forck - systematic methods to address root and contributing causes.pptx

8/17/2019 Forck - Systematic Methods to Address Root and Contributing Causes.pptx

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Systematic Methods To

Address Root AndContributing Causes

Expectations inNRC Inspection Procedures 95! and95"

#rederic$ %& #orc$4' onsu(ting) **C


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+sing Too(s

+SE A T,,* +SE A T,,* T, -+I*.


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+sing Cause Ana(ysis Too(s

CA+SE ANA*/SIS T,,*S +SE T,,*S T, REC,NSTR+CT

!& #au(t tree ana(ysis"& Critica( incident techni0ues1& E2ents 3 causa( 4actors

ana(ysis& Pareto Ana(ysis5& Change ana(ysis6& -arrier ana(ysis7& Management ,2ersight 3

Ris$ Tree 8M,RT ana(ysis:& ;hy Staircase

NRC IP 95!


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Systematic E2a(uation Norma((yInc(udes<

Clearly identify problem State assumptions Data

Timely collection

Verification Preserve evidence Document analysis so

•Progression of the problem

is clearly understood

•

Any missing information orinconsistencies are identified

•Problem can be easily explained

and/or

understood by others

Determine cause & effect

relationships resulting in dentification of root and contributing

causes that

Consider the follo!ing typesof issues"• #ard!are" design$ materials$ systems aging$

and environmental conditions%

• Process" procedures$ !or practices$

operational policies$ supervision and oversight$

preventive and corrective maintenanceprograms$ and 'uality control methods% and

• #uman performance" training$ communications$

human(system interface$ and fitness for duty

)!hich includes managing fatigue*+

NRC IP 95!


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-asic In2estigation Steps

Recommend correcti2e actions

.isco2er causes&

Reconstruct the incident&

=ather in4ormation


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Continuous PerformanceImprovement

ProblemPrevention

Symptom/Eect Analysis

CauseAnalysis

SolutionAnalysis

Follow UpAnalysis

A2atar Internationa( Inc&) !9:5

I n c i d e n t

ProblemPrevention

Symptom/EffectAnalysis

CauseAnalysis

SolutionAnalysis

Follow UpAnalysis


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=enera( %ob>Tas$ Ana(ysis

.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis

Process


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Instructions, Proceures, ! "rawin#sCriterion $ of Appeni% & to '(CF)*(

;ritten #o((oed

Inclue AcceptanceCriteria

!C#R5) App& -Ca((aay P(ant Lead Auditor

Training


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,2era(( Method Steps & Techni0ues

.eri2ed 4rom!& INP, 9?

"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis

Process


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SC+PE -E P)+&.E0Step '1


Process

Techni0ues•Deviation Statement •Diference Mapping•Problem Description•Extent o ConditionRevie!

•Met"odology Selection


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EBecti2e Prob(em .escription

dentify the GAP" 1hat is the Problem2

Metod !" Deviation Statement )noun/verb*

#$%EC&" What is te item tat is affected'

(EFEC&" Identify te )(E*IA&I#+, from te )E-PEC&E(, or ).EUI.E( S&A+(A.( of PE.F#.MA+CE0,

E1ample" Five 2allons of oil spilled 3defect4

on te )$, Emer2ency (iesel Generator room floor 3ob5ect4 0

#. Use"

Metod 6" .xpected vs+ Actual Statement

Compare )78A& S8#U9( $E,:" .e;uirement< Standard< +orm< or E1pectation

!ith

)78A& IS," &e e1istin2< as=found condition,

3Sometimes the 41hat Should 5e6 is implied+

-PI Problem Solving#Decision Ma$ing#Planning

'epner?Tregoe)T"e %e! Rational Manager


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@,;< Extent o4 2Averse3Condition E2a(uate ,N*/ 4rom Prob(em .escription

Perspecti2e

Then e2a(uate 2arious combinations• Same Same Same• Same Same Simi(ar

• Simi(ar

Same

Same• Simi(ar Simi(ar Same• etc&

.ocument the basis 4or bounding iththe associated ris$ and conse0uence

.e2iation Statement< &b'ect Deect Application

SameSameSame

An Identica( &b'ect

in an E0ui2a(ent Application

ith a Matching Deect

SameSameSimilar

An Identica( &b'ect in an E0ui2a(ent Application

ith a Re(ated Deect

SimilarSameSame

A Comparab(e &b'ect

in an E0ui2a(ent Application

ith a Matching Deect *eis A((en ) STP) !5th Annua( @PRCT


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-ow to o an E%tent of Conition )eview

