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When conducting a formal root cause analysis, it can be difficult to resist the temptation to only pursue the most obvious of root causes: employee behavior. Behavior is easily criticized in hindsight, but the distance between causality and failure is neither proximal nor linear. Certainly, unsafe employee behavior, whether intentional or not, contributes to workplace incidents. However, making an immediate connection between an employee's action and an undesired consequence based on intuition or perception reveals more about a management system's failures than anything else. Behavior is often impulsively and erroneously targeted because of the proximity between actions and outcomes, when in reality the true root causes are buried far from view beneath multiple layers of casual factors.
Assumptions in the Field
The assumptive mind-set, no matter how innocuous, is a dangerous thing. It can steer event timelines to fit investigator biases and develop self-gratifying narratives regardless of tangible evidence or objective fact. This is especially true when examining incidents involving an employee's actions. Assumption is a means to ignore (consciously or unconsciously) the organizational inadequacies or professional shortcomings of the management system to which one is accountable, whether it reflects a poorly devised investigative tool, a limitation in investigative expertise, or the fear of reprisal. Applying speculative behavior has no place in the professional setting, where the consequences of instant unverified postulation can result in the loss of employment, revenue, reputation or, most importantly, life.
Examining employee behavior can be an easy starting point for a rootcause analysis, although investigations have an obligation to venture beyond this point. In the author's experience, employee behavior will be promoted as a sole leading root cause by someone on an investigative team. It follows a predictable process: a behavior is identified, an assumption about the outcome follows suit and an inadequate root cause is put forward based on the limited scope of analysis.
This flawed reasoning was exemplified in a real-life investigation of an OSHA-recordable hand injury. The assigned task required moving a heavy object (> 200 lb) from one area to another. After a quick risk assessment, the responsible employee began to pull the object toward the desired location as it was too heavy to manually lift. Unfortunately, the object was off-kilter in its initial condition and...