Safely Managing
Compliance strategies and solutions for supervisory personnel
Why bother digging for a root cause?
No matter what industry you’re in, incidents that result in injuries or property damage, especially repeat incidents, are often very disruptive. They can hinder productivity, damage employee morale, and could lead to fines or lawsuits.
When workplace incidents, even close calls, are investigated, it’s important to remove the immediate hazard, such as a faulty piece of machinery, but even more crucial is figuring out the
underlying reason for the problem. — the root cause.
Conducting what’s known as a root cause analysis (RCA) can go along way toward preventing similar incidents, and their consequences.
The Canadian Centre for Occupational Health and Safety notes that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause.
For example, it says, an ‘investigation’ that concludes an incident was due to worker carelessness, and goes no further, fails to find answers to several important questions, such as:
• Was the worker distracted? If yes, why was the worker distracted?
• Was a safe work procedure being followed? If not, why not?
• Were safety devices in order? If not, why not?
• Was the worker trained? If not, why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction.
You’ll notice that the CCOHS example uses the word “why” in each question.
The Five Whys is a problem-solving technique used to identify the root cause by asking “why” five times (sometimes more, sometimes less). It helps uncover the underlying reasons for an issue, going beyond superficial symptoms.
Here’s how it works:
• Begin with a specific problem. What is it that you are having an issue with?
This can also help the team focus on
n The risk of fatigue is raised by heat
n Corrosives pose numerous hazards
n Proper forklift training is essential
n Safety snippets
Safety Meeting: Positive results form a negative...
the same problem.
• Ask why the problem happened and write the answer down below the specific problem you listed in step one.
• Keep asking “why” to each of the successive answers you write down until you reach the root cause of the problem.
Most guidelines on the Five Whys do not insist that five questions must always be asked. The actual number depends on the complexity of the problem. The key is to keep asking “why” until the real root cause is found.
RCAs aren’t just for workplace accidents, though. You can use the process to resolve:
• Physical and data security breaches.
• Workplace violence, harassment, discrimination and bullying.
• Quality control problems.
• Processes and procedures.
• Equipment or tool failure and malfunction.
It is important to differentiate between a root cause analysis and an incident report.
An incident report describes the immediate facts of an incident, while an RCA digs deeper to identify underlying causes.
An RCA report focuses on prevention, whereas an incident report captures details for documentation.
There are three basic types of root causes and they need to be approached differently.
Environmental. These are external conditions and physical factors within the workplace and include unsafe equipment design, lighting issues, temperature extremes, noise levels,
or hazardous materials in the work environment. They create underlying risks that can lead to incidents if not managed, as they directly affect the ability of workers to perform tasks safely.
Environmental factors are particularly significant because they influence how tasks are performed and equipment and personnel interact with their surroundings. Addressing environmental root causes requires focusing on facility layout, engineering controls, and adherence to standards designed to mitigate environmental hazards in high-risk settings.
Individual. Factors such as fatigue, insufficient training, or stress affect task performance. They can make personnel more prone to error in complex or high-risk tasks. Individual root causes stem from a workers personal actions, decisions, or errors. These can include improper skill application or personal risk-taking behaviour.
Analysis of individual root causes goes beyond blaming workers. It evaluates how workload, repetitive shifts, cognitive demands, and stress affect human performance.
By examining human error rates and performance metrics data, an RCA identifies specific areas where training or procedural adjustments can reduce the likelihood of error.
Organizational. Factors, such as inadequate standard operating procedures (SOPs) or poor communication create systemic vulnerabilities that can increase the likelihood of workplace accidents. Organizational root causes are linked to structure, policies and culture. This includes issues such as
There are three basic types of root causes and they neeed to be approached differently
insufficient resource allocation for safety, ineffective communication channels, poor leadership and toxic work environment, and lack of safety protocol enforcement. Analysis in this category assesses how organizational decisions and safety practices contribute to incident risk.
No matter what method or tool you use to conduct your root cause analysis, you should follow the same general steps:
Define the scope. Identifying the specific issue you want to address increases the odds that you’ll find the root cause and correct it.
Assemble the analysis team. Include employees who are familiar with the processes related to the problem. The victim’s manager and coworkers who have experience with the work can shed light on root causes best. While one person could conduct a root cause analysis on their own, brainstorming as a team works better.
