This document discusses root cause analysis and accident investigation. It provides definitions and outlines the process for investigating accidents, including notification, fact-finding, analysis and corrective action. Key aspects covered include identifying direct and root causes, common errors in investigations, and tools for analysis like events and conditions charting, fishbone diagrams and the 5 whys technique. The goal is to develop effective corrective measures by thoroughly understanding causal factors in order to prevent future accidents.

1. Accident Investigation &Root Cause AnalysisSteve Madsen

2. Food for thought Big things go wrong because we don’t act on small things.

3. Food for thought “Only investigating big things will insure that you’ll continue to have big things.”

5. Root Cause Analysis Defined A Structured Investigation that Aims To Identify The True Causes Of A Problem, and The Actions Necessary To Eliminate Them.

6. Work Organization Work Environment Work Space Conditions Behaviors Goal: Smooth Flow of Profitable Production Accidents

7. Weeding

8. Direct Causes of Injury/Illness Strains Burns Cuts “Weeding Out” The Causes Of Injuries And Illnesses Surface Causes of the Accident Conditions Behaviors Root Causes of the Accident

9. Accident Investigations Why Investigate Benefits Who Investigates Current Effectiveness Common Errors Obstacles

10. Why Investigate Accidents? Protect people, Property, and Communities Data for trending ID Deficiencies in Safety Programs Morale Stimulate Interest in Safety Legal considerations: Quality of the information Ensuring that we correctly identified deficiencies

12. Develop “Effective” Corrective/Preventive Measures to Prevent Recurrence

13. Improve Effectiveness of Management Systems

14. Share Lessons Learned

15. Improve Safety Performance

16. Reduce Direct & Indirect Accident Costs

17. Improve Efficiency, Productivity, Profitability & Morale

18. Enhance Product Quality & Public Image

19. Demonstrate Commitment To Continual ImprovementBenefits

21. Complexity of conditions/operations/hazards

23. Time Information Company Culture Obstacles

24. Facilities Temperature Environment Methods Rules Procedures Agents Atmosphere System Faults Supervision Polices System Faults Accident Output Input System Faults System Faults Equipment Training Personnel Fatigue Guards Machinery Protection Fitness Materials Product Accident Causation Model

25. Accident Investigation Process Notification Analysis Response Follow-Up Corrective Action Fact-Finding

26. Notification Phase Do we have effective processes in place to encourage immediate reporting of incidents to the stakeholders? Plan to notify the right people? What is the Flow of information? Are we identifying and removing barriers to reporting? Back-up plans in place?

28. Eliminate obvious hazards - don’t wait for investigation process to control a known hazard.

29. Determine if the area needs to be secured:

30. unsafe conditions exist

31. critical evidence needs to be preserved

32. possible third party involvement

34. Who, What, Where, When , Why, How

35. Keep Probing for More Information

36. “What else can you tell me that might have been a factor ?”

37. Don’t jump to conclusions and recommendations too quickly

38. Avoid the “quick fix” if a system problem exists.

39. Video/Photograph/Diagram scene

41. Interview Techniques Conduct the interview as soon as possible after the incident. Create a relaxed atmosphere, avoid blame, get all sides and request ideas for prevention. Keep the interview private to avoid group biases.

42. Interview Techniques Look for facts, beware of smoke screen. Listen, test, investigate and validate all evidence. Repeat the story back, probe into all aspects of the non-conformance or accident, get all sides of the story. Have witnesses sign their statements.

44. Unique hazardous conditions

45. Individual unsafe behaviors

46. Events occur close to the injury event

47. Controllable or uncontrollable factors

48. Failure to perform safety practices, procedures, processes

50. Specific hazardous conditions

51. Individual unsafe behaviors

52. Events occur distant to the injury event

53. Controllable or uncontrollable factors

54. Failure to perform safety practices, procedures, processes

56. Inadequate implementation of safety policies, programs, plans

57. Inadequate design of processes & procedures

58. Pre-exist the surfaces causes

59. Controllable

61. Pre-exist all other causes

62. Controllable

63. CEO, Top management – anytime, anywhereInadequate training No recognition No discipline procedures Inadequate labeling No orientation process Outdated hazcom program No recognition plan Inadequate training plan No inspection policy No accountability policy Lack of vision

