1. Accident Investigation Root Cause Analysis Accident Investigation Root Cause Analysis

2. Accident investigation is REACTIVE So what's the point?

3. The reasons for investigating accident are:- To understand failures which gave rise to the pattern of events. Fix the conditions that have proven inadequate. Reduce the possibility of a reccurrence.

4. What can analytical accident investigation give us? Assists the process of gathering the facts. To verify the investigation findings. To co-ordinate the investigation. To identify root cause. To assist in communicating the finding. To learn.

5. The traditional approach to accident investigation Accident Investigation Identify primary unsafe condition Identify primary unsafe act Devise fixes - guards, PPE etc. Devise procedures or rules Corrective Action

6. Active Unsafe Acts (willful performance of unsafe act) Operating a machine without a guard -usually resolved by proper supervision and discipline. Passive Unsafe Acts (developed through habit and bad custom and practice) No safe systems of work - requires training, supervision, publicity, consultation.

7. Root Cause Analysis The process of identifying the ‘initiating’ event. The process of asking ‘why,why, why’ until the answer is no longer useful.

8. Tree Diagram Injury damage or near miss Unsafe Condition Unsafe Act Accident Cause Sub-cause

9. Example Multi-causal approach to the problem of accidents caused by fork lift trucks Injury Unsafe Acts Unsafe Conditions Accident Changes in materials handling Changes in pallets Wrong attitudes Economy drive Different work undertaken Poor lighting/ surface Change in shift system Poor conditions Need for refresher training Changes in equipment used New fork lift truck introduced Poor Supervision Age of employees

10. Main Points So far Accidents are the result of events which precede it. There are many factors or sub- events which contribute to an accident.

11. Example An accident in which a person sustains minor injuries as a result of falling from a ladder.

12. Single Causation Approach Unsafe act - using defective ladder. Unsafe condition - the defective ladder. Corrective action - replace ladder.

13. Multi-Causation Approach Unsafe act - using defective ladder. –Inspection procedures missed defect –Supervisor allowed it to be used –Storeman allowed it to be issued –Previous user did not report defect –No risk assessment carried out. Unsafe condition - the defective ladder. –Injured person not properly trained –Inadequate inspection –Inadequate reporting procedures –Adverse weather conditions Corrective action - replace ladder. –Retrain operatives, Inc risk assessment. –Improve reporting procedure –Implement safe system of work –Implementation of new issuing procedures –Review procedure.

14. Finally Health and safety at work is about protecting people. Management plays a significant part Attitude is one of the key drivers. Health & safety is everyone’s responsibility and involvement is key.