@uman Per4ormance Too(

Peer Chec$


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In4ormation =athering Strategy

'8 "etermine 9ow best to :ll your information nees88In4ormation you ha2e 2s& In4ormation you sti(( need• re2ie o4 (ogsheets) charts) draings) etc&

• area a($dons

• inter2ies

•.ecide ho to inter2ie and hat you hope to (earn 4rom them&

78 "etermine w9ic9 information to pursue :rst8

Considerations


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@o is Interviewin# done

Close


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woPron#e

Approac9 toIncient

Prevention

)e

Adapted 4rom INP, 6?

1

@uman #actors ProngSystem ,actors Prong


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Factor ree

P"oenix ,andboo$ ) Corcoran.ana Coo(ey


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)EC+5S)UC -E S+)= 0Step ;1

Techni0ues•0ault Tree•Tas$ Analysis•Critical ActivityC"arting• Actions + 0actors C"art


Process


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Adapted 4rom Ca((aay P(ant F#au(t Tree Ana(ysisG Training

-umanac9ine Interface


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: Steps o4 #au(t TreeAna(ysis

Step 1:

Identify the

Undesirable

Incident

Step 2:

Identify

1st Level

Inputs

Step 7:

InvestigateRemaining

Inputs

Step 6:

DevelpRemaining

Inputs

Step !:

"valuate

Inputs

Step #:

Lin$ Using

Lgic %ates

Step &:

Identify

2nd Level

Inputs

Step ':Determine

(ntributing)actrs

*+hysical

Rts,

0ault Tree Analysis) C(emensCa((aay P(ant F#au(t Tree Ana(ysisG Training

ac or


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E;uipment

8uman=Macine

Interface

Pysical

.oots

8uman

.oots

.esponse

&in> 3#peration4

Stimulus

(efense=In=(ept

9atent

#r2ani?ational

7ea>nesses

9atent

.oots

ac orFlow


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@o is Tas$ Ana(ysis done

Step 1:Obtain

Preliminary

Information

Step 2:Select

Task(s) of

Interest

Step 3:Obtain

Backgron!

Information

Step ":Prepare a Task

Performance

#i!e

Step $:

%&alate '

Integrate

in!ings

Step :

*eenact

Task

Performance

Step +:

Select

Personnel

Step ,:

#et amiliar

-it. t.e

#i!e

Step /:Inter&ie0

Personnel

(/lternate

et.o!)

Paper & Pencil P.ase

Walk-Through Phase

.,E?NE?ST.?!?9"


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Critica( @uman Action Concept

Note< Not a(( steps o4 a or$ acti2ity

are e0ua((y important&

Critica( @uman Actions 8steps inc(ude<• Actions aimed at changing the state o4

4aci(ity structures) systems) or components

• Steps that are irreco2erab(e or

actions that cannot be re2ersed• Steps here the outcome o4 an error

is into(erab(e 4or personne( or 4aci(ity sa4ety

&hano2er&go2

NRC N+RE=>CR?555) %RC ,P(P


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A >Critical> -uman Action IS<

A step in the acti2ity that caused or cou(d ha2emade the incident (ess se2ere&It is a C@A i4 the step<

Might cause an incident i4 the step is not done Might cause an incident i4 an error is made

Might cause an incident i4 done some other ay

Ma$es incident (ess se2ere i4 done the right ay&

Cou(d be a FCritica( StepG re(ated to the incident

NRC N+RE=>CR?555) %RC ,P(P


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=enera( Systems Ana(ysisE2ents 3 Causa( #actors Charting

Action Action Action Action

Adapted 4rom .,E Accident In2estigation Program

@o did the 4actors originate

Incident

Institutional

Causes

;hat systems a((oed The Conditions toexist

Factor

Process

Causes

?or@ActivityCauses

Factor

Contributin2

Factor

;hy did thisIncidenthappen

Contributin2Factor

Contributin2

Factor


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6eneral Format


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ESA&.IS- C+5)I&UI56FAC+)S 0Step 41

Techni0ues•C"ange Analysis•1arrier Analysis•Production.ProtectionStrategy )Deense#(n#Dept"- Analysis

•0actor Tree

.eri2ed 4rom!& INP, 9?"& N+RE=>CR?555) NRC @PIP1& Entergy Root Cause Analysis Process


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-ow is C9an#e Analysisone

'

