accident investigation root cause analysis. identify three consistent and systematic approaches to...
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Accident Investigation Root Cause Analysis
Accident Investigation Root Cause Analysis
• Identify three consistent and systematic approaches to investigating workplace accidents.
• Understand how to apply these approaches to a workplace accident investigation.
Root Cause AnalysisObjectives
Root Cause AnalysisObjectives
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisOverview
Root Cause AnalysisOverview
•Interviews
•Photographs
•Equipment Specs.
•Equipment Manuals
•Safety Rules
•Training Records
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisData Collection
Root Cause AnalysisData Collection
•Organizes collected data for analysis
•Sequence diagram
•May uncover needs for additional data collection
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisEvent Charting
Root Cause AnalysisEvent Charting
Mary starts
cooking
Mary leaves kitchen
Smoke alarm
sounds
Mary enters
kitchen
Mary uses fire ext.
FE fails
Mary throws
water on fire
Fire spreads
Fire
starts
Mary calls 911
Fire department
arrives
FD puts out fire
Kitchen destroyed
Smoke damage throughout restaurant
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisEvent Charting
Root Cause AnalysisEvent Charting
Mary starts
cooking
Mary leaves kitchen
Smoke alarm
sounds
Mary enters
kitchen
Mary uses fire ext.
FE fails
Mary throws
water on fire
Fire spreads
Fire
starts
Mary calls 911
Fire department
arrives
FD puts out fire
Kitchen destroyed
Smoke damage throughout restaurant
Grease ignites on
burner
AL pan melts
Arcing heats pan
Electric burner
shorts out
FE not charged
Mary sees fire
Grease fire
Root Cause AnalysisEvent Charting
Root Cause AnalysisEvent Charting
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Phone rings in front of
restaurant
Casual Factors:
1. Direct Cause: Immediate event/ condition that caused accident)
2. Contributing Cause: Event/condition that increased probability or severity of the accident
3. Root Cause: Event/condition that, if corrected, will prevent recurrence
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisCausal Factor Analysis
Root Cause AnalysisCausal Factor Analysis
Potential Causal Factors:
• Lack of awareness
• Lack of safe work practices
• Lack of adherence/enforcement to safe work practices
• Improper/inadequate equipment/materials
• Improper/inadequate design
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisCausal Factor Analysis
Root Cause AnalysisCausal Factor Analysis
Mary starts
cooking
Mary leaves kitchen
Smoke alarm
sounds
Mary enters
kitchen
Mary uses fire ext.
FE fails
Mary throws
water on fire
Fire spreads
Fire
starts
Mary calls 911
Fire department
arrives
FD puts out fire
Kitchen destroyed
Smoke damage throughout restaurant
Grease ignites on
burner
AL pan melts
Arcing heats pan
Electric burner
shorts out
FE not charged
Mary sees fire
Grease fire
Root Cause AnalysisCausal Factor Analysis
Root Cause AnalysisCausal Factor Analysis
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Electric burner
shorts out
Mary leaves kitchen
FE not charged
Mary throws
water on fire
Phone rings in front of
restaurant
Used to identify deviations from the norm
• “What happened” vs. “What should have happened”
• Used mostly when operations and standardized
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisChange Analysis
Root Cause AnalysisChange Analysis
Common Changes and Differences:
• Personnel
• Plant
• Hardware
• Procedures
• Managerial Controls
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisChange Analysis
Root Cause AnalysisChange Analysis
Mary starts
cooking
Mary leaves kitchen
Smoke alarm
sounds
Mary enters
kitchen
Mary uses fire ext.
FE fails
Mary throws
water on fire
Fire spreads
Fire
starts
Mary calls 911
Fire department
arrives
FD puts out fire
Kitchen destroyed
Smoke damage throughout restaurant
Grease ignites on
burner
AL pan melts
Arcing heats pan
Electric burner
shorts out
FE not charged
Mary sees fire
Grease fire
Root Cause AnalysisChange Analysis
Root Cause AnalysisChange Analysis
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Electric burner
shorts out
Mary leaves kitchen
FE not charged
Mary throws
water on fire
Phone rings in front of
restaurant
Basic premise is that there is a flow of energy associated with all accidents– Kinetic– Potential– Electric– Thermal– Steam– Pressure
Barriers are placed to reduce the energy from people, property, environment.
