What is the purpose of conducting root cause analysis after a safety incident, and which tool is commonly used in OJS?

• A. To assign blame to individuals; use a blame chart.
• B. To prevent recurrence; use the 5 Whys or Ishikawa diagram.
• C. To document the incident without changing processes; use a diary.
• D. To determine penalties for fault; use a risk matrix.

Answer: (B)

Root cause analysis after a safety incident focuses on finding the underlying factors in the system that allowed the incident to happen and on putting changes in place to prevent it from occurring again. In OJS, the 5 Whys and the Ishikawa (fishbone) diagram are commonly used because they help the team move beyond surface symptoms to deeper causes. The 5 Whys technique digs layer by layer by repeatedly asking why the incident occurred, which can reveal issues like gaps in training, unclear procedures, equipment maintenance lapses, or management expectations. The Ishikawa diagram organizes possible causes into categories such as people, processes, equipment, materials, environment, and management, showing how different parts of the system contribute to the event. Using these tools supports actionable corrective actions that improve safety and promote ongoing learning.

Options that emphasize blaming individuals, merely documenting the incident without changing processes, or assigning penalties don’t provide a structured method for preventing recurrence and aren’t aligned with the goal of root cause analysis.