7

; 4 * B

E2a(uate by as$ing these 0uestions<• ;hat as diBerent about this time 4rom a((

the other times the same hardare

operated ithout a prob(em or the sametas$ or acti2ity as carried out ithouterror

• ;hy no and not be4ore• ;hy here and not there

Root Cause Ana(ysis Training Course CAP?") Pa(o Jerde Nuc(ear =enerating Station

Ammerman) T"e Root Cause Analysis ,andboo$


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Ientify )is@ "efenses0&arriers ! Controls1

.ocalFactorControl

En#ineere

&arriers

AminControl

s

+versi#9t

ControlsCulturalControls

.liminate tas+

Prevent error+

Catch error+

Detect defect+

7itigate harm+

Accept ris>0

)Carelessness and overconfidence are more dan2erous tan deliberately accepted ris>0,

Wilbur Wright, 1901 )&4aa&go2Muschara) Managing Critical Steps) @PRCT"9

Muschara) Managing Deenses2 @PRCT ":


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Systematic &arrier Analysis

Identi4y each Target o4 haDards>threats& Identi4y each @aDard 8ad2erse eBect>conse0uence Identi4y -arriers that shou(d ha2e contro((ed @aDard

• Pre2ented contact beteen @aDard and Target ,R• Mitigated conse0uences o4 @aDard>Target contact

Assign a Sa4ety Precedence Se0uence K to each-arrier

Assess -+? -arrier 4ai(ed• not pro2ided>missing 8not in p(ace• not used>circum2ented 8but ere in p(ace• ineBecti2e

.etermine ?-= -arrier 4ai(ed 8Step 5 Ja(idate ana(ysis resu(ts Integrate this in4ormation in E 3 C# Chart

Ammerman) T"e Root Cause Analysis ,andboo$

AS


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System Safety "esi#n +rer +fPreceence

!& E(iminate haDards through design se(ection

"& Incorporate Sa4ety .e2ices

1& Pro2ide ;arning .e2ices

& +se Procedures 3 Administrati2e Contro(s

5& Se(ect) train) super2ise) and moti2ate to or$

sa4e(y6& Accept ris$s at appropriate management (e2e(

MI*?ST.?

::".

M,STE##ECTIJE

*EASTE##ECTIJE

*,; @+MANINTER#ACE

@I=@ @+MANINTER#ACE


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"efense Analysis Form

Ammerman) T"e Root Cause Analysis

,andboo$ AS

.,,.CT/C89S.:.9C.S

)1hat #appened*

0ist one at time(

se'uential order

not re'uired

5A--.-/C89T-80 T#ATS#80D #AV. P-.C0D.D

T#. 9CD.9T

list all applicable physical and

administrative defenses for each

conse'uence


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Examp(e

&sandia&go2

&sandia&go2


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on r u n# ausa ac or


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on r u n# ausa ac orestIentify Contributin# InDuences

Evaluate factors 3ovals4 and flawed defense 3bro>en barriers4 on te Actions @ Factors Cart by as>in2"• If tis factor ad not e1isted< could tis incident ave occurred'• If te answer is no< ten youre on your way toward findin2 a )Contributin2 Factor,B

NRC Inspection Procedure 95!


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$A.I"AE U5"E).=I56 FAC+)S0Step *1

Techni0ues•*,3 0actor Staircase• A#1#C Analysis•,&*#To#*,3 Matrix

•Cause + Efect Tree•Root Cause Test •Root Cause Evaluation•Extent o CauseRevie!•Common 0actor Analysis


Process


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9e ?-= Factor

Staircase

ncident

.xecution Preparation ,eedbac

Capabilities/0imitations Tas Demands/.nvironment

8utcomes 7ethods -esources

Plan/Do/Chec/Act

Vision 5eliefs Values

P"oenix ,andboo$ ) Corcoran

Root Cause2 Martin) @PRCT "6


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Culture


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Active Error Analysis

obPerformer

&e9avio

r

6oals !$alues

&usiness

)esults

INP, ,uman Perormance 0undamentalsCourse

Pre(;ob

5rief

T1 9

Analysis

Tas

Previe!

Post(;ob

-evie! I n c i d e n t

)e


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9e A&CGsH'st +ccurrence

.esired beha2ior< ;ear sa4ety g(asses

Consequences for current or past behaviors have

the strongest influence on our future behavior.

