12/09/2026
FISHBONE ANALYSIS IN HSE: LOOK BEYOND THE INCIDENT
In HSE, incident investigation should not stop at:
“What happened?”
The more important question is:
“Why did it happen?”
A professional investigation must identify not only the immediate cause, but also the contributing and underlying/root causes that allowed the incident to occur.
One powerful tool for this is Fishbone Analysis, also known as the Ishikawa Diagram or Cause-and-Effect Diagram.
It provides a structured way to identify and analyze potential causes of an incident, accident, non-conformity, or workplace problem.
The 6M Approach
👥 People – Competence, training, communication, supervision, workload and human factors.
⚙️ Process – SOPs, work instructions, risk assessments, JSA, permits, standards and compliance.
🔧 Equipment – Design, maintenance, inspection, tools, guarding, reliability and availability.
📦 Materials – Quality, specifications, storage, handling, labelling and chemical compatibility.
🌍 Environment – Lighting, temperature, ventilation, noise, housekeeping, workplace layout and weather.
🏢 Management – Leadership, resources, planning, competency, monitoring, auditing, contractor management and safety culture.
Don't Stop at “Human Error”
For example, if a worker is injured because PPE was not used, simply concluding:
“Worker failed to wear PPE.”
may not be enough.
A deeper investigation should ask:
Was the correct PPE available?
Was the worker trained?
Was the PPE suitable for the hazard?
Was supervision adequate?
Was PPE use included in the risk assessment?
Was compliance being monitored?
Why did the existing controls fail?
This moves the investigation from blame to prevention.
Fishbone + 5 Why
Fishbone Analysis helps identify different categories of potential causes, while the 5 Why technique can be used to drill deeper into a specific causal chain.
However, potential causes should always be validated with evidence, such as:
📄 Procedures
📋 Risk assessments
🔧 Maintenance records
🎓 Training records
📹 CCTV
🗣️ Witness interviews
📑 Inspection reports
📸 Photographs
The Ultimate Objective
A good Root Cause Analysis should lead to effective corrective and preventive actions, not simply a completed investigation report.
Where appropriate, corrective actions should follow the Hierarchy of Controls:
1️⃣ Elimination
2️⃣ Substitution
3️⃣ Engineering Controls
4️⃣ Administrative Controls
5️⃣ PPE
Don't just fix the symptom — control the cause.
The purpose of incident investigation is not to find someone to blame.
It is to understand why the system allowed the incident to happen and implement controls that prevent recurrence.
Remember:
“An incident is the symptom. Root Cause Analysis helps us understand the system that allowed it to happen.”
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