scat investigations

P bar Y Safety Consultants Alberta Canada

S.C.A.T. that Incident Away

Reduce the Risk Increase the Performance in

Loss Prevention


S C A TSystematic

Cause Analysis

Technique

Accident/Incident InvestigationWhy because every day 104

people are injured on the Job Site


Seems Simple because it is!


SCAT Benefits• Excellent for checking investigation

effectiveness• A system for analyzing and evaluating causes• A system for developing control effectiveness• Reinforces the Principle of Multiple Causes• A reminder of causes and control of

accidental losses


Reasons for Inadequate Causal Identification

1. Failure to do a good investigation

2. Failure to take enough time

3. Failure to use a systematic approach

4. Forgetting previous training

5. Improper motivation


6. Lack of method for checking results

7. Identifying only obvious causes

8. Many causes easy to overlook

9. Some causes difficult to identify

10. Causes selected haphazardly

Reasons for Inadequate Causal Identification


Accidents

If someone says “I had an accident”

what assumptions do you make?


What is an accident?

• In the OSH setting– Unintended and untoward event – Unplanned, unexpected event, in a sequence of

events; it results in physical harm, injury or disease to an individual, damage to property, a near miss, a loss, or any combination of these effects

– A failure of a person to cope with the true situation presented to him.


Who cares?

• Victim• Governments• Researchers • Employers• Engineers, organisational psychologists, socioligists,

quality controllers, high risk industries• Safety managers and other OSH professionals


Accident Prevention

• Hazard Identification• Risk Assessment• Controls

• Tools for Occupational Health and Safety Management


OSH reasons for collecting accident information

• Analysis of past accidents, patterns and trends• Accident investigation • Accident notification requirements (the law)• Insurance company requirements – claims

management • Allocation of blame

• Collecting information = accident investigation


Accident Investigation

• Purpose– To prevent accidents happening in the future– To determine the immediate (proximate) AND the underlying

(distal or root) causes of accidents• Methods vary

– Systematic look at all contributing factors• Outcomes

– Focus on the root cause as opposed to the consequences or a scapegoat

– Conclusions linked to what actually happened – A list of recommendations for change


OSH law

• Injury and illness prevention is a legal requirement • Accident reporting to a competent authority is a legal

requirement• Accident investigation is not a legal requirement• Analysis of organisational data is not a legal

requirement


Accident Causation Models

• Heinrich’s domino model (1920s)• Bird’s loss control model (1960s)• Hale and Hale’s model (1971)• Reason’s organisational accidents model (1990s)

• There is NO universally accepted model• Causes are generally seen to be at individual level or

organisational level (work activity, working environment and organisational factors)


Accident Causation

• Accidents usually arise from a particular combination of circumstances, not from a single cause (but it is often necessary to attribute a principal cause)

• Accidents often preceded by near misses• No one causitive factor is implicated in all accidents• There are wide variations in the consequences of

similar accidents/incidents


BIRD Accident Triangle (1969)

1

10

30

600

Major injury

Minor injury

Damage only

No injury or damage


Principle of Multiple Causes

Accidents and other problems are seldom,

if ever, the result of a single cause.


Loss Causation Model

LOSSINCIDENTIMMEDIATE CAUSES

BASICCAUSES

LACK OFCONTROL

UnintendedHarm and / orDamage

Event

SubstandardPractices,Acts& Conditions

Personal&Job/SystemFactors

Inadequate:

System

SystemStandards

Complianceto SystemStandards

Threshold Limit



LOSS

UnintendedHarm and / orDamage

• People• Property• Process• Product• Planet• Profit



INCIDENT

EVENT

Events are NormallyContacts with an Energy Source or Substance:

Struck Against Caught InStruck By Fall ToCaught Between Fall OnContact With Overstress



IMMEDIATE CAUSES

SUBSTANDARDACTS,PRACTICES,& CONDITIONS

Examples:

Substandard Acts Substandard& Practices Conditions

Failure to warn Inadequate guardsFailure to secure Inadequate PPEImproper lifting CongestionFailure to use PPE Excessive ExposuresHorseplay DisorderDefective Tools Noiseetc. etc.



BASIC CAUSES

PERSONAL & JOB/SYSTEMFACTORS

Job /System Personal FactorsFactors

Inadequate: Inadequate:- Leadership - Capability- Engineering - Knowledge- Purchasing - Skill- Tools / Eqpt. Stress- Work Standards Improper MotivationWear and TearAbuse and Misuse



LACK OFCONTROL

INADEQUATE:

SYSTEM

SYSTEMSTANDARDS

COMPLIANCETO SYSTEMSTANDARDS

Is there a loss control managementin place?

