Technical Resource Guide Root Cause Analysis

Transcription

1 Technical Resource Guide Root Cause Analysis Prepared by: Employer s Claim Management, Inc. P.O. Box 5614, Montgomery, Alabama (334) (800) FAX (334)

2 Root Cause Analysis Root cause analysis is based on the concept that behind every accident, there are primary factors that directly contributed to the occurrence of the accident. The goal of a root cause analysis is to identify the underlying or root causes of accidents, and apply corrective countermeasures to eliminate those type of accidents from occurring in the workplace. A root cause analysis is performed on an individual loss, accident or incident. Larger accidents and accidents that are frequent occurrences are good candidates for root cause analysis. The root cause analysis should be used as a tool to help prevent accidents. The following questions should be asked of the injured employee(s), witnesses and management: What was the employee doing? Describe the activity, as well as the equipment, materials, people and environmental conditions involved in the accident. Use the attached Appendix A to help isolate the factors responsible for the accident or injury. Be specific, such as climbing a ladder while carrying roofing materials or unfastening chlorine hose from a spray nozzle. What happened? Describe how the injury or illness occurred. Indicate in detail what took place, describe the accident, specify the type of injury or illness, and describe if the employee was wearing the appropriate safety equipment. For example, when the ladder slipped, the worker, who was not wearing his fall protection equipment, fell 20 feet and broke his leg. Worker was sprayed in the face with chlorine and he was not wearing any eye protection. What caused the accident? Explain in detail the condition, act or malfunction that caused the accident. Remember that it is possible there were more than one reason or cause for the accident. For example, Rainwater entered the hole in the roof and caused the floor to be wet and the ladder slipped out from under the worker. Worker was repairing a gasket, which broke during replacement. The line was not drained and de-pressurized prior to performing the maintenance. A good technique to problem solving is the 5 Why s Analysis. This technique of asking why 5 times helps you reached the root cause and prevent you from assuming the cause without all the pertinent information. For example, a slip and fall accident:

3 Why did the employee slip and fall? There was water on the floor. Why was there water on the floor? There was a leak in the processing pipe. Why was there a leak in the processing pipe? The valve was worn. Why was the valve worn? Maintenance did not replace it. Why did maintenance not replace it? There is no inspection program to detect worn valves and report it to maintenance. The slip and fall initially appeared to be simply from water on the floor. But further investigation by continuing to ask why indicated it was more of a management system failure of lack of effective inspection program. Here's another example. A worker loses the tip of his finger when it's pinched between a drive belt and an unguarded pulley. The first step is to identify the problem. Why was the worker's finger crushed? His finger was caught between a moving pulley and belt. Why was the finger caught between the pulley and the belt? The guard on the pulley was missing. Why was the guard missing? A mechanic had overlooked replacing it. Why was it overlooked? There is no written equipment servicing checklist. Why is there no checklist? No hazard assessment has been completed. What can be done to prevent a similar accident? Indicate the corrective action to prevent reoccurrence. Results of the root cause analysis can be recorded on the attached Root Cause Analysis form. See Appendix A for Finding The Root Cause, which can help lead you through the process. There are sample causes, as well as examples of corrective actions.

4 Root Cause Analysis Name: Company: Date: Time: Department: Age: Job: How Long on Job: What was employee doing? Describe the activity, equipment, materials, people and environmental conditions involved in the accident. What happened? Indicate in detail what took place. Describe the accident, the type of injury, and if the employee was wearing the appropriate safety equipment. What caused the accident? Explain in detail the condition, act, malfunction, and/or system failure that caused the accident.

5 Corrective action recommended: Root Cause Analysis (continued) Investigated by: Date: Reviewed by: Date:

6 Appendix A Finding The Root Causes Who Employee Name Job Title Department/Shift Age Years with Company Years in Position PPE worn Other employees involved What Employee activity Employee task Object or materials handled Machine or equipment involved Tools involved Chemical involved Type of injury or illness

7 Where Location or department Area inside or outside Environment wet or dry Adequate lighting When Date of Accident Day of Accident Time of Accident Why Unsafe act Unsafe condition Personal factors Job factors Safety management system failure Corrective Action Taken

8 ACCIDENT CAUSES Unsafe Acts Operating without authority Working at unsafe speed Making safety devices inoperable Using defective equipment Failure to use protective equipment Improper lifting or handling Working in an unsafe position Working on moving equipment Horseplay Drug of alcohol use Personal Factors Lack of knowledge or skill Improper motivation Physical or mental problems Unsafe Conditions Inadequate or no guards Defective tools or equipment Poor housekeeping Unsafe design or construction Hazardous procedure Inadequate dress or apparel Inadequate lighting Inadequate ventilation Slippery walking surfaces Congested work area Job Factors Inadequate work standards Inadequate design or maintenance Inadequate purchasing standards Management Systems Inadequate safety program Inadequate or lack of safety training program Inadequate or lack of safety inspection program Inadequate enforcement of safety program

9 EXAMPLES OF EFFECTIVE ACCIDENT CONTROL Implement formal training program Give personal reinstruction Establish proper job instruction program Institute a safety instruction program Implement job analysis program Revise existing job analysis Institute job observation program Reassign person to another job task Establish new or improve inspection program Institute pre-use checkout of equipment Establish or revise orientation for new or transferred employees Repair or replace equipment Improve ergonomic design of equipment Establish ergonomic requirements for new equipment Improve identification or color code for safety Install or improve safeguards Eliminate unnecessary material in area Improve housekeeping program Establish or improve personal protective equipment program User safer material Establish purchasing standards Improve physical examination program