Article by Bob Lapidus, CSP, CSMS

It is the rare organization that truly wants to know the real reasons for why losses are being sustained for two major reasons:

  1. The process is time-consuming
  2. The process may point fingers at someone other than the first-line employee,  meaning that management and supervision may actually have a role in why losses are being sustained – and they do not want to be held accountable

Historically, loss investigations targeted:

  1. The unsafe acts of employees
  2. The unsafe conditions in the work environment
  3. What the immediate supervisor did or did not do to prevent the employee from getting hurt

Even though these factors may play a role in any given loss, we do not get very far by limiting our search to these three causation factors.  The true causes may come from other factors such as:

  1. Decision-making on the part of top, middle, and first-line management
  2. The lack of policies, procedures, and rules
  3. The lack of initial and refresher training regarding knowledge, skills and judgement regarding policies, procedures, and rules
  4. Non-enforcement by all levels in the organization of the established policies, procedures, and rules
  5. Failure to hold people accountable for working safely both in terms of praise for doing what is wanted and coaching and correcting for not working safely
  6. Physical and/or mental issues
  7. Not purchasing the right and safe equipment

For those organizations that decide they want to identify the true foundational causes that lie beneath why their losses have occurred, digging deeper may provide answers that could reduce the frequency of losses. The real reasons for these causes provide the organization with the essence of why the identified problems exist.  Accordingly, it may be possible to develop more effective solutions to eliminate or mitigate these problems.

Ask the question why for each initially-identified cause.  For example:

# Identified Causes Dig Deeper
1 Employee made an incorrect decision Why did the employee make an incorrect decision?
2 Managers and/or supervisors placed unreasonable pressures or demands on employees Why did the managers and/or supervisors place unreasonable pressures or demands on employees?
3 Lack of sufficient training Why was there insufficient training?

Answers to your “why” questions may trigger additional questions. The idea is to find the variety of causes involved in a given loss.


  1. Digging deeper may threaten some people in the organization.  Oftentimes, such analyses identify problems in the organization that some people would rather not emphasize.
  2. Do not attempt digging deeper without top management’s thorough support.
“Depending on your situation, it might not be wise to use the whys.”  
Curtis Christy with Contra Costa County

The idea is to seek to prevent similar losses from being sustained.  Digging deeper to identify the causes and their respective solutions, and then taking positive action will do much to help your safety efforts.

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For more information:

To become part of discussions on topics like the one above, go to www.safetycenter.org to obtain information about Safety Center’s Safety Management Specialist Certificate.

After completing this nine-day program, graduates may take the exam to achieve the Certified Safety Management Specialist (CSMS) designation.  Once this certification is achieved, successful candidates keep it for the rest of their live without any additional requirements or fees.