Organize data. Creating a timeline to describe the incident will help you visually organize the investigation information and see where things went wrong.
Identify contributing factors. Add details to the timeline, asking why each event occurred. This helps you figure out factors that led to the accident.
Determine the root cause(s). Ask why each contributing factor occurred. You may find the same root cause for multiple contributing factors. Develop an action plan. Based on your findings, determine how to remove immediate hazards and reduce the risk of similar incidents in the future.
The risk of fatigue is raised by heat
Fatigue is more than just feeling tired – it’s a form of impairment.
Although the warm, sunny days of late spring and summer are welcome after months of dreary winter weather, anyone who has spent time under a hot sun knows there can be a serious downside.
A bad sunburn, heat exhaustion and heat stroke are the most serious concerns — but a condition that can occur earlier — fatigue — also poses potential problems, especially in a work setting.
High temperatures can sap energy for several reasons. The body is working overtime to keep itself cool, dehydration sets in faster and UV rays from the sun trigger chemical changes in the body.
Fatigue is more than just feeling tired –it’s a form of impairment. It can reduce mental and physical functioning, affect judgment and concentration, slow reaction time and lower motivation.
Signs that a worker may be fatigued include:
• Weariness.
• Irritability.
• Reduced alertness.
• Lack of motivation.
• Headaches.
• Loss of appetite.
To maintain an average normal body temperature of 37 C (98.6 F), something called vasodilation needs to happen. This is the process by which your blood vessels dilate, allowing more blood flow close to the surface of your skin, which releases heat. It allows you to cool down but also can make you appear “flushed,” taking up energy and making you tired.
Sweating is another process to regulate body temperature, allowing the skin to cool as the sweat
evaporates. On the inside, however, sweating causes both a person’s heart rate and metabolic rate to increase, which also can take large amounts of energy.
Excessive sweating can make you extremely tired and sleepy.
Fatigue is among the symptoms of heat cramps, the mildest form of heatrelated illness. Prompt treatment can prevent heat cramps from progressing to more-serious heat illnesses. Other symptoms of heat cramps often include heavy sweating and thirst.
Before cramps happen, though, there are measures to help minimize the likelihood of fatigue and other symptoms:
Stay hydrated. Drink plenty of fluids throughout the day. Dehydration can contribute to fatigue, so keep a water bottle or sports drinks handy.
Cool your environment. Use fans or air conditioning to keep your working space cool. If you don’t have air conditioning, try using shades or curtains to block out direct sunlight.
Dress accordingly. Wear lightweight and loose-fitting clothing made of
breathable fabrics such as cotton. Light colours can also help reflect heat. A wide-brimmed hat and sunglasses are also advised.
Avoid peak sun hours. If possible, limit outdoor activities during the hottest parts of the day (typically midday) and schedule activities for cooler mornings or evenings.
Take breaks. When you feel fatigued, allow yourself to rest frequently and avoid overexertion.
Eat properly. Opt for lighter meals that include plenty of fruits and vegetables. Heavy or greasy foods can make you feel more lethargic in hot weather.
Stay in the shade. When outdoors, avoid direct sunlight as much as possible to help maintain a lower body temperature.
Manage your schedule. Plan activities wisely, tackling more strenuous tasks during cooler parts of the day.
Get adequate sleep. Ensure you’re getting enough quality sleep at night, as heat can disrupt sleep patterns and contribute to fatigue.
ManagementTips
Corrosives pose numerous hazards
Corrosive materials might easily be thought of just as liquids, but they also can be a solid or gas.
In whatever form, corrosives can burn, irritate or destroy living tissue. When inhaled or ingested, lung and stomach tissue are affected.
Materials with corrosive properties can be either acidic (low pH) or basic (high pH). They are present in almost any workplace, either by themselves or contained in other products, such as cleaning agents.Some are so powerful they can damage or destroy metal.
Common acid corrosives include hydrochloric acid, sulphuric acid, acetic acid, and nitric acid.
Common alkaline/bases include ammonium hydroxide, potassium hydroxide, and sodium hydroxide (caustic soda). Cement contains lime, which is a base or caustic compound. Corrosive gases are absorbed readily into the body through skin contact and inhalation.
Corrosive liquids have a high potential to cause external injury to the body.
Corrosive solids cause delayed injury. They dissolve rapidly in moisture on the skin and in the respiratory system, so their effects depend largely on the
duration of contact.
