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716 Safety Management System Evaluation
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Underlying Root Causes

By analyzing the information collected in the baseline survey and program analysis, we can identify the root causes of various symptoms.

program binders
Missing or inadequate positions, policies, programs, plans, processes, procedures, and practices are all root causes for accident.

This analysis can help us determine if certain programs or parts of programs are missing or don't exist at all.

System Design Weaknesses

Design weaknesses are basically a failure to plan the work. They describe the overall "condition" of the SMS. They also represent the "deep" root causes for the symptoms above. Characteristics of system design failures include:

  • Missing or inadequate positions, policies, programs, plans, processes, procedures, and practices
  • Missing or inadequate resources - money, time, people, materials, etc.

The resulting effects of a system that is not designed adequately are system performance failures.

System Performance Weaknesses

Performance weaknesses describe a failure to work the plan. The system fails to "behave" properly. The system's behavior is a function of the performance of the people within the system. Characteristics of system performance failures include:

  • Failure to effectively accomplish safety policies, plans, processes, procedures or practices. For instance, supervisors may not be performing safety inspections as required.
  • Failure to provide training, resources, enforcement, supervision, and leadership. For example, although it's required by the training plan, written tests are not being administered during lockout/tagout training.

Why is conducting a baseline survey important? Conducting a baseline survey and program analysis can provide safety staff with valuable information to develop solutions and recommendations that can improve employee safety. It's essential to understand that every effect has a cause, and the survey can help identify hidden root causes.

Knowledge Check Choose the best answer for the question.

2-6. Failure to conduct safety inspections as required is a good example of _____.