Perormance Management2.anie(s

0oundations o 1e"avioral Accident Prevention4 Eagles Management Support Course)

-ST) Inc&

A• Sa4ety po(icy

• Sa4ety signs• Sa4ety procedure• Sa4ety brieng• %ust?in?time

training

&• ;ear sa4ety

g(asses

C• Ears hurt

• CanLt seec(ear(y

• +ncom4ortab(e• #ee( odd


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The FA?-?CLsG<Subse0uent ,ccurrence

.esired beha2ior< ;ear sa4ety g(asses

A• Peers donLt ear• Super2isors

occasiona((y donLtear

• *ea2e at home• Embarrassed to as$

4or spare pair

&• ;or$ >o sa4ety

g(asses

C• Ears donLt hurt• Can see c(ear(y• *ess bother

Consequences for current or past behaviors have

the strongest influence on our future behavior.

Perormance Management2

.anie(s

0oundations o 1e"avioral Accident Prevention4 Eagles Management Support Course)-ST) Inc&


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"efense ana#ement Analysis

Processes/Practices

as@s/&e9aviors

6oals/$alues

Resu(ts>

Conse0uences

Self(Chec

Peer Chec

< Part Communication

:uestioning Attitude

Stop=1hen nsure

Procedure seProcedure Adherence

Place(eeping 8bservations

Conservative Decision(7aing

1al(do!ns

Tas Previe!Pre(;ob 5rief

Turnover

neasy Attitude1ritten nstruction :uality

;ob Performer Sill$ >no!ledge$ Proficiency#ouseeeping

7orale

1or(Arounds & 5urdens

,itness(,or(Duty

Tool :uality & Availability

.'uipment 0abeling & Condition

.'uipment .rgonomics

1al(do!ns

0ocout(Tagout

Tas 'ualifications

Tas assignment

Performance ,eedbac

Post(;ob Criti'ues-oot Cause Analysis

Tas assignmentPerformance ndicators

ndependent Verificationnterlocs

Alarms

Personal Protective

.'uipment

-edundant trains

Containment

.'uipment Protection Systems

5erms

.'uipment -eliability

Safeguards .'uipmentndependent 8versight

Continuous 0earning

Staffing

Problem(Solving

Accountability

5enchmaring

Clear .xpectations

Communication Practices -evie!s & Approvals

7anagement Practices

Change 7anagement

-e!ards & -einforcement

#andoffs

Simple$ .ffective Processes

INP, ,uman Perormance 0undamentalsCourse

I n c i d e n t

.e4ense In .epth*eadership


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"eeper Unerstanin#

a e y u ure enera


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a e y u ure eneraree

NRC IM Chapter 15 Areas

Sa4ety Cu(ture


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Sa4ety Cu(tureAna(ysis

NRC IMC 15

as@s/

&e9aviors

Processes/

Practices

6oals/$alues

Do Last!!!


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)oot Cause est

Adapted 4rom or$ o4 .r& ;i((iam R& Corcoran) NSRCCorp&

w % u


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w % u)eview

@uman Per4ormance Too(

Peer Chec$


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Common Factor Analysis Steps

Adapted 4rom (ncident (nvestigation Training) Ca((aay

P(ant

Step !

(etermine te

Scope of

te CFA

Step

(etermine 7ic

Information to

Evaluate

Step 6

Gater

(ata

Step D

Cate2ori?e

te (ata

Step

Identify Areas

for Furter

Analyses

Step Analy?e

Areas of

Interest

Step (evelop and

*alidate Causal

&eories

Step HPlan

Corrective

Actions

Step

.eport

9earnin2s


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P.A5 C+))ECI$E ACI+5S0Step B1

Techni0ues• Action Plan•Solution SelectionTree

•Solution SelectionMatrix •C"ange Management • Active Coac"ing Plan•S5M5A5R5T5E5R5•Efectiveness Revie!

•Contingency Plan•Communication Plan


Process

. ( i A C ti A ti P(


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.e2e(oping A Correcti2e Action P(an To Pre2ent Recurrence

P(an 4or contingencies&

Map out imp(ementation o4 inter2entions>actionsthat i(( pre2ent or mitigate recurrence&

.ecide hich a(ternati2es i(( be recommended to management&

Ensure correcti2e actions address the under(ying 4actors 6i5e5 t"eroot cause)s-75

E2a(uate a(ternati2e courses o4 action&

.e2e(op a(ternati2e actions hich address the under(ying 4actors6i5e5 t"e root cause)s-75


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The Success Cyc(e

& 9 i C9


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&e9avior C9an#eInstitutionaliJation Plan 7o 7en

