Use root cause analysis to understand and improve process safety culture

Abstract This article describes the topics of root cause analysis and company culture. An evaluation of the root causes of incidents can help identify areas where the culture requires improvement. In addition, an analysis of the nature of root cause can help companies understand their culture. Following an incident, root cause analysis can be conducted for at least four levels of management, (a) line supervision, (b) facility management, (c) executive management, and (d) professionals who write and then implement regulations and standards. This article makes a distinction between root causes for occupational losses and for major process accidents; it emphasizes the teachings that improve one does not automatically improve the other. In other words, a root cause analysis program that addresses the behaviors that correct occupational safety problems may not help correct those behaviors that cause process safety incidents. Examples of how root cause analysis can help a company understand and improve its culture are provided. For instance, companies should recognize the need for both training and education. If process risk is to be reduced, employees need to be educated as well as trained because education creates new behaviors that allow for improved root cause analysis and the aversion of major events. © 2008 American Institute of Chemical Engineers Process Saf Prog 2008