. If the root cause would have been eliminated, the incident would not have happened. I’ve been involved in numerous incident investigations throughout my career. During the last few years, I’ve reviewed over a dozen incident reports, some of them for serious incidents that resulted in unacceptable worker exposure, injury or property damage. In every single one of those dozen-plus reports, the investigator listed “Lack of training” as a root cause of the incident. I rejected every one of them.
“Lack of training” is never a root cause for an incident. Never.
Nowhere has the laboratory safety professional seen management failure more clearly than with the death of Sheri Sangji in the Patrick Harran Laboratory at UCLA in 2008/2009. While loss of containment was the direct cause, management’s failure to identify and control the pyrophoric hazard was the root cause of the fatality and it was that management failure that led to Harran’s criminal indictment and subsequent deferred prosecution agreement, set to expire in 2019.
In general, it is fairly easy to identify proximate (immediate) and contributing causes of incidents. Examples of proximate causes include but are certainly not limited to:
- Over-pressurization of a reaction vessel resulting in a chemical release.
- Energized circuit resulting in an electrocution.
- Failure of a pressure regulator resulting in a chemical release.
But these are just the beginning points of an investigation.
Using an example of the over-pressurization of a reaction vessel resulting in a chemical release:
- Why did the reaction vessel over-pressurize? (A: Runaway reaction).
- Why did the reaction run away? (A: Technician added too much of “A”)
- Why did the technician add too much of “A”? (A: Technician didn’t weigh the “A” properly and doubled the amount.)
- Was “A” identified as a critical reagent in the Standard Operating Procedure knowing that too much would result in a potential incident? (A: What is a Standard Operating Procedure?)
- Why was management unaware that adding too much reagent “A” could result in an over-pressurization? (A: We did not thoroughly understand the reaction kinetics and thermodynamics)
The proximate or immediate cause of the incident is clearly the over-pressurization of the reaction vessel. A contributing cause is the technician added too much reagent to the system. That is not the root cause though. In this simple example, management failed to identify critical steps in the procedure that, if should steps fail, could result in an unacceptable release.
Likewise, if management had understood the reaction dynamics, they would have known that additional reagent “A” could lead to unintended consequences.
Part Five of the EHS Leadership series discusses the importance and safety of problem solving. Assessing and handling problems is a task every problem investigator must know.
Don’t be a lazy investigator. “Peel the onion” to find the root cause of your incidents.
For more information or to start a conversation, shoot me an email (firstname.lastname@example.org), comment on our Facebook page (https://www.facebook.com/midwestchemsafety) or comment below. To learn more about effective chemical safety management, take one our of workshops (Effective Chemical Safety Management, Research Without Rules and/or Chemical Reactivity Hazards: Laboratory Scale Recognition and Control: http://midwestchemsafety.com/workshop.php)