,actor/Cause5eing Addressed

CorrectiveAction Step

?+ -ightPicture

@+ Communicate


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S88A8)88E8)8 Criteria

• 1 h a t e x a c t l y n e e d s t o b e d o n e 2 , o c u s o n r e s u l t s + • 1 # 8 d o e s 1 # A T b y 1 # . 9

Specic

• D e s c r i b e s d e s i r e d b e h a v i o r s s o a n o b s e r v e r c a n c o m p a r e o b s e r v e d b e h a v i o r t o a d e s i r e d b e h a v i o r

Measurab(e

•

D o a b l e 2 , e a s i b l e 2 - e a l i s t i c 2 C o s t / 5 e n e f i t 2

• A g r e e d t o b y S t a & e h o l d e r 2 B o o d b u s i n e s s 2

Attainab(e • 0 o g i c a l t i e b e t ! e e n t h e p r o b l e m a n d c a u s e ) s * • 0 o g i c a l t i e b e t ! e e n c a u s e ) s * a n d c o r r e c t i v e a c t i o n s

Re(ated

• S h o u l d b e c o m p l e t e d b e f o r e n e x t 4 s h o t o n g o a l 6 • f n o t $ i n t e r i m c o r r e c t i v e a c t i o n s a r e n e e d e d

Time?sensiti2e

• D e g r e e o f D e p e n d a b i l i t y / - e l i a b i l i t y • 0 e v e r a g e d s o l u t i o n ! + 5 e h a v i o r . n g i n e e r i n g 7 o d e l

EBecti2e

• 5 y S t a & e h o l d e r s 2 5 y S u b e c t 7 a t t e r . x p e r t s 2 • , o r n i n t e n d e d C o n s e ' u e n c e s 2

Re2ieed&han4ord&go2


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InstitutionaliJationPlan S88A8)88E8)8

1#8 1#.9

Cause>#actor-eing

Addressed

Correcti2e Action P(an To Pre2ent Recurrence

Specific Measurable Attainable .elated &imely Effective .eviewed,ne

r.ue.ate

'8 )i#9t Picture

78 Communicate

;8 onitor

48 Feebac@

Correcti2e Action


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MI*?ST.?::".

Correcti2e ActionEBecti2eness Sca(e

EBecti2eness Re2ie =enera(


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EBecti2eness Re2ie =enera(#(o


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8A8S88 Eectiveness Plan

• . e s c r i b e t h e m e a n s t h a t A i ( ( b e u s e d t o 2 e r i 4 y t h a t t h e a c t i o n s t a $ e n h a d t h e d e s i r e d o u t c o m e &

ET@,.

•

. e s c r i b e t h e p r o c e s s c h a r a c t e r i s t i c s

t o b e m o n i t o r e d o r e 2 a ( u a t e d &A TTRI-+TES

• E s t a b ( i s h t h e a c c e p t a n c e c r i t e r i a 4 o r t h e a t t r i b u t e s t o b e m o n i t o r e d o r e 2 a ( u a t e d &

S+CCESS

• . e C n e t h e o p t i m u m t i m e t o p e r 4 o r m t h e e B e c t i 2 e n e s s r e 2 i e A &

IME*INESS

=rand =u(4 Nuc(ear Station


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Performance Inicator "evelopment@o is it done

Improving Performance: How to Manage the White Space on the Organiation !hart, -ummler & 5rache

)EP+) .EA)5I56S


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)EP+) .EA)5I56S0Step L1

#orms•Report Template•8rade Cards.Scores"eets


Process


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Report Ansers =enera( uestions

The in2estigation i(( ha2e determined the4o((oing<

;hat as expected 8anticipatedconse0uences

;hat has happened 8rea(conse0uences

;hat cou(d ha2e happened 8potentia(conse0uences

Cause?eBect re(ations #au(ty>4ai(ed technica( e(ements8structures) systems) or

components Inappropriate actions 8human) management)

organiDationa(

IAEA?TEC.,C?!6


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Report Ansers Specic uestions

;hat as the %ob Per4ormer 4ocused onCou(d they do the %ob i4 their (i2es depended

on itE0ua((y 0ua(ied person (i$e(y to ma$e same

error;hat ere the 4actors that direct(y resu(ted in

the nature) the magnitude) the (ocation) andthe timing o4 the $ey conse0uences

;hat happens to them hen they do hatthey do

Mager 3 Pipe) Analy9ing Perormance ProblemsCorcoran ) P"oenix ,andboo$

.anie(s) Perormance Management


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Extent of Condition

Review Criteria

Obect

(Person Place T.ing)

