OHS Committees do Root Cause Analysis. Does yours know how?
How deep do we have to drill to understand what caused this outcome?
Someone, somewhere, is hiding something, or is unaware of the impact of their actions. Either way, we need to prosecute this circumstance vigorously to ensure that they do not cause further harms.
Question everything and everyone. Accept nothing at face value. Trust, but verify.
Who did what, when, where, how, and why?
What were the physical and environmental conditions before and during the incident?
What psycho-social factors were at play within the actors prior to the incident?
What concerns and trends existed prior to the incident?
What evidence of actor competency and compliance exists?
Are you able to identify the causes of the incident exactly?
Are you able to determine the degree of responsibility for each of the factors?
Are you able to determine the degree of responsibility for each of the actors?
How certain are you of your conclusions?
What new information would be necessary for you to alter your conclusions?
How likely is it that there is another reasonable explanation?
Tips & Tools for Root Cause Analysis
Accident and Operational Safety Analysis (U.S. DOE)
Assessment of organisational culture (Reiman & Oedewald)
Ethos of Error: Analyzing Investigations of Industrial Events (Sweeney, 2004)
Evaluating Training Programs: Kirkpatrick’s 4 Levels
Five Whys Tool for Root Cause Analysis
Intelligence Analysis for Problem Solvers (Eck & Clarke, 2013)
Inventory of Human Factors, Tools, and Methods
Miniature Guide to Critical Thinking (Paul & Elder)
Risk Management (Det Norske Veritas)
Root Cause Analysis: A Brief Overview of Methods
Root Cause Analysis Following an Event at a Nuclear Installation (IAEA, 2015)
Selection of a Supervisor (Workplace Safety North, 2013)
School Improvement Planning: Root Cause Analysis (CCSD, 2012)
Structured Analytic Techniques for Improving Intelligence Analysis (USA, 2009)
Final Analysis: Conclusion
Small But Deadly “The biggest extinction in history was probably caused by a space rock that changed the climate.
…most people think [the] Araguainha [crater] is too small to be the culprit. It is a mere 40km (25 miles) across. The Chicxulub crater in Mexico, which did for the dinosaurs, is 180km in diameter, and it may have been paired with an even bigger impact in the Indian Ocean. …
After an extensive geological survey, [Dr. Tohver] and his team discovered that a sizeable amount of this rock is oil shale. Any hydrocarbons in the crater would certainly have been vaporised. More intriguingly, the researchers calculate that the impact would have generated thousands of earthquakes of up to magnitude 9.9 (significantly more powerful than the largest recorded by modern seismologists) for hundreds of kilometres around. In effect, it would have been the biggest fracking operation in history, releasing oil and gas from the shattered rock in prodigious quantities.
The upshot, Dr Tohver believes, would have been a huge burp of methane into the atmosphere. Since methane is a powerful greenhouse gas, that burp would have resulted in instant global warming, making things too hot for much of the planet’s animal life. Presto! The Permian mass extinction is explained.”
OHS Committee 
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