Accident Investigation & RCA

Accident Investigation &Root Cause Analysis

Steve Madsen

Food for thought

Big things go wrong because wedon’t act on small things.

Food for thought

“Only investigating big thingswill insure that you’ll continue tohave big things.”

Motor Vehicles32%

Struck by Moving, Falling or Stationary

Objects18%

Heart Attacks/Strokes

13%

Slips and Falls8%

Gunshot Wounds8%

Airplanes5%

Caught Between Object/Equip

5%Miscellaneous

11%

Leading Causes of Workplace Deaths

Root Cause Analysis DefinedA Structured Investigation thatAims To Identify The True

Causes Of A Problem, and The Actions Necessary To

Eliminate Them.

Work Space

Work Environment

Work Organization

Conditions

Behaviors

Goal: Smooth Flow of Profitable Production

Weeding

“Weeding Out” The Causes Of Injuries And Illnesses

CutsBurns

Strains

Conditions

Behaviors

Surface Causes of the Accident

Root Causes of the Accident

Direct Causes of Injury/Illness

Accident InvestigationsWhy InvestigateBenefitsWho InvestigatesCurrent EffectivenessCommon ErrorsObstacles

Why Investigate Accidents?Protect people, Property, and CommunitiesData for trendingID Deficiencies in Safety ProgramsMoraleStimulate Interest in SafetyLegal considerations:

Quality of the informationEnsuring that we correctly identified deficiencies

Identify “True” Multiple Root Causes Develop “Effective” Corrective/Preventive Measures to

Prevent Recurrence Improve Effectiveness of Management Systems Share Lessons Learned Improve Safety Performance Reduce Direct & Indirect Accident Costs Improve Efficiency, Productivity, Profitability & Morale Enhance Product Quality & Public Image Demonstrate Commitment To Continual Improvement

Benefits

Who Investigates?

Supervisors/Managers/TrainersSerious Accidents may need a Team Approach

• Death, multiple serious injuries, or potential for multiple serious injuries.

• Complexity of conditions/operations/hazards

• Near miss with high risk potential

Common ErrorsStating the apparent cause rather than the root cause.

Slip on oil spot on floor.Cause is related to outcome rather than the incident itself.

Foreign Object in the eye - “employee not using safety glasses”

Stopping investigation too soon or not going far enough.Facility equipment failure Lack of Training“Be more careful”

Time Information

Company Culture

Obstacles

System Faults

OutputInput

MethodsSupervision

Rules Procedures

Polices

System Faults

System Faults

System Faults

Accident

EnvironmentAgents

Facilities Temperature

Atmosphere

Equipment

Product

Guards Machinery

Materials

PersonnelProtection

Training Fatigue

Fitness

Accident Causation Model

Accident Investigation Process

Follow-Up

Corrective Action

Response

Fact-Finding

Analysis

Notification

Notification PhaseDo 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?

Response• Ensure medical treatment• Eliminate obvious hazards - don’t wait for investigation

process to control a known hazard.• Determine if the area needs to be secured:

• unsafe conditions exist• critical evidence needs to be preserved• possible third party involvement

• Identify stakeholders that will need to be involved and how investigation will be done.

Fact Finding Phase • Conduct interviews using Simple Approaches

• Who, What, Where, When , Why, How• Keep Probing for More Information

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

• Don’t jump to conclusions and recommendations too quickly

• Avoid the “quick fix” if a system problem exists.• Video/Photograph/Diagram scene• Examine equipment*

Interviews: Who? By Whom?

Injured Person Witnesses Pre-Accident Accident Post-Accident Non Witnesses

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.

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.

Analyzing the Facts

Primary Surface Causes•Directly causes the injury event•Unique hazardous conditions•Individual unsafe behaviors•Events occur close to the injury event•Controllable or uncontrollable factors•Failure to perform safety practices, procedures, processes•Involves the victim, others

Secondary Surface Causes•Indirectly causes the injury event•Specific hazardous conditions•Individual unsafe behaviors•Events occur distant to the injury event•Controllable or uncontrollable factors•Failure to perform safety practices, procedures, processes•Co-workers, supervisors – anytime, anywhere

Implementation Root Causes• Common conditions & behaviors• Inadequate implementation of

safety policies, programs, plans• Inadequate design of processes &

procedures• Pre-exist the surfaces causes• Controllable• Middle management – anytime,

anywhere

System Design Root Causes• Inadequate design of safety

policies, programs, plans• Pre-exist all other causes• Controllable• CEO, Top management – anytime,

anywhere

Fails to inspect

No recognition planInadequate training plan

No accountability policy No inspection policy

No discipline procedures

Outdated hazcom programNo orientation process

Unguarded machineHorseplay

Fails to trainTo much work

Defective PPEFails to

report injury

Inadequate training

Create a hazard

Fails to enforce

Untrained worker

Broken tools

Ignore a hazard

Lack of time

Inadequate labeling

No recognition

CutsBurns

Lac

k of

vis

ion

Strains

No

mis

sion

sta

tem

ent

Chemical spill

Root Cause Analysis

Root Cause Analysis Tools

Events & Condition Charting

Fishbone Diagrams

Cause & Effect Model – “5 Whys”

Events & Condition ChartingGraphical representation to illustrate

• Facts as they occurred• In the sequence they occurred• Additional known conditions• Deviation or change from expected step or action

Foundation for investigation organizationCondition

Event Event Event

Condition Condition

Events & Condition ChartingEvents- "Who did What“ action statements that describe what led up to the incident .

