How to find the reason behind a safety issue
When a safety concern comes to light, the first question transport management should ask is “why.”
This simple three-letter word often takes pages to completely answer. And even then, it may be an educated guess.
One model to help arrive at why a problem exists is root cause analysis (RCA). RCA helps single out and verify a primary reason for a problem area. Once the variable is removed from the process, the problem should (in theory) be eliminated.
RCA is a different discipline than problem-solving. Problem-solving looks for solutions and trouble-shoots, while RCA looks for the underlying issue.
The RCA model:
- Gathers all known facts,
- Identifies all possible causes,
- Narrows the list of possible causes, and
- Then verifies the root cause.
A root cause must be something that management has control to fix.
The RCA investigation
The RCA model helps managers investigate why a violation, commercial vehicle crash, or other safety issue occurred, and help ensure it does not occur in the future.
A team should be assembled to investigate the safety problem and consist of employees who understand the underlying issues surrounding the event.
During the analysis, the investigative team must:
- Stick to the facts,
- Identify the correct people to interview,
- Find out if the event or violation has occurred prior,
- Steer clear of jumping to conclusions right away, and
- Avoid trying to fix the problem too quickly.
A few methods can be used to perform a root cause analysis, including the 5 Whys model.
| Check out “Compliance, Safety, Accountability” for details on DOT’s safety analysis model. |
A solution based on the cause
When using the 5 Whys, you may find yourself sounding like a three-year-old. You drill down using a series of why questions until the root cause is revealed. You are not limited to 5 Why questions if it takes you longer to draw a conclusion.
Once you determine why an event occurred, you can offer a solution. However, you need to make sure that another problem isn’t created by providing countermeasures for this one. If possible, use quantifiable data to gauge the effectiveness of the new policy, procedure, training, or equipment.
5-why scenario
To better understand the 5-Why process, consider this scenario.
A self-audit reveals that your motor carrier’s motor vehicle records (MVRs) were consistently requested 30 days following a CDL driver’s medical exam. Your investigation starts out with an obvious question.
Why are MVR requested 30 days after a CDL driver’s physical rather than the required 15 days? The employee responsible for requesting the MVRs is also the carrier’s administrative assistant. When posed the question, her response was she thought she had 30 days.
Using the response to your first question, the follow-up questions might be:
Q: Why did the administrative assistant think she had 30 days to request the MVR?
A: She confused the 30 days for new-hire MVRs for your box-truck drivers (non-CDL) with the medical status MVRs for CDL drivers.
Q: Why did the administrative assistant confuse the regulations?
A: She was not formally trained in her DOT role.
Q: The supervisor was asked, why wasn’t the administrative assistant trained on her DOT role?
A: Her manager felt it was not necessary.
Q: Why did her manager feel it was not necessary?
A: It is only a small part of her job functions.
The root cause in this situation was poor or inadequate training because the supervisor was not identifying her DOT compliance role. If the employee was instructed on the timing of MVR requests, she may not have confused the two similar-but-different rules. Once trained, the violations should not recur.
If the administrative assistant is trained and the violations persist, you know that it was not the root cause. You should start a new list of questions. Suppose the new list showed, despite training, the primary issue was roles and responsibilities and priorities. The administrative assistant did not take her minor DOT role seriously since she is swamped with other tasks in the office. In that instance, the carrier must decide on how to handle the assigned role. Is it a corrective action since the administrative assistance isn’t following procedures for her role? Or does the carrier need to reassign of the role to another employee since the administrative assistant is burdened with so many other non-DOT tasks?
Whatever the decision, the motor carrier must monitor whether the solution corrected the problem.
Key to remember: Determining why a specific violation or safety event occurred requires asking the right questions of the right people and offering a solution to remedy the root problem.
























































