April 28, 2008 | Mark Paradies

Monday Accident & Lessons Learned: Simple Construction Fatality Investigation – Were the Root Causes Identified?

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WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:


Here is a link to the audio slide show:


Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

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