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Accident Investigation Root Cause Analysis. Identify three consistent and systematic approaches to investigating workplace accidents. Understand how to.

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Presentation on theme: "Accident Investigation Root Cause Analysis. Identify three consistent and systematic approaches to investigating workplace accidents. Understand how to."— Presentation transcript:

1 Accident Investigation Root Cause Analysis

2 Identify three consistent and systematic approaches to investigating workplace accidents. Understand how to apply these approaches to a workplace accident investigation. Root Cause Analysis Objectives

3 Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Root Cause Analysis Overview

4 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 Analysis Data Collection

5 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 Analysis Event Charting

6 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 Analysis Event Charting

7 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 Analysis Event Charting Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Phone rings in front of restaurant

8 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 Analysis Causal Factor Analysis

9 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 Analysis Causal Factor Analysis

10 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 Analysis Causal 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

11 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 Analysis Change Analysis

12 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 Analysis Change Analysis

13 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 Analysis Change 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

14 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 Analysis Barrier Analysis

15 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 Analysis Barrier Analysis

16 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 Analysis Barrier 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.

17 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 Analysis Root Cause Identification

18 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 Analysis Root Cause Identification

19 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 Analysis Root Cause Identification

20 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 Analysis Root Cause Identification

21 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 Analysis Recommendations

22 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 Analysis Recommendations

23 Unattended stove RC #1: Facility design less than adequate RC #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

24 Heating element failure RC #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

25 Fire Extinguisher failure RC #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

26 Water on grease fire RC #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

27 Identify three consistent and systematic approaches to investigating workplace accidents. Understand how to apply these approaches to a workplace accident investigation. Root Cause Analysis Objectives


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