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Root Cause Analysis Flowchart (RCAF) Personal Factors Did not follow procedures or acceptable practices because... Did not follow procedures or acceptable.

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Presentation on theme: "Root Cause Analysis Flowchart (RCAF) Personal Factors Did not follow procedures or acceptable practices because... Did not follow procedures or acceptable."— Presentation transcript:

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3 Root Cause Analysis Flowchart (RCAF) Personal Factors Did not follow procedures or acceptable practices because... Did not follow procedures or acceptable practices because In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equip damage, regulatory assessment or production delay). 4. In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equip damage, regulatory assessment or production delay). 2. Doing the job according to procedures or acceptable practices takes more time/effort 3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated 1 1. Lack of skill or knowledge 5. Lack of or inadequate procedures 6. Inadequate communication of expectations regarding procedures or acceptable practices. 6. Inadequate communication of expectations regarding procedures or acceptable practices. Development of solutions Implementation of solutions Organizational Factors 8. External Factors Verification and validation of solutions Questionable Item, Near Loss, Loss Occurs... WHY? 7. Inadequate tools or equipment

4 When to Use RCAF JHA and SAI Level 3’s Observations and Walkthroughs Near Loss Incidents (NLIs) when IRAT <400 Loss Incidents when IRAT <400

5 STEP #1 - Use 5-Why Process to Identify Logical Root Causes Questionable Item, Near Loss, Loss Occurs WHY? Questionable Item, Near Loss, Loss Occurs WHY? Root Causes Incident: Worker’s hand was cut by a fan on running rig welder

6 STEP #2 – Use RCAF Flowchart to Determine Factors Because we didn’t have an inspection checklist to verify that rig welders’ equipment is in safe operating condition before being allowed into the plant.

7 Personal Factors Did not follow procedures or acceptable practices because... Did not follow procedures or acceptable practices because... In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equipment damage, regulatory assessment or production delay). In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equipment damage, regulatory assessment or production delay). Doing the job according to procedures or acceptable practices takes more time/effort. Short-cutting procedures or acceptable practices is positively reinforced or tolerated. Lack of skill or knowledge Lack of skill or knowledge

8 Lack of or inadequate procedures Inadequate tools or equipment (available, operable & safely maintained; proper task & workplace design) Inadequate tools or equipment (available, operable & safely maintained; proper task & workplace design) Inadequate communication of expectations regarding procedures or acceptable practices Inadequate communication of expectations regarding procedures or acceptable practices Development of solutions Implementation of solutions Organizational Factors External Factors Verification and validation of solutions

9 STEP #3 – Develop Solutions to Address Factor Factor Identified Solution(s) 1)Develop procedure with checklist form to inspect all rig welders as they come into the plant to ensure they are in safe working condition before being sent to the jobsite 2)Communicate new procedure to the affected workforce 3)Train personnel that will be performing the inspections STEP #4 – Implement Solutions STEP #5 – Verify and Validate Solutions Track solutions to completion, ensure they are implemented in agreed upon timeframe Must verify that the Solution(s) worked. Test it to be sure it is fully implemented and doing what it was supposed to do.

10 1 - Lack of Skill or Knowledge o Training not conducted or not available o Worker missed required training o Training completed but not understood (no validation) o Task completed/attempted by unqualified worker o Training inadequate or ineffective o Training not required but is necessary to do job properly 2 - Doing the job according to accepted practice takes more time/effort o Worker took unapproved shortcut in order to save time or effort o PPE available but not utilized in order to save time, make task simpler, or for worker comfort o Work team(s) did not adequately discuss job roles or requirements in an effort to save time (includes shift turnover) o Worker(s) did not prepare for task in order to save time (includes LPSA, SJHA's, Daily Addendum, Permits, Safety standards, other work planning) 3 - Deviating from accepted practices is reinforced or tolerated (short cutting) 3 - Deviating from accepted practices is reinforced or tolerated (short cutting) o Supervisor implied need for shortcut o Supervisor or peer influence for "friendly competition" including the use of shortcuts or deviations from procedures o Inadequate reinforcement or compliance with policy or procedure by the supervisor, even though management expectations are clear o Inadequate verification of proper use of policy or procedure by supervisor (management presence in the field) o Required job supervision and/or intervention not provided o Supervisor allowed unqualified or impaired worker(s) to perform task, despite indications of worker deficiencies 4 - Past deviations from procedures or acceptable practices produced no negative results o SPSA not performed regularly o Procedures and/or work standards not consulted regularly o Job habits/common practices have deviated from procedures or acceptable standards o Routine task performed without prior planning or preparation o SHE risks, and decision to not minimize them, were understood and accepted by worker(s) o Worker(s) knowingly deviated from accepted practice based on similar instances in the past that yielded favorable results Decision Support Tools Personal Factors

