2Agenda EMS Incidents Investigations Root Cause analysis Implement Corrective/Preventative MeasuresEvaluation of conformanceScenarioObjective of Course:Improve understanding of Incident Reporting and Investigating processImprove identification of the “root cause” of incidents to better develop corrective and preventative action plans to address “root cause”Improve understanding of evaluation process of corrective and preventative action plans
3EMS Incidents Emergency Response Incidents Potential Non-compliance FireSpillsErosion/Landslide EventsPotential Non-complianceSignificant Non-conformanceFire – any uncontrolled fire related to BCTS activitiesSpills – any spill exceeding BCTS reportable levels or any amount spilled into or immediately adjacent to a stream, lake or running waterErosion/landslide event - any emergency situation or potential emergency exists, abnormal movement has or is occurring, abnormal sedimentation, a volume of material greater than 250m3 has moved or is a imminent risk of movement, or a land area greater than 0.25 ha is disturbed through erosion processPotential non-compliance – in the opinion of the person reporting, legislation and regulation has been violated and there may be a agency investigation to determine fact and possible enforcement options.Significant non-conformance – an occurrence or event that has or will likely result in a negative impact to a significant environmental aspect and cannot be immediately rectified. Where the EMS program has been severly compromised and or a “Notice to Comply” has been issued at the discretion of local management. This includes repeated non-conformances that may become significant if not addressed promptly.
4Incident Reporting / Investigation EMS Issue Reporting Business Process MapThe decision processCHK DocumentationEOP 06 – Roles and Responsibilities
5Why Investigate? Determine what happened Determine why it happened Figure out what to do to reduce the likelihood that it will happen again
7Root Cause Analysis Investigation tool Uses a systematic approach to identify the origin of a problemFinding the Root Cause should:Use a disciplined approachAddress the system problemBe a team effortBe verifiedNot stop at “Operator Error”Root Cause Analysis assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the incident you're now facing.
8Root Cause Analysis Follows a specific set of steps Define the problem Collect dataIdentify possible causal factors – 5 WhysIdentify root cause(s)Recommend and implement solutionsEvaluate solutions (Continuous improvement)
9Define the problem What happened? When did it happen? Where did it happen?What was the impact?
10Collect Data What proof do you have that the problem exists? How long has the problem existed?What is the impact of the problem?You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your Root Cause Analysis, get together everyone – experts and front line staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.
11Identify Possible Causal Factors What sequence of events lead to the problem?What conditions allow the problem to occur?What other problems surround the occurrence of the central problem?
12Contributing factors: Human causes – people did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (ex no one filled the brake fluid, which lead to the brakes failing)Physical causes – tangible, material items failed in some way (ex car’s brakes stopped working)Organizational causes - a system, process, or policy that people use to make decisions or do their work is faulty (ex no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid)Root cause analysis looks at all three types of causes. Often more than one root cause is determined.
13Where to look for contributing factors 1) Tasks...policy procedures, guidelines2) environment and site conditions (weather, noise, air)3) Materials/equipment4) Personnel (training, stress, fatigue, experience)5) Management (supervision, inspections, action plan follow-up)
14Causal Factor Identification Tools 5 whys – Ask “why” until you get to the root of the problemDrill Down – Break down a problem into small, detailed parts to better understand the big pictureCause and Effect Diagrams – Create a chart of all the possible causal factors, to see where the trouble may have begun
155 WhysVery often, the answer to the first "why" will prompt another "why" and the answer to the second "why" will prompt another and so on; hence the name the 5 Whys strategy.Benefits of the 5 Whys include:It helps to quickly determine the root cause of a problemIt is easy to learn and apply
16Cause and Effect Diagrams Identify the problem – who, what, when, whereWrite exact problem on a box on the left hand side of the paper and draw a line horizontally from this boxWork out the major factors involved – there may be severalDraw lines off the “spine” for each factor involved and label them (these are the ‘bones’)Identify possible causesDisplay on diagram as smaller lines coming of the ‘bones’ of the fishAnalyze your diagramExampleAlso called Fish or Fish bone diagrams, Ishikawa diagramsKey points:Cause & Effect analysis (or Fishbone Analysis) provides a structured way to help you think through all possible causes of a problem. This helps you to carry out a thorough analysis of a situation.
17Identify the Root Cause(s) Why does the causal factor exist?What is the real reason the problem occurred?Use the causal factor identification tools to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect
18Brainstorm SolutionsWhat can be done to prevent the problem from happening again?Two types of solutions:Corrective – reactive, the problem has already occurredPreventative – proactive, problem has not happened yetRecord all solutions
19Evaluate Solutions For: EffectivenessEase of ImplementationReturn on Investment (not always applicable especially with Safety Incidents)Potential Negative Effects – you don’t want your solution to cause other problemsEvaluate Solutions before you implement them
20Implementation This is essentially your action plan How will the solution be implemented?Who is responsible for the solution?Target dates for completionUse specific languageExample: purchase 15 ¾” steel bolts instead of purchase bolts.