Corrosives can also present other hazards, such as catching fire, exploding or reacting dangerously with other substances.
Before using a material with which you are not familiar, always read the safety data sheet (SDS) to know what is in it and how to use it safely. Always store corrosives in suitable containers and away from incompatible materials (for example: acids and bases should be stored separately). Remember to store, handle and use corrosives in well-ventilated areas.
Here are some more ways to avoid the hazards of corrosive materials:
• If it is not possible to eliminate use of the product, determine whether it is possible to substitute a less hazardous one.
• Inspect containers for damage or leaks before handling.
• Prevent the release of dust, gas, mist, vapour or spray into the workplace.
• Use the smallest amount necessary.• Wash hands and skin thoroughly after handling.
• Wear skin, eye and respiratory protection appropriate for the job as specified by your employer.
• Dispense corrosives carefully and keep containers closed when not in use. Use corrosion-resistant equipment such as pumps, scoops or shovels.
• Do not add water to the corrosive product. If it is necessary to mix a corrosive product with water, do so slowly adding the corrosive to cold water, in small amounts, and stir frequently.
• Move large drums using drum cradles. Carboy caddies and safety bottle carriers are available for smaller, common container sizes.
• Immediately report leaks, spills or failures of the safety equipment such as ventilation system.
• Clean up any spills promptly and safely.
• Do not reuse empty containers; hazardous corrosive residue could remain inside.
• Inspect containers and storage area regularly for signs of leakage or damage.
• Store in a corrosion-resistant container with a resistant inner liner.
• Store containers at a convenient height for handling, below eye level if possible. High shelving increases the risk of dropping containers and the severity of damage, injury and/or exposure if a fall occurs.
• Keep the amount of product in storage as small as possible.
• Use proper corrosive storage cabinets for large quantities of corrosive products.
• Ensure that appropriate firefighting and spill cleanup equipment is readily available.
SuperCompliance
Proper forklift training is essential
Being properly trained to operate a forklift and being able to prove that training was received successfully isn’t just a good idea — it’s the law.
Forklifts have become indispensable for moving materials in warehouses, manufacturing plants and distribution centres, but they’re dangerous if not handled correctly.
Non-compliance with training requirements and safety regulations can lead to serious consequences.
An Ontario building supply company was fined $70,000 after an incident involving two of its workers. They had been asked to move some returned lumber, a task they had previously done by hand. On this occasion, one worker used a forklift to carry the lumber while being assisted by the other worker, who was walking alongside the forklift. The forklift struck the walking worker, who sustained critical injuries.
Neither worker was certified to operate the forklift, nor had they completed forklift pedestrian safety training.
The employer was found to be in breach of Canada’s Occupational Health and Safety Act for failing to ensure its employees were provided information, instruction and supervision regarding the operation
of forklifts at a workplace.
The court also imposed a 25 percent victim fine surcharge to be credited to a special provincial government fund to assist victims of crime.
A much larger penalty — nearly $300,000 — was levied against a British Columbia employer after one of its workers died in the workplace.
The incident happened when a forklift operator was taking down a row of six loaded pallets of boxes. The worker then left to chat with a coworker. Before the worker could reach the vehicle on his way back, a bundle of two pallets weighing a total of 340 kilograms (750 pounds) fell on him.
Another forklift operator heard the stack fall, and 911 was called, but the victim later died from his injuries.
WorkSafeBC handed the company a $290,548.37 penalty for that incident and related “high-risk violations,” including “inadequate” risk assessment, supervision and training, which it says contributed to the fatality.
In Canada, the regulatory framework
for forklift certification is governed primarily by occupational health and safety regulations at the federal and provincial levels. Operators must undergo formal training programs offered by certified training providers. These programs cover essential aspects of forklift operation, including safety procedures, equipment maintenance, and load handling techniques.
After completing the formal training program, operators are required to pass a theory examination. This written test assesses their understanding of the theoretical aspects of forklift operation, including safety regulations, equipment specifications, and workplace hazards.
In addition to the theory examination, operators must undergo a practical skills assessment. This hands-on evaluation is conducted to ensure that operators can apply their knowledge in real-world scenarios.
Skills such as maneuvering, load handling, and emergency procedures are tested to verify the operator’s ability to operate a forklift safely.
Upon successful completion of both the theory examination and practical skills assessment, operators are issued a forklift certification. This certification serves as proof that the operator has met the necessary training and evaluation requirements, making them eligible to operate forklifts in a professional setting.