Are there system standards?

Are the standards adequate?

Is there compliance to system standards?

At what level is the compliance?



The Management Work for Loss Control Success:

1. Leadership & Administration 11. Personal Protective Equipment 2. Leadership Training 12. Health & Hygiene Control 3. Planned Inspections & Maintenance 13. System Evaluation 4. Critical Task Analysis & Procedures 14. Engineering &Change Management 5. Accident / Incident Investigation 15. Personal Communications 6. Task Observation 16. Group Communications 7. Emergency Preparedness 17. General Promotion 8. Rules & Work Permits 18. Hiring & Placement 9. Accident / Incident Analysis 19. Materials & Services Management10. Knowledge & Skill Training 20. Off-the-Job Safety


Full Circle Prevention and Thinking


Major accidents are unplanned and unintentional events that

result in harm or loss to personnel, property, production, theenvironment or anything that has some value.• Barriers (physical and management) should exist to preventaccidents or mitigate their consequences. Major accidents occurwhen one or more barriers in a work system fail, to fulfill itsfunctions, or do not exist.• Major accidents almost never result from a single cause; mostaccidents involve multiple, interrelated causal factors.• Major accidents are usually the result of management systemfailures, often influenced by environmental factors or the publicsafety framework (e.g., set by contracts, the market, theregulators or the Government)• Accident investigators should remain neutral and independentand present the results from the investigations in an unbiasedway3.


Systematic Cause Analysis Technique

Description of accident / incident

Evaluation of loss potential

Type of contact or near contact

Immediate / direct causes

Basic / underlying causes

Control action needs


Think out side the Box


The purpose of accident investigation

An accident investigation may have different purposes:• Identify and describe the true course of events (what, where,when)• Identify the direct and root causes / contributing factors of theaccident (why)• Identify risk reducing measures to prevent future, comparableaccidents (learning)• Investigate and evaluate the basis for potential criminalprosecution (blame)• Evaluate the question of guilt in order to assess the liability forcompensation (pay)


Step by Step


Before you begin, it is best to list all the losses and near-misses in the order in which they occurred in the following fashion: Supervisor nearly fell on concrete floor of Inventory Room (near-miss)Damage to the computer equipment (property damage)QC Supervisor's broken leg (injury) You should analyze each incident separately using the SCAT® Chart. You will find the task easier if you analyze the losses in the order in which they occurred. Determine the loss potential using the block directly beneath the "Description of Accident or Incident." List the incident that you wish to analyze in the "Loss" line of the Worksheet, e.g., "Supervisor nearly fell on concrete floor of Inventory Room."


Note that beginning with the block entitled "Type of Event" on the SCAT® Chart, each selection is followed by parenthetical suggestions such as "(See I.C.s: 1, 2, 4, 5, 12, 14, 15, 16, 17 18, 19, 26)." These suggestions indicate that for that kind of event, those are the most likely immediate causes for that kind of event. For example, "1. Struck Against" is followed by suggestions to look at ICs 1, 2, 4, 5, 6, etc. (Bear in mind, however, that Immediate Causes other than those designated can be causes of that type of event.) The same kind of suggestions appear in the Immediate and Basic Causes blocks as well. These numbers may be helpful in directing the course of your analysis. Throughout your analysis, always remember the Principle of Multiple Causes: problems and loss-producing events are seldom, if ever, the result of a single cause. Your task is to find ALL the relevant causes of the incident under analysis. In doing so, you reveal more options and avenues to correct system deficiencies


Treat the phrases in the Event, Immediate Cause, and Basic Cause blocks as questions, i.e., did someone/something Strike Against (Run or Bump into) someone/something else? Did someone Operate Equipment Without Authority? Did someone have Inadequate Physical/Physiological Capability? That was the format of the original SCAT® Analysis tool, before it was compressed into the Chart format. The event in this case might be described as "Slipped in puddle of oily liquid on floor." As you scan each "question" (phrase), ask yourself if the evidence shows that it was a factor in the loss you are analyzing, i.e. "Did someone fail to follow a procedure?" If not, then move on to the next "question (phrase)." If yes, do not write "Failure to Follow Procedure." Instead, write the specific discrepancy that led you to select that factor, e.g., "3,000-mile service not performed during the last 11,000 miles of operation." Please feel free to write the number from the SCAT® Chart in front of your selection, e.g., "IC 16: 3000-mile service not

performed during the last 11,000 miles of operation," if that helps you keep your thoughts more organized.


