One of the Most Overlooked “Root Causes” of Loss Events
… properly trained at hire? Was the guard in the way? Was the operation of removing the guard a common practice? Were the rules adequately enforced? Many more questions arose – and all of them uncovered problems that led to physical and administrative improvements to prevent further disaster. Upon closer investigation, the root cause of this accident was the change in the process (the machine) without the necessary change in procedure. When clear expectations are not communicated, it is human nature to make assumptions. One of the corrective actions was to implement a change management plan. In an unrelated event, an automatic
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