Forklift certification is not a onetime process, though. Canadian regulations mandate that forklift operators undergo refresher training and certification renewal at regular intervals.
Work zone TCPs play a vital role
Traffic control persons, commonly known as TCPs, are essential figures in the road safety landscape. They are responsible for maintaining order and safety in work zones, ensuring the well-being of both road users and construction workers.
The role is challenging and demands a high level of responsibility. To ensure their safety and the safety of others, TCPs should follow these safety tips:
• Always wear the appropriate personal protective equipment (PPE), including high-visibility clothing, hard hats, and safety boots.
• Maintain focus and stay alert to the traffic and construction activities around you.
• Position themselves in a way that provides a clear view of traffic while
remaining safe from oncoming vehicles.
• Ensure that hand signals are clear and standardized, as they are a primary means of communication with drivers.
• Make sure their reflective vest and safety gear are visible to approaching drivers, especially in low-light conditions.
• Never stand in the path of oncoming traffic. Always remain in designated safety zones.
• Be prepared for changing weather conditions, and adjust PPE accordingly.
• Familiarize themselves with the operation of traffic control devices and use them correctly.
• Keep a cool head, especially in highstress situations. Maintain a professional demeanor when dealing with frustrated or impatient drivers.
Avoiding cuts and lacerations
Some of the most common and preventable workplace injuries are cuts and lacerations. The key to preventing them is keeping body parts away from hazards. Employers should establish work procedures to identify and control exposure to those hazards.
Suggested control measures include:
• Training employees to use established safety procedures.
• Maintaining proper machine guarding.
• Using lockout/tagout procedures.
• Wearing personal protective equipment.
• Safe tool use.
• Good housekeeping. Most minor cases can be treated with basic first aid. Wash the wound with clean soap and water. Apply an antiseptic. Cover the wound with a bandage to prevent further contamination. Medical attention will be required if reddish streaks are observed traveling out from the injury site or if the person experiences shaking chills, a rapid temperature rise, rapid, pounding heartbeat, and warm, flushed skin.
Key scissor lift precautions
Scissor lifts – named for the way the lifting mechanism’s crossed beams raise and lower the work platform – are often used by manufacturing, warehouse and construction workers. To safely operate a scissor lift, two main elements must be addressed before work begins — proper positioning and stabilization.
Here’s what workers and employers can do:
Positioning
• Implement measures around the lift to prevent other workers or equipment from approaching.
• Use ground guides when operating or moving the lift.
• Place the lift at least 3 metres (10 feet) away from power lines and other sources of electricity, as well as away from overhead hazards such as tree branches.
Stabilization
• Don’t move the lift while it’s in the upright position.
• Work in areas that have a level surface and don’t have holes or bumps that can cause instability.
• Use the lift outside only if weather conditions are good.
• Don’t bypass safety features designed to stop the lift from collapsing.
• Never allow the weight on the work platform to exceed the manufacturer’s load rating.
• Don’t use equipment (such as a forklift) other than the scissor lift mechanism to raise the work platform.
Stay prepared for emergency
Emergencies can create a variety of hazards for workers in the impacted area. Preparing before an incident occurs helps ensure that employers and workers know where to go and how to keep themselves safe.
Your safety, and the safety of others, relies on your ability to respond calmly and appropriately. Take the time to make sure everyone on your team is aware of their role and responsibilities.
SafetyMeeting
Positive results from a negative...
A key element of accident prevention can be an accident itself
Although what happened might have been tragic, there’s a positive side. Circumstances under which it occurred need to be identified and measures taken to reduce or eliminate the chances of something similar happening in the future.
That’s the main reason why the accident investigation process is so important.
The term “accident” can be defined as an unplanned event that interrupts the completion of an activity, and may or may not include injury or property damage.
The term incident is used in some situations and jurisdictions to cover both an “accident” and “incident.” Some argue the word “accident” implies the event was related to fate or chance. An incident usually refers to an unexpected event that did not cause injury or damage this time but had the potential to do so. “Near miss” or “dangerous occurrence” are also terms for an event that could have caused harm but did not.
There’s value in examining each of these closely, with the aim of determining the root cause. When this is done, it is usually found that many events were predictable and could have been prevented.
For this safety talk, the term accident will be used to mean all of the above events.
