#Root causes
Root Causes mapping the subterranean venom of failures. Halting the pathetic witch-hunt of low-level scapegoats to slaughter the true 'pathogen'. Aggregates hacks pivoting blame to corroded tech logs or sloppy time-tables.
“Culture Eats Strategy for Breakfast”: How Safety Brings Back Production Targets
At Metalloinvest, the phased development of production culture—from stabilization to systematization—is directly linked to meeting production targets and achieving financial results. This approach helps move away from constant “firefighting” and build stable, systematic operations.
My Resource for Improving Safety
A ready-to-use practical exercise for developing critical thinking and a mindful approach to occupational safety. We break down the step-by-step "My Resource in Safety" case study: how to analyze recent violations in three stages, identify their internal and external causes, and outline concrete steps for personal and team growth.
The Psychology of Unsafe Employee Behavior
Why do employees continue to violate occupational safety requirements even under strict supervision? We examine the psychological and social causes of unsafe acts, explain why punishment without root cause analysis harms safety culture, and discuss how to improve human reliability.
AI as the Investigation Committee’s Assistant: From a Cloud Agent to Offline Incident Investigation
How we moved from our first cloud experiments to an operational “masking tool → AI agent → unmasking” workflow, then built a test offline investigation system, and are now preparing for the next step: Fire, a secure corporate AI environment.
Leadership: Do You Really Need It?
Transformation of safety culture at a large industrial enterprise through the transition from directive control to engaging leadership. Implementation of developmental feedback tools, behavioral safety audits, and Just Culture principles for proactive management of minor injuries and near misses.
Destructive Thinking Patterns: Who Hides the Truth During Investigations
A methodology for internal incident investigations that eliminates experts' cognitive biases. The approach is based on perceiving a person as an adapter of an imperfect system, rather than a mechanism, and avoiding evaluative words when formulating root causes.
The Swiss Cheese Model in Occupational Safety
The "Swiss cheese" concept, proposed by psychologist James Reason, explains how the overlap of vulnerabilities in different protection systems leads to industrial accidents. The article analyzes the functioning of the main levels of industrial safety — from design solutions to personal protective equipment — and the potential weaknesses of each of them. From the material, you will learn which practical methods, including barrier audits, redundancy of measures, and digitalization, help build a re...
Development of an Electronic Risk Register through the Improvement of HSE Tools
Integration of disconnected mobile and desktop occupational safety applications into a unified electronic risk register. Implementation of root cause analysis functionality and automatic selection of additional PPE based on identified occupational risks.
Regular Incident Analysis: From Blaming Individuals to Systemic Solutions
Traditional blame-seeking in occupational health and safety incidents is ineffective and is giving way to a systemic approach, where every incident is viewed as a symptom of deep organizational problems. Regular analysis of even minor incidents allows identifying up to 80% of potentially dangerous situations before they escalate into severe accidents. Such an approach transforms industrial safety from a formal procedure into a living system that reliably protects the lives and health of workers.
Incident Investigation: Not About Blame, But Hunting for Root Causes
The article explains why a punitive "find and punish" approach when investigating an industrial incident is dangerous, and how failures due to the "human factor" hide systemic flaws. The author shows how switching to a "search for causes" helps discover weak links in occupational health and safety and work organization. Using the "5 Whys" method as an example, it examines a way to find the root cause of an accident and eliminate a real threat in production.
Exercise for Practicing the Identification of Accident Causes: Immediate, Underlying, and Root
The publication presents a practical exercise for determining the immediate, underlying, and root causes of an accident using a case study as an example. Based on a story about a female employee being injured on stairs, it is proposed to analyze the combination of factors that led to the incident. At the end of the material, the author provides their own version of the analysis for checking and comparing the results obtained.
Immediate, Underlying, and Root Causes of an Accident?
The article explains the three-level classification of workplace accident causes — immediate, basic, and root — and explains why incident investigations should not be limited to recording obvious facts. The author shows how identifying deep systemic violations in occupational health and safety management helps eliminate the root causes of incidents instead of a formal search for culprits. Understanding the difference between these levels allows implementing sustainable corrective actions, improv...