11 5 - Lack of/or inadequate Procedures/Policies o Policy/Procedure is needed; but does not exist or is not available o Policy/Procedure not required; but should be o Policy/Procedure not updated when changes made o Policy/Procedure content does not address hazards leading to incident o Policy/Procedure is confusing, incomplete, or incorrect o Policy/Procedure contains errors (sequence wrong, typos, wrong calculations/conversions, wrong names/identifications…) o No way to implement Policy/Procedure as written o Policy/Procedure creates unnecessary risks, difficulties, or inefficiencies (ergonomics, fatigue, repetition, etc.) 6 - Inadequate Communication of Critical Information or Expectations o Inadequate communication of expectations by management o Management actions appear to contradict stated expectations o New or modified Policy/Procedure or job standard not received by worker (not communicated by management or central staff) o Special task requirements (procedure, SJHA, work permit, PPE, etc.) identified, but not communicated to workers o Inadequate communication between work teams or key individuals o Communications incorrect or misunderstood 7 - Inadequate Tools, Equipment, Facilities o Correct tools, equipment, or PPE not available or inadequate (includes communication equipment) o Inadequate human/machine interface (alarms,displays,controls,layout) o Labeling, signs, or identification non-existent or incorrect o Inadequate work environment (lights, noise, housekeeping, barriers) o Ergonomics of task need improvement (excessive physical activity,etc) o Task too complex (too many actions or decisions required)) o Inadequate design or specification of equipment for purpose o Defective equipment fabrication/construction o Equipment damaged prior to installation/use o Wrong equipment ordered or installed o Inadequate inspection and/or preventive maintenance o Hazards or errors not detectable prior to incident o Equipment repaired, but failure repeated o Fault identified but not yet repaired 8 - External Factors o Natural disaster o Act of vandalism o War/Sabotage o Other Decision Support Tools Operational /External Factors

12 Incident: Worker was observed running impact w/o a faceshield Incident: Worker was observed transitioning w/o maintaining 100% tie-off Using the 5-Why Process it was determined that: Worker had started task with faceshield on He was in a very tight congested area When he repositioned his body, the faceshield was knocked off and fell 30’ to grade He had less than a minute left to finish tightening one nut and the task was complete Using the 5-Why Process it was determined that: Job had been in progress for ~ 2hours Worker had all proper fall arrest equipment on, dismantling scaffold Workcrew was on the next to last level, they had already dismantled 3 levels When moving on the same level the worker often moved w/o 100% tie-off The Crew’s Foreman had been on the jobsite all morning observing the work What is the Root Cause & Factor?

13 Root Cause Analysis Flowchart (RCAF) Personal Factors Did not follow procedures or acceptable practices because... Did not follow procedures or acceptable practices because In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equip damage, regulatory assessment or production delay). 4. In past, did not follow procedures or acceptable practices and no incident occurred (injury, product quality incident, equip damage, regulatory assessment or production delay). 2. Doing the job according to procedures or acceptable practices takes more time/effort 3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated 1 1. Lack of skill or knowledge 5. Lack of or inadequate procedures 6. Inadequate communication of expectations regarding procedures or acceptable practices. 6. Inadequate communication of expectations regarding procedures or acceptable practices. Development of solutions Implementation of solutions Organizational Factors 8. External Factors Verification and validation of solutions Questionable Item, Near Loss, Loss Occurs... WHY? 7. Inadequate tools or equipment


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