Accident Investigation Root Cause Analysis

1. Accident Investigation Root Cause Analysis

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

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

4. Root Cause AnalysisData Collection • Interviews • Photographs • Equipment Specs. • Equipment Manuals • Safety Rules • Training Records Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

5. Root Cause AnalysisEvent Charting • Organizes collected data for analysis • Sequence diagram • May uncover needs for additional data collection Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

6. Root Cause AnalysisEvent Charting Mary starts cooking Mary leaves kitchen Fire starts Smoke alarm sounds Mary enters kitchen Mary throws water on fire Mary uses fire ext. Fire spreads Mary calls 911 FE fails Data Collection Kitchen destroyed Event Charting Fire department arrives FD puts out fire Change Analysis Causal Factor Analysis Barrier Analysis Smoke damage throughout restaurant Root Cause ID Recommendations

7. Root Cause AnalysisEvent Charting Phone rings in front of restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out Mary starts cooking Mary leaves kitchen Fire starts Smoke alarm sounds Mary enters kitchen Mary sees fire Grease fire FE not charged Mary throws water on fire Mary uses fire ext. Fire spreads Mary calls 911 Data Collection FE fails Event Charting Kitchen destroyed Change Analysis Causal Factor Analysis Barrier Analysis Fire department arrives FD puts out fire Smoke damage throughout restaurant Root Cause ID Recommendations

8. Root Cause AnalysisCausal Factor Analysis Casual Factors: • Direct Cause: Immediate event/ condition that caused accident) • Contributing Cause: Event/condition that increased probability or severity of the accident • Root Cause: Event/condition that, if corrected, will prevent recurrence Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

9. Root Cause AnalysisCausal Factor Analysis 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

10. Root Cause AnalysisCausal Factor Analysis Phone rings in front of restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out Electric burner shorts out Mary starts cooking Mary leaves kitchen Fire starts Smoke alarm sounds Mary enters kitchen Mary leaves kitchen Mary sees fire Grease fire FE not charged FE not charged Mary throws water on fire Mary throws water on fire Mary uses fire ext. Fire spreads Mary calls 911 Data Collection FE fails Event Charting Kitchen destroyed Change Analysis Causal Factor Analysis Barrier Analysis Fire department arrives FD puts out fire Smoke damage throughout restaurant Root Cause ID Recommendations

11. Root Cause AnalysisChange Analysis Used to identify deviations from the norm • “What happened” vs. “What should have happened” • Used mostly when operations and standardized Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

12. Root Cause AnalysisChange Analysis Common Changes and Differences: • Personnel • Plant • Hardware • Procedures • Managerial Controls Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

13. Root Cause AnalysisChange Analysis Phone rings in front of restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out Electric burner shorts out Mary starts cooking Mary leaves kitchen Fire starts Smoke alarm sounds Mary enters kitchen Mary leaves kitchen Mary sees fire Grease fire FE not charged FE not charged Mary throws water on fire Mary throws water on fire Mary uses fire ext. Fire spreads Mary calls 911 Data Collection FE fails Event Charting Kitchen destroyed Change Analysis Causal Factor Analysis Barrier Analysis Fire department arrives FD puts out fire Smoke damage throughout restaurant Root Cause ID Recommendations

14. Root Cause AnalysisBarrier Analysis 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

15. Root Cause AnalysisBarrier Analysis Barrier Categories: • Equipment • Design • Administration (procedures processes) • Supervisory/Management • Warning Devices • Knowledge and Skills Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

16. Root Cause AnalysisBarrier Analysis Phone rings in front of restaurant Grease ignites on burner Grease on burner ignites Electric burner shorts out AL pan melts Arcing heats pan Arcing heats pan Electric burner shorts out Electric burner shorts out Mary leaves kitchen Smoke alarm sounds Mary starts cooking Mary leaves kitchen Fire starts Smoke alarm sounds Mary enters kitchen Mary sees fire Grease fire FE not charged Mary throws water on fire Mary throws water on fire Mary calls 911 Mary uses fire ext. Fire spreads Fire spreads Mary calls 911 Data Collection Mary uses fire ext. FE fails FE fails Event Charting Kitchen destroyed Change Analysis Causal Factor Analysis Barrier Analysis Fire department arrives FD puts out fire FD puts out fire Smoke damage throughout restaurant Root Cause ID Recommendations

17. Root Cause AnalysisRoot Cause Identification Root causes • Derived from the facts and analysis conducted • Should answer two questions: • What happened? • Why it happened? Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

18. Root Cause AnalysisRoot Cause Identification • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

19. Root Cause AnalysisRoot Cause Identification • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

20. Root Cause AnalysisRoot Cause Identification • Fire Extinguisher failure • Inadequate inspection program • Water on grease fire • Inadequate training (abnormal events) Data Collection Event Charting Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

21. Root Cause AnalysisRecommendations 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

22. Root Cause AnalysisRecommendations • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

23. Root Cause AnalysisRecommendations - Direct/Contributing Cause #1 • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

24. Root Cause AnalysisRecommendations - Direct/Contributing Cause #2 • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

25. Root Cause AnalysisRecommendations - Direct/Contributing Cause #3 • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

26. Root Cause AnalysisRecommendations - Direct/Contributing Cause #4 • 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 Change Analysis Causal Factor Analysis Barrier Analysis Root Cause ID Recommendations

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