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisBarrier Analysis
Root Cause AnalysisBarrier Analysis
Barrier Categories:
• Equipment
• Design
• Administration (procedures processes)
• Supervisory/Management
• Warning Devices
• Knowledge and Skills
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisBarrier Analysis
Root Cause AnalysisBarrier Analysis
Mary starts
cooking
Mary leaves kitchen
Smoke alarm
sounds
Mary enters
kitchen
Mary uses fire ext.
FE fails
Mary throws
water on fire
Fire spreads
Fire
starts
Mary calls 911
Fire department
arrives
FD puts out fire
Kitchen destroyed
Smoke damage throughout restaurant
Grease ignites on
burner
AL pan melts
Arcing heats pan
Electric burner
shorts out
FE not charged
Mary sees fire
Grease fire
Root Cause AnalysisBarrier Analysis
Root Cause AnalysisBarrier Analysis
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Electric burner
shorts out
Arcing heats pan
FE fails
Mary throws
water on fire
Electric burner
shorts out
Grease on burner ignites
Fire spreads
FD puts out fire
Mary leaves kitchen
Phone rings in front of
restaurant
Smoke alarm
sounds
Mary calls 911
Mary uses fire ext.
Root causes– Derived from the facts
and analysis conducted– Should answer two
questions:
1. What happened?
2. Why it happened?
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRoot Cause Identification
Root Cause AnalysisRoot Cause Identification
• Root causes should identify reasons for each casual factor identified by the analysis.
• Root causes which can not be completely supported by fact should identified in the report.
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRoot Cause Identification
Root Cause AnalysisRoot Cause Identification
• Unattended stove– Facility design less than adequate
– Lack of operational policy
• Heating element failure– Lack of preventative maintenance
program
– Facility design less than adequate (auto-suppression system)
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRoot Cause Identification
Root Cause AnalysisRoot Cause Identification
• Fire Extinguisher failure– Inadequate inspection program
• Water on grease fire– Inadequate training (abnormal
events)
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRoot Cause Identification
Root Cause AnalysisRoot Cause Identification
Identify the corrective actions for each cause.
Ensure the corrective action is viable by answering:
• Will the corrective action prevent recurrence?
• Is the corrective action feasible?
• Does the corrective action introduce new hazards/risks?
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRecommendations
Root Cause AnalysisRecommendations
• What are the consequences of not implementing the recommendations?
• What time frame is adequate to implement the recommendations?
• Is the implementation of the recommendations measurable?
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause AnalysisRecommendations
Root Cause AnalysisRecommendations
• Unattended stoveRC #1: Facility design less than
adequateRC #2: Lack of operation policy
• Install phone in kitchen• Implement policy that hot oil is never
left unattended (any other operations?)
• Modify procedure development process to identify and address potential emergencies and hazards (JSA).
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause Analysis Recommendations - Direct/Contributing Cause #1
Root Cause Analysis Recommendations - Direct/Contributing Cause #1
• Heating element failureRC #3: Lack of preventative maintenance
program• Develop preventative maintenance strategy
to periodically replace burner elements.
RC #4: Facility design less than adequate (auto-suppression system)
• Consider alternative preparation methods (baking) or alternative equipment (gas stove). Consider additional hazards these my introduce.
• Install commercial kitchen fire suppression system per building code.
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause Analysis Recommendations - Direct/Contributing Cause #2
Root Cause Analysis Recommendations - Direct/Contributing Cause #2
• Fire Extinguisher failureRC #5: Inadequate inspection program
• Refill/replace extinguisher.
• Inspect all extinguishers monthly/annually.
• Report incidences using extinguishers to owner to trigger refilling (training).
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause Analysis Recommendations - Direct/Contributing Cause #3
Root Cause Analysis Recommendations - Direct/Contributing Cause #3
• Water on grease fireRC #7: Inadequate training
• Review training program for adequacy (contingency plan in case of extinguisher failure).
• Provide hands-on training on fire extinguishers.
• Review other skill-based activities to ensure level of hands-on training is adequate.
Data Collection
Event Charting
Root Cause ID
Recommendations
Causal Factor Analysis
Barrier Analysis
Change Analysis
Root Cause Analysis Recommendations - Direct/Contributing Cause #4
Root Cause Analysis Recommendations - Direct/Contributing Cause #4
• Identify three consistent and systematic approaches to investigating workplace accidents.
• Understand how to apply these approaches to a workplace accident investigation.
Root Cause AnalysisObjectives
Root Cause AnalysisObjectives