Gaining Compliance with Standards

• Communicate standards• Review and update standards• Reinforce performance to standards• Reeducate / review for understanding• Practice progressive discipline


Sources of Loss / Control Opportunities for

PEME

People

Equipment

Materials

Environment


Analytical Thinking follows the scientific approach to problem solving

Problem

Hypothesis

FactsAnalysis

Solution


Getting to the "Root" of the Problem

• Sometimes the thing we think is a problem is not the real problem, so to get at the real problem, probing is necessary

• Root Cause Analysis is an effective method of probing – it helps identify what, how, and why something happened

• Definition of root cause:– Specific underlying cause– Those that can reasonably be identified– Those that management has control to fix


Root Cause Analysis Technique - Five Why’s

Five Why's refers to the practice of asking, five times, why the problem exists in order to get to the root cause of the

problem

Why? Why? Why? Why? Why?

Employee turnover rate has

been increasing

Employees are leaving for other

jobs

Employees are not satisfied

Employees feel that they are underpaid

Other employers are paying higher

salaries

Demand for such employees has increased in the

market


Root Cause Analysis Technique – Fishbone Diagram

The value of the Fishbone Diagram is that it provides a method for categorizing the many potential causes of problems or issues

in an orderly way and in identifying root causes

Cause

Detail

Cause

Detail

Cause

Detail

Cause

Detail

Fishbone Diagram (a.k.a. Cause and Effect Diagram) is an analysis tool that provides a systematic way of looking at effects

and the causes that create or contribute to those effects.

Result (Problem)


Other Root Cause Analysis Techniques

• Force Field Analysis – Visually show forces that impact your problem or issue

• Scatter Diagrams – Graphs the relationship of two variables – quantifies the correlation, showing how one variable influences another

• Process Mapping – Maps the “as is” flow of activities that make up a process – look for excessive handoffs, redundancies, and other root causes of inefficiencies

• Benchmarking – Compares existing performance to another internal or external source, identifies issues not otherwise revealed through other techniques


Basic Questions to Ask in Defining the Problem (regardless of the technique used)

• Who is causing the problem?• Who says this is a problem?• Who are impacted by this

problem?• Etc.

Who What Where

When Why How

• What will happen if this problem is not solved?

• What are the symptoms?• What are the impacts?• Etc.

• Where does this problem occur?• Where does this problem have

an impact?• Etc.

• When does this problem occur?• When did this problem first start

occurring?• Etc.

• Why is this problem occurring?• Why?• Why?• Etc.

• How should the process or system work?

• How are people currently handling the problem?

• Etc.


Issue Diagram is an effective method for breaking down problems and formulating hypotheses

ProblemProblem

Issue #1Issue #1

Issue #2Issue #2

Issue #3Issue #3

Hypothesis #1AHypothesis #1A

Hypothesis #1BHypothesis #1B

Hypothesis #1CHypothesis #1C

Hypothesis #1DHypothesis #1D

Key Questions #1C-aKey Questions #1C-a

Key Questions #1C-bKey Questions #1C-b

Key Questions #1C-cKey Questions #1C-c

Key Questions #1C-dKey Questions #1C-d


Status of Current Control Activities

P: Do we have a system and / or system standards for this activity?

Yes or No

If “No,” check P and begin by developing a system and / or system standards.

S: Are existing system standards adequate?

Yes or No

If “No,” check S and develop adequate system standards.

C: Is there full compliance with system standards?

Yes or No

If “No,” check C and develop means to ensure compliance.


Factors Determining Control Actions

1. Risk of further losses?

2. Potential for other types of losses?

3. Investigation quality?

4. Extent of management participation?

5. Funds, time, manpower available?

6. Level of control excellence desired?


Guide to Risk Decisions

1. Potential loss severity if an accident occurs: A - Major B - Serious C - Minor

2. Probability that loss will occur: A - High B - Moderate C - Low

3. Cost of recommended control: A - High B - Medium C - Low

4. Degree of control: A - Substantial B - Moderate C - Low (67 - 100%) (34 - 66%) (0 - 33%)

5. What are the alternatives?

6. Justification: Why were the control(s) suggested?


Criteria related to output and usefulness

• DirectThe investigation process should provide results that do notrequire collection of more data before the needed controls can be identified and changes made.• UnderstandableThe output should be readily understandable.• SatisfyingThe results should be satisfying for those who initialised theinvestigation and other individuals that demand results from the investigations.

scat investigations

Presentations & Public Speaking

accident investigation

investigation effectiveness

reminder of causes

obvious causes

causes easy

good investigation

osh reasons

principle of multiple