21Risky Solutions to watch out for Applying solutions with no due date assignedNon acting solutions – they require more information before being implemented. These are action items, not solutionsSolutions that begin with “re”example: re-train, re-writeOverdependence on procedures - developing a new procedure should not be the first line of defense
225 Why AnalysisExampleAn employee in the plant slipped and fell while performing their regular duties.Why? – There was oil on the floor.Why? – The machine in that cell was leaking oil.Why? – A pressure fitting on the machine failed.Why? – Inspection of hoses and fittings is not part of the preventive maintenance (PM) schedule.Why? – The PM system does not consider Equipment Manufacturer’s recommendations to develop PM schedules.
23We Have Successfully Established: What the problem wasA pressure fitting on the machine failed.How the problem occurredInspection of hoses and fittings is not part of the preventive maintenance (PM) schedule.Why the system failedThe PM system does not consider Equipment Manufacturer’s recommendations to develop PM schedules.
24Corrective ActionEffective Corrective Action will focus on eliminating the cause of the stated problem.This will eliminate the Why and How and prevent the What from recurring.Disciplined problem solving will also verify the effectiveness of Corrective Actions.
25Containment vs. Corrective Action Address the incident or symptom not the root causeHas no long term effect on the system
26Containment vs. Corrective Action Containment action in our example without determining the root causeWait for Bob Jones to get better.Retrain Bob to watch for oil hazards.Remove or cover up the current oil leak.Pray that it doesn’t happen again.
27Containment vs. Corrective Action Containment in this case should include:Clean up the oil leak.Repair the leaking equipment.Inspect other similar equipment for similar problems.Send Bob a “Get Well Soon” card
28Effective Corrective Action Effective Corrective Action Usually Includes the Following:State the problem clearlySelect a champion and corrective action teamContain the problem (Short term corrective action)Investigate the problemPerform Root Cause AnalysisLong term Corrective ActionVerification of effectivenessClosure
29Effective Corrective Action In Our Example:State the Problem Clearly:Problem StatementNonconformity: The system for ensuring employee safety in production areas is not effective.Requirement: Quality, Environmental and Occupational Health and Safety Policies require management to maintain safe production facilities. Ministry of Labour Requirements.Objective Evidence: Bob Jones slipped and fell in the plant on Dec. 15, Lost Time Accident records for December 2005.
30Effective Corrective Action In Our Example:Select a Champion and Corrective Action Team:Champion: Martin WillemCorrective Action Team: All
31Effective Corrective Action In Our Example:Contain the Problem (Short Term Corrective Action)Clean up the oil leakFix broken pressure fittingCheck other similar machines
32Effective Corrective Action In Our Example:Investigate the Problem:Interview affected personnel (Bob will have the most information about the incident).Look at the affected area.Observe the process in regular operation.Record the facts.
33Effective Corrective Action In Our Example:Perform Root Cause AnalysisWhy? – There was oil on the floor.Why? – The machine in that cell was leaking oil.Why? – A pressure fitting on the machine failed.Why? – Inspection of hoses and fittings is not part of the preventive maintenance (PM) schedule.Why? – The PM system does not consider Equipment Manufacturer’s recommendations to develop PM schedules.
34Effective Corrective Action In Our Example:Long term Corrective ActionWhat should our long-term Corrective Action focus on?
35Effective Corrective Action In Our Example:Long term Corrective Actions may include:Updating maintenance proceduresRevise PM schedules based on equipment manufacturer’s recommendationsTraining maintenance personnelTesting pressure fittings on machinesRe-Designing cell layouts to eliminate the effect of spilled oil
36Effective Corrective Action Long Term Corrective Action Should:Address the system problemEliminate the Root CauseBe implemented in a timely mannerInclude a detailed plan if it will take considerable timeBe commensurate with the risk involvedRisk to the customer, employee, organization, public, etc.
37Effective Corrective Action In Our Example:Verification of effectivenessMonitor and measure if anyone else sustains a similar injury?This seems like a logical way, but is reactive in nature.Someone has to get hurt before we take further action.Risk may be too great.Additional methods should be considered.
38Effective Corrective Action Verification of EffectivenessOften confused with verification of implementation.Completion of corrective action tasks.Monitor and measure the process to verify the effectiveness of the actions taken.Poor results often indicate wrong Root Cause or wrong Corrective Action(s).Consider performing audits as a verification tool.
39Effective Corrective Action In Our Example:Verification of effectivenessPerform regular audits of:Production AreasCheck for oil leaks in production cellsPreventive Maintenance ProcessPM scheduleMaintenance personnel trainingIntroduction of new equipment
40Effective Corrective Action In Our Example:ClosureClosure can only happen after successful verification of Corrective Actions.By nature, effective Corrective Actions will prevent recurrence.If Corrective Actions cannot be called effective, then Root Cause Analysis should be repeated.Record the date of closure.