Other reasons to investigate a workplace accident include:
• Fulfilling legal requirements.
• Determining the cost of an accident.
• Compliance with applicable safety regulations.
• Processing workers’ compensation claims.
The purpose of these activities is not to find fault or lay blame, but
rather to identify the basic causes of accidents so controls can be put in place to prevent further occurrences. Information from the investigation should be put on the record, but not used to discipline anyone.
This policy encourages witnesses to tell investigators everything they know.
The accident investigation process involves the following steps:
• Report the accident to a designated person within the organization.
• Provide first aid and medical care to injured person(s) and prevent further injuries or damage.
• Investigate the incident.
• Identify the causes.
• Report the findings.
• Develop a plan for corrective action.
• Implement the plan.
• Evaluate the effectiveness of the corrective action.
• Make changes for continuous improvement.
Ideally, an investigation is conducted by someone trained and experienced in accident causation, investigative techniques, and be fully knowledgeable of the work processes, procedures, persons, and industrial relations environment of a particular situation.
Other members of the team can include:
• The supervisor.
• Employees with knowledge of the work.
• Safety officer.
• Health and safety committee.
• Union representative, if applicable.
• Employees with experience in investigations.
• “Outside” expert(s).
The accident scene should be inspected as soon as possible.
An essential part of the process is interviewing eyewitnesses and victims (if they’re not too seriously injured). This is not an interrogation, and should be done in familiar surroundings to put the person as much at ease as possible. After all the facts have been gathered the causes can be examined.
Obvious causes: These usually are easy to find. They are brought about by an unsafe act or condition.
Root causes: These are personal or job factors brought about by faulty equipment, environmental conditions, or failures in the organization’s safety program. This can include lack of supervision or discipline, lack of training and/or lack of management awareness.
The findings of every accident investigation must be recorded in a systematic way to enable the report to be read by the people who are responsible for reviewing and implementing necessary changes. Since good communication is a very important part of the safety effort, information about an accident and remedial actions should be passed to all relevant staff who might encounter similar incidents.
Positive results from a negative...
The Quiz
These questions are meant to help you remember what was discussed today — not to test your patience or challenge your intelligence. The answers are at the bottom of the page. Cover them up, and complete the quiz as quickly as you can.
The primary reason for an accident investigation is to prevent a similar occurrence in the future. 1
True False
When the root cause of an accident is determined, does it usually indicate that what happened was predictable and could have been prevented? 2
Yes No
3
Which of these is not a reason to conduct a workplace accident investigation:
A. To fulfill legal requirements.
B. To protect an organization’s public image.
C. To determine the cost of an accident.
D. To process workers’ compensation claims.
Is the purpose of accident investigation procedures to lay blame for what happened? 4
Yes No
Which of the following are part of the accident investigation process: 5
A. Report the accident to a designated person within the organization.
B. Identify the causes.
C. Develop a plan for corrective action.
D. All of the above.
Does your organization have a written accident investigation procedure in place? 6
Yes No
Don’t Know
Publisher: Stefan Dreesen
Editor: Bryden Winsby
H&S Communication Specialists: Alan Haycroft | Liz Slobodin | Kevin Harvey TOLL FREE: 1-888-655-4800
Mailing Address: 2010 Winston Park Drive, Suite 200, Oakville, ON L6H 5R7 www.smartworkplace.ca | info@smartworkplace.ca
Hold These Thoughts !
Workplace accident reports are as important as any step in the accident investigation process. The report should include the who, what, where, when and to what extent, as well as recommendations for prevention of future accidents of the same nature.
If your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented.
Nevertheless, you should be aware of, and try to overcome, shortcomings such as:
• If a limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to “use back of form if necessary.”
• If a checklist of causes is included, possible causes not listed may be overlooked.
• Headings such as “unsafe condition” will usually elicit a single response even when more than one unsafe condition exists.
• Differentiating between “primary cause” and “contributing factors” can be misleading.
All accident causes are important and warrant consideration for possible corrective action.Your previously prepared draft of the sequence of events can now be used to describe what happened.
Remember that readers of your report do not have the intimate knowledge of the accident that you have so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.
If doubt exists about any particular part, say so. The reasons for your conclusions should be stated and followed by your recommendations. Weed out extra material that is not required for a full understanding of the accident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere.
The measure of a good accident report is quality, not quantity.