Methods for conducting an effective incident analysis (on-site) Become familiar with the 5 Why analysis process

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2 Discuss: Methods for conducting an effective incident analysis (on-site) Become familiar with the 5 Why analysis process Become familiar with the Fishbone Diagram analysis process All Rights Reserved 2

The analysis of an incident or event to identify causal factors and the

6 Causal Factors - an action or lack of action that caused an Incident or made the incident worse. An action someone performed An action, a piece of equipment, component or process transaction performed An action not performed by someone An action not performed by piece of equipment, component or process transaction (TapRooT) All Rights Reserved 6

7 Root Cause is an initiating cause of a causal chain which leads to an outcome or effect of interest (Webster). Goal: Seek to identify and address root causes rather than causal factors. All Rights Reserved 7

Injury Near Miss Property Damage Environmental Release

10 Managers/supervisors of the employees involved or those who work in the area where the incident took place Employees involved or witness to incident Employees who have expertise with the work being performed or area where the incident took place Facility safety committee Corporate Safety Department Third party experts All Rights Reserved 10

At the scene of the incident if the analysis can be done safely.

13 Appropriate PPE Digital Camera/Video Capability Tape Measure/Measuring Wheel Flashlight Caution/Danger Tape Lockout/Tagout Equipment (locks/tags) Pens, paper, legal pads, etc. Others? All Rights Reserved 13

14 The degree of analysis is determined by the severity or potential severity of the incident. Regardless of the severity/potential severity of an incident, thorough analysis will provide a valuable learning opportunity for all involved. All Rights Reserved 14

Secure the scene immediately after the incident: Caution/Danger Tape Barricades Divert Traffic

17 Identify, eliminate or reduce any hazards that may be present. This may include: Lockout/Tagout Bloodborne Pathogen Issues Ensuring Adequate Lighting Filling Out Applicable Permits Note: These activities should be performed by qualified individuals. All Rights Reserved 17

18 All tools and equipment should be left in place until all critical information has been gathered. Photos of the area should be taken to include: Equipment Involved Property damage Location of equipment/vehicles/employees Hazards/working conditions Others? All Rights Reserved 18

Helpful to ask preliminary questions of those involved

20 What was the exact location of the incident? What time did the incident occur? What was the person doing at the time of the incident (if applicable)? What types of equipment were involved? Was equipment involved in proper working order? Was the employee qualified to perform the task? All Rights Reserved 20

21 Was proper equipment available and in use during the task? Do operating procedures or JSA exist for the task? Was the employee trained on the SOP or JSA? Was the person following established procedures? Others? All Rights Reserved 21

What were the physical conditions of the area prior to and during the events leading to the

24 Provide information critical to the analysis Help identify causal factors Should involve anyone directly involved and witness to the incident Should take place ASAP after the event All Rights Reserved 24

25 Tips for Conducting a successful interview Conduct in a neutral area where interviewee will feel comfortable Establish the purpose of the interview as fact finding, not for placing blame or finding fault Have interviewee give their version of the incident and the sequence of events Repeat the chain of events to the interviewee to ensure that they are accurate All Rights Reserved 25

Discuss possible ways to prevent future incident Have the interviewee

28 Many factors trigger the sequence of events that lead to an incident. In order to effectively identify the causal factors and root causes we will explore two tools: Five Why Analysis The Fishbone (Cause and Effect) Diagram All Rights Reserved 28

29 What is it? Systematic technique used to identify the causal factors and root cause of a problem. Can be used for all incidents regardless of severity. Preferred for injuries, or near misses with low potential for causing injury, environmental releases, property damage, etc. All Rights Reserved 29

30 Assemble the Analysis Team De fine the Problem Ask the First Why Ask Why at Least Four More Times in Succession Identify the Root Cause De velop an Action Plan to Identify the Root Cause Ensure that Action is Taken. All Rights Reserved 30

Should consist of persons knowledgeable of the incident, work being done, general area, etc.