64. Root Cause Analysis Tools Events & Condition Charting Fishbone Diagrams Cause & Effect Model – “5 Whys”

66. In the sequence they occurred

67. Additional known conditions

68. Deviation or change from expected step or actionFoundation for investigation organization Condition Condition Condition Event Event Event

69. 6:56 am John Doe reports to work Obtain fuse from store room Tagged out fuse box Replaced fuse Energized System John assigned to change fuse Tied out the interlocks Put meter across fuse John open fuse box System not functioning Fireball exploded in John’s face Events & Condition Charting Events-"Who did What“ action statements that describe what led up to the incident . Include one action per box. Quantify when possible. Use precise factual words. What action happened next? Arrange chronologically Times can be added to chart.

70. Events & Condition Charting Conditions - Amplify or explain the event For each event box ask, "what else do I know about it?" Conditions are information, including problems, about an action Use precise, factual, non-judgmental words Quantify when possible Use dotted ovals for assumptions

71. Regular employee sick 6:56 am John Doe reports to work Obtain fuse from store room Tagged out fuse box Replaced fuse Energized System John assigned to change fuse Not supervised Wanted to check again Pressure to get back on line Defect not corrected System blowing fuse when starting System designed for continuous op Fuse out of date Meter not properly installed Tied out the interlocks Put meter across fuse John open fuse box System not functioning Fireball exploded in John’s face Did not follow procedures Lack of training Wanted to check voltage across line Did not follow procedures Fuse blown Not experienced Safety requirement Wanted to check it out Used 600 volt meter Events & Condition Charting

72. Regularemployee sick. 6:56 am John Doe reports to work Obtain fuse from store room Tagged out fuse box Replaced fuse Energized System John assigned to change fuse Not supervised Pressure to get back on line. Wanted to check again Defect not corrected System blowing fuse when starting Fuse out of date Meter not properly installed System designed for continuous op. CF CF CF CF CF CF Tied out the interlocks Put meter across fuse John open fuse box System not functioning Fireball exploded in John’s face Did not follow procedures Lack of training Wanted to check voltage across line Did not follow procedures Fuse blown Not experienced Wanted to check it out. Used 600 volt meter Safety requirement Events & Condition Charting

73. Regular employee sick. 6:56 am John Doe reports to work Obtain fuse from store room Tagged out fuse box Replaced fuse Energized System John assigned to change fuse Not supervised Pressure to get back on line. Wanted to check again Defect not corrected System blowing fuse when starting System designed for continuous op. Fuse out of date Meter not properly installed CF CF CF CF CF CF Tied out the interlocks Put meter across fuse John open fuse box System not functioning Fireball exploded in John’s face Did not follow procedures Lack of training Wanted to check voltage across line Did not follow procedures Fuse blown Not experienced Safety requirement Wanted to check it out. Used 600 volt meter Events & Condition Charting –Causal Factors

76. People Methods Roots Problem Equipment Environment Fishbone Diagram

78. Assists in categorizing many potential causes of problems in orderly way.

79. Start with categories – people, methods, environment, equipment, etc.

81. Cause & Effect Analysis – “5 Whys” Why? Why? Simply put, a ‘5 Why’ analysis adds discipline to the problem investigation to ensure that as many contributors as possible are reviewed up front. This makes it possible to create an action plan taking into account all the information . . . which should lead to much better results. Why? Why? Why?

82. Cause & Effect Analysis – “5 Whys”

85. Physical Changes Personnel Behavioral Environment Changes Program Procedure Changes Training Areas for Corrective Action

87. 32% were deficient

89. 23% were deficient

90. 24% included no solutionsSource: Hagan, P.(2001). Accident Prevention Manual – Administration & Programs, 12th Edition, National Safety Council, Itasca, IL

91. Areas for Corrective Action Environment Facilities Temperature Methods Rules Procedures Agents Atmosphere Supervision Polices System Faults System Faults Accident Output Input System Faults System Faults Personnel Training Fatigue Equipment Guards Machinery Protection Fitness Product Materials