John Doe reports to work

John assigned to change fuse

Obtain fuse from store room

Tagged out fuse box

Replaced fuse

Energized System

System not functioning

John open fuse box

Tied out the interlocks

Put meter across fuse

6:56 am

Fireball exploded in John’s face

What action happened next? Arrange chronologically Times can be added to chart.

Include one action per box.

Quantify when possible. Use precise factual words.

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 wordsQuantify when possibleUse dotted ovals for assumptions

Regular employee sick

Safety requirement

Wanted to check it out

System blowing fuse when starting

System designed for

continuous op

Defect not corrected

Fuse outof date

Fuse blown

Meter not properly installed

Used 600 volt meter

Pressure to get back on line

Wanted to check again

Did not follow

procedures

Wanted to check voltage

across line

Not experienced

Did not follow procedures

Lack of training

Not supervised




Tagged out fuse box

Replaced fuse

Energized System


John open fuse box



Events & Condition Charting6:56 am


Regular employee sick.

Safety requirement

Wanted to check it out.

System blowing fuse when

starting

System designed for

continuous op.


Fuse outof date

Fuse blown


Used 600 volt meter

Pressure to get back on line.


Did not follow

procedures


across line

Not experienced


Lack of training

Not supervised




Tagged out fuse box

Replaced fuse

Energized System


John open fuse box




6:56 am


CF

CF

CFCF

CF

CF

Events & Condition Charting – Causal Factors

6:56 am Regular employee sick.

Safety requirement

Wanted to check it out.

System blowing fuse when starting

System designed for

continuous op.


Fuse outof date

Fuse blown


Used 600 volt meter

Pressure to get back on line.


Did not follow

procedures


across line

Not experienced


Lack of training

Not supervised




Tagged out fuse box

Replaced fuse

Energized System


John open fuse box




CF

CF

CFCF

CF

CF

Events & Condition Charting – Causal Factors

Conditions that if removed would keep the incident from happening or make it less severe in its consequences.

Not all conditions are necessarily Casual Factors.

Utilize analysis tools on the identified causal factors to determine Root Cause



Fuse outof date

Fuse blown

Did not follow

procedures


Lack of training

Not supervised

CF

CF

CFCF

CF

CF

ProblemRoots

People

Environment

Methods

Equipment

Fishbone Diagram

Fishbone Diagrams

Analysis tool for systematic review of cause and effects.

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

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

“Brainstorm” within each category.

ProblemRoots

People

Environment

Methods

Equipment

System Faults

OutputInput

Methods

System Faults

System Faults

System Faults

Accident

Environment

Equipment Personnel

Fishbone Diagrams: – Root Examples

People – Rules Known But Not Used, Did Not See Hazards During Field Inspections, Misaligned Parts, etc.

Methods – Inadequate/ Non-Existent Procedures, Training

Environment – Noise, Cold/Hot, Inadequate Lighting, Slippery Floors, etc.

Equipment – Worn or Defective Bearing, Seal, Pump, Motor, Switch, Light, etc.

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.

Cause & Effect Analysis – “5 Whys”

Why?

Why?

Why?

Why?

Why?



Why are we notable to build good

widgits?

Don’t producegood widgits

Poor Material

Insufficient Definition

Insufficient Tools

Poor Processing

Once you have your basic problem determined, ask yourself ‘why’ that may be happening.

Be sure to consider all areas of the process, not just ones that you know are involved. Brainstorming is a useful tool in this stage.

Why would we havepoor processing?

Staff not TrainedCorrectly

Paint too old

Vendor Change

ProceduresIncorrect

Insufficient Definition

Insufficient Tools

Poor Processing

Poor Material


The process of questioning the answer is continued at least 4 more times (ie, 5 Why) off each response.

Be sure to keep your questions in line with the original issue. Otherwise, you can stray into unrelated areas and waste time.


The resultant tree of questions and answers should lead to a comprehensive picture of POTENTIAL root causes for the incident.

Corrective Action

Identify and address multiple root causes - not just the apparent, immediate causes.

Develop system controls to solve the causes:

“If this is corrected, will the likelihood of recurrence be eliminated?”

Multiple root causes will need multiple controls so don’t focus on a single solution.

Areas for Corrective Action

EnvironmentChanges

ProcedureChanges

Training

Program

BehavioralPersonnel

PhysicalChanges

Current Effectiveness (Nationally)

A Study of Accident Investigations Showed The Following:Root Cause Identification

43% were appropriate 32% were deficient 25% included no causes

Corrective Action 53% were appropriate 23% were deficient 24% included no solutions

Source: Hagan, P.(2001). Accident Prevention Manual – Administration & Programs, 12th Edition, National Safety Council, Itasca, IL

Areas for Corrective Action

System Faults

OutputInput

MethodsSupervision

Rules Procedures

Polices

System Faults

System Faults

System Faults

Accident

EnvironmentAgents

Facilities Temperature

Atmosphere

EquipmentProduct

Guards Machinery

Materials

PersonnelProtection

Training Fatigue

Fitness

Business

Accident Investigation & RCA