33 Example: Why are employees slipping on the exterior walkway between warehouse #1 and #2. Answer: Rain or water from snow melt is draining to this area, settling and freezing during cold weather. All Rights Reserved 33

34 Example: Why is water draining from the roof and settling in this area rather than being diverted to a drain. Answer: The condition of the warehouse gutters has deteriorated. Water from the roof is not being directed away from the area. All Rights Reserved 34

Example: Why have the gutters deteriorated?

37 Why hasn t a program been developed to evaluate roofs, gutters, etc. on a consistent basis? Answer: Management/Maintenance had not identified the gutter condition as an issue/concern. All Rights Reserved 37

38 Management will require an annual inspection process for roofs, gutters, etc. Deteriorated gutters will be replaced within the next four weeks. In the meantime all employees will be briefed on the hazard and instructed to use other routes if possible, ice-melt will be applied to the area as needed. All Rights Reserved 38

39 1 st Why (is that)? Water is accumulating in this area and freezing during cold weather. 2 nd Why (is that)? Water from warehouse roofs is draining to this area and settling. During cold weather the water freezes. 3 rd Why (is that)? The condition of the gutters has deteriorated. Water from roofs is not directed away from the area. Remember that sometimes the process may involve asking why more than five times. 4 th Why (is that)? Gutters are over forty years old and have not been replaced. 5 th Why (is that)? Building roofs and gutters are not being evaluated consistently and replaced as needed. Corrective Action Level of Why Corrective Action: Develop an annual inspection process for roofs/gutters. Replace deteriorated gutters. Short term ensure that all employees are aware of the hazard and apply ice melting products as needed. All Rights Reserved 39

41 Tool that can be used to identify causal factors/root causes and corrective actions Recommended use: All incidents, injuries or near misses or those with significant potential A greater level of analysis than The Five Why s Performed with a diagram that looks like the skeletal system of a fish All Rights Reserved 41

42 The following materials are needed to conduct a fishbone analysis: Large flip chart or dry erase board Tape Markers (dry erase, other), pens, etc. Persons knowledgeable with the problem or process being analyzed. Post-its Facilitator All Rights Reserved 42

43 Assemble the Team Decide on Problem and Write it Down Draw a Fishbone Diagram Identify the Major Causal Factors and Connect them to the Backbone of the Fish Brainstorm for Each Major Causal Factor. Place the Causal Factors of the Major Causes in Their Appropriate Place. Identify Potential Root Causes Evaluate the Root Causes and Develop Corrective Actions. All Rights Reserved 43

The problem may include incidents such as: Near Miss Property Damage

The problem becomes the head of the fish and the backbone becomes

47 The major causal factors form the major bones of the skeletal system. Causal factors - referred to as the six M s Man (people, physical work, etc.) Machine (technology, machinery, etc.) Materials (raw materials) Method (process) Management (leadership, supervision, etc.) Mother Nature (weather, environmental factors, condition, time, etc.) All Rights Reserved 47

49 Brainstorm for causes for each of the major causal factors (major bones). Think of an area that contributes to the problem. Example: A faulty tool would be a causal factor under the equipment section. For each identified cause ask: Why does this happen? What could happen? Can also implement the 5 why approach to each causal factor. All Rights Reserved 49

53 Evaluate each root cause and develop a corrective action. Corrective actions should eliminate or further reduce the exposure. Helpful to use the hierarchy of controls to help eliminate or reduce exposure. All Rights Reserved 53

54 Hierarchy of Controls Start Here Elimination Substitution Engineering Controls Administrative or Process Controls Personal Protective Equipment Eliminate the hazard all together. Example: good housekeeping Using a less hazardous means Of accomplishing the task. Example: safe chemical Design to eliminate hazards. Example: Installing guards, interlocks, barriers, ventilation, etc. Organize work in a way to minimize hazards. Example: job rotation The last resort when trying to eliminate or decrease exposure All Rights Reserved 54

55 As a team develop an action plan for implementing corrective actions. Each individual action should be tracked until completion. Follow up until corrective actions are implemented, the problem has been eliminated or its exposure reduced. All Rights Reserved 55

Implement improved incident analysis for incidents Invest time to identify the root

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