!pplication

(/cti&ity orm it nction)

"efect

(la0 ailing eficiency)

Deviation Statement

Same=Same=SameAn dentical 8bect

in an .'uivalent Application !ith a 7atching Defect+

Same=Same=SimilarAn dentical 8bect

in an .'uivalent Application !ith a -elated Defect+

Similar=Same=SameA Comparable 8bect

in an .'uivalent Application

!ith a 7atching Defect+Similar=Same=Similar

A Comparable 8bectin an .'uivalent Application

!ith a -elated Defect+

Same=Similar=SameAn dentical 8bect

in a Corresponding Application !ith a 7atching Defect+

Similar=Similar=SameA Comparable 8bect

in a Corresponding Application !ith a 7atching Defect+

Same=Similar=SimilarAn dentical 8bect

in a Corresponding Application !ith a -elated Defect+

E t t f C diti Ob t ! li ti " f t


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Extent of Condition

Review Criteria

Obect

(Person Place T.ing)

!pplication

(/cti&ity orm it nction)

"efect

(la0 ailing eficiency)

Deviation Statement Driver’s Side Front Tire on

Rental Car

Parked in My Driveway Flat

Same=Same=SameAn dentical 8bect


?+ 8ther Tires on -ental Car

@+ Tires on Picup Truc

?+ Pared in 7y Drive!ay

@+ Pared in 7y Drive!ay

?+ ,lat

@+ ,lat

Same=Same=SimilarAn dentical 8bect


?+ 8ther Tires on -ental Car

@+ Tires on Picup Truc



?+ 0o! on Air

@+ 0o! on Air

Similar=Same=SameA Comparable 8bect


?+ Tires on 5oat Trailer

@+ Tires on 5icycle



?+ ,lat

@+ ,lat

Similar=Same=SimilarA Comparable 8bect


?+ Tires on 5oat Trailer

@+ Tires on 5icycle



?+ 0o! on Air

@+ 0o! on Air

Same=Similar=SameAn dentical 8bect

in a Corresponding Application

!ith a 7atching Defect+

?+ Car Spare Tire

@+ Tires on Sons Vehicle


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Fault ree Form

,R

,R

,R

,R

,R

Adapted 4rom Ca((aay P(ant F#au(t Tree Ana(ysisG Training


70/76

Tas$ Ana(ysis Techni0ue

(1)

Paper & Pencil Input

Steps in

Procedure

or Practice

(2)

Walk Through

by Analyst

or trained

individual

(!)

#uestions$

%onclusions about

ho task

as$should be

per'ored

;CN,C


71/76

Examp(e< Tas$ Ana(ysis Techni0ue

(1)

Paper & Pencil Input

Steps in

Procedure

or Practice

(2)

Walk Through

by Analyst

or trained

individual

(!)

#uestions$

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?+ 0ocate proper 4pig trap6+

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Examp(e< C9lorine an@erFill Critical -uman Activity

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Error Type< ;rong In4ormation ,btainedError .escription< ;rong ;eight EnteredConse0uence< A(arm does not sound be4ore tan$ero2er((s

Error Type< Chec$ ,mittedError .escription< Tan$er not monitored hi(e((ingConse0uence< *ea$s not detected ear(y


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Examp(e

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Factorstat Influence

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FailedPerformance

PastSuccessful

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(ifferenceor Can2e

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)Jes/9o*

7en ;ob Performercame in early toavoid the heat+

;ob Performerstarted day thesame time as co(

!orers+

9o co(!orers !ere available tohelp !ith the ob+

Jes+ 1orercame to !orearly$ so !as

!oring alone$carrying tools+

Supervision

.mployee didnot meet !ithsupervisor themorning of theaccident+

.mployee met !ithsupervisor todiscuss the days

!or activities+

1or activities !ere notdiscussed+

Jes+ 5ecause !orer came to !or early$ obhaEards !ere notdiscussed+

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E2ents 3 Causa( #actors Chart


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E2ents 3 Causa( #actors Charta4ter Change 3 -arrier Ana(ysis

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Prob(em Correction #(ochart


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Prob(em Correction #(ochart

EBecti2eness Re2ie .etai(ed


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EBecti2eness Re2ie .etai(ed#(o

forck - systematic methods to address root and contributing causes.pptx

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