Root Causes

Step 1 

Read the following scenario describing a workplace incident: Amy worked for Chris’s Catering, a small catering company that specializes in special events.10 On June 12, Amy was dispatched to work a small outdoor wedding taking place in a park overlooking the river. The size of the job called for two chefs in the kitchen (the husband and wife co-owners), one wait staff responsible for clearing plates after guests were finished, and two porters who would set up the serving tables and carry chafing dishes (hot metal pans for buffet-style serving) and other serving trays from the kitchen to the serving tables. Amy was assigned as a porter and was required to wear a short-sleeved black uniform with the company’s logo.

A Incident Investigation 199 The wedding was located outside a community hall. The kitchen was inside the hall. The buffet table was at the opposite end of the small park, about 100 metres away. It was a hot and sunny afternoon. The other designated porter, Andy, called in sick at the last minute, leaving Amy to do the job alone with occasional help from the wait staff. As the time of the reception neared, the chefs were running behind schedule. Amy began shuttling chafing dishes to the buffet table. The dishes weighed approximately 12 kg each when filled with food. Amy used dishcloths to protect her hands from the heat of the dishes. She delivered eight dishes to the table.

As Amy was about to place the ninth and final tray, containing a hot minestrone soup, she took a sudden step backward, bumping into a guest behind her. The collision caused Amy to lose control of the dish, which spilled over her and the guest. It also caused Amy to fall into the buffet table. Amy suffered a severely sprained ankle, burns on her arms, and some bruising to her face and arms. The guest also experienced some minor burns.

Step 2 Write 200-word answers to each of the follow questions:

1. How would you conduct the investigation? What tools and techniques you would use and who you would interview?

2. How you would analyze and report the information you gathered?

3. Identify the potential causes of the incident, distinguishing between proximate and root causes.

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