Root Cause Analysis Tool (RCAT): An Old Tool with a Critical New Twist for Better Prevention AND Safety Culture

Transcription

1 Rt Cause Analysis Tl (RCAT): An Old Tl with a Critical New Twist fr Better Preventin AND Safety Culture Cathy A. Hansell, SMS, CSM, CCSR, MS, JD chansell@breakthrughresults.rg Agenda: Assumptins Rt Cause Analysis Tl (RCAT) Definitins Prcess Cnsidering the Influencers : What Peple Knw, See and Feel Rt Cause Chart Tips and Traps Practical Applicatin 1

2 Assumptins An underlying rt cause and ther cntributry causes Peple react t their current wrk design, peple and systems First seek the underlying wrk, safety management system and cultural defects, nt placing blame. A tl easy t use and effective fr future preventin Incident Investigatin Prcess Map Rt Cause Incident Investigatin and Crrective Actin Prcess Key Prcess Input American Standard Incident Investigatin Prcedure Lcal Regulatry requirements Site emplyee listing Management decisin Incident investigatin prcedure Identified team members Develp Lcal Incident investigatin Prcedure Select pssible incident investigatin Team members Prepare team members thrugh training and exercise Key Prcess Output Lcal Incident investigatin prcedure listing with incident investigatin team members members trained, ready t deply prcedure INCIDENT Brken Prcess Unsafe Acts Fatality, Injury, First aid, Near miss Unsafe Cnditins Envirnmental Spill Questins : Wh? What? When? Where? Incident ntificatin Prblem Statement (cncise event descriptin) Incident investigatin prcedure Appint team leader and activate team Incident investigatin start Prblem Statement 6 hurs Interviews Observatin Cllect evidence - Dcumented direct evidence (scene, witnesses) Pht's - Indirect evidence (written surces) RCAT Direct/Indirect evidence 5 Why Organize evidence fr immediate cause identificatin Fishbne with 6 M's Excell tab Immediate cause listing 24 hurs Answer n "Hw the accident happened" Fishbne with immediate causes 5 Why Identify System Rt cause fr each immediate Rt cause and cntributry cause listing Excell tab Ptential system cause listing cause 48 hurs Rt cause and cntributry cause listing Develp prpsal fr crrective actin that eliminate 72 hurs Crrective actin plan with respnsible persn and target date identified rt causes Preventive actin plan with respnsible persn and target date Rt cause listing Actin plan Actin plan - actin steps Prepare reprt fr management apprval Implement crrective actins and check effectiveness Reprt and actins apprved by management Crrected wrk envirnment Safety Alert Crrected wrk envirnment Incident investigatin reprt Share key learnings Cntinuus imprvement 2

3 Definitins Prblem Obstacle t safety. The effect f an incident Rt Cause Basic, underlying reasn fr an undesirable cnditin r prblem which, if eliminated r crrected, wuld have prevented the prblem frm existing r ccurring. Systemic, prcess, lng-term Causes: Immediate seen ; shrt-term Cntributry - wrsens effect, severity and frequency f prblem; shrt-term Slutin - Permanent eliminatin f the prblem and rt cause. Implementatin Actin plan: dcumentatin; intrductin; training, tracking and auditing. The 4 Twists Prcess and Influencers 1. Underlying Belief: Emplyees are influenced by wrk, prcesses, supervisrs and peers that surrund them...t the pint f creating a rt cause 2. Examine wrk prcess steps, equipment, envirnment, supprt prcesses FIRST 3. Influencers at wrk Peple Knw influencing minds Peple See influencing hands Peple Feel influencing heart 4. Persnal influencers Wrk histry, physical cnditin, gegraphic lcatin 3

4 Prcess UNDERSTAND THE WORK PROCESS AND INFLUENCERS Quick Review Fishbne (Ishikawa) Diagram (six M s: Man, Materials, Methd, Machine, Measurement/Metrics, Mther Nature\Envirnment) Five WHY Technique r Fault-Tree add ther influencers Utilize the Rt Cause chart t identify persnal and jb factrs and specific underlying rt cause Link causes t the Maturity Path/Management System CORRECTIONS - Implement, track and mnitr The Fishbne Diagram: Metrics/Measurement Manpwer Machines Effect Suggested frmat (Injury/Illness) frm (Event r Task) Materials Methds Mther Nature/Envirnment 4

5 5 Why Example 1. Why did the shipment arrive late? The driver did nt get t wrk n time blame the driver 2. Why did the driver nt get t wrk n time? He ver slept blame the driver 3. Why did he versleep? He was wrking t much vertime blame the driver 4. Why was he wrking t much vertime? There weren t enugh drivers available System prblem 5. Why weren t there enugh drivers available? Because three drivers quit last week System/cultural prblem 5 Why s - TIPS AND STEPS 1. Use a fishbne chart t identify immediate causes. Cnsider these the 1 st why f 5 whys 2. Brainstrm pssible causes frm these first immediate causes. These will be the 2 nd why f the 5 whys. 3. Select a target fr deeper rt cause evaluatin: Lk fr reccurring pattern f causes; r an issue, which if slved, wuld remve all thers causes. 4. Brainstrm pssible deeper causes 3 rd, 4 th and 5 th whys 5. Selecting the rt cause by definitin: Basic reasn fr an undesirable cnditin r prblem which, if eliminated r crrected, wuld have prevented the prblem frm existing r ccurring. Systemic r cultural based. A gd rt cause is ne where we can change r influence a prcess r system t remve the reasn r influence fr an unsafe act r cnditin fr gd. 5

6 5 th RCAT SELECTION - TIPS AND STEPS Lk at the: wrk prcess wrk systems the influencers what peple knw, see and feel as pssible rt cause, and ther cntributing causes RCAT: Persnal r Jb factr; thers-cntributers Check Chart fr specific cause A gd rt cause is ne where we can change r influence a prcess r system t remve the reasn r influence fr an unsafe act r cnditin fr gd. Rt Cause Analysis Tl Chart (partial detail view) Leadership and Management Cmmitment (A) 8. Management / Emplyee Leadership 8.01 (A) Cnflicting rles/respnsibilities Cntractr Selectin and Oversight Lack f cntractr prequalificatins 10. Engineering Design 11. Wrk Planning Inadequate technical design Inadequate wrk planning Assciate Invlvement (B) 8.02 (A) Inadequate leadership 9.02 Inadequate cntractr prequalificatin Inadequate technical design: design input bslete (E) Inadequate Preventive maintenance KEY: American Standard Maturity Path S&H Business Integratin S&H Risk Identificatin and Expsure Assessment (D) S&H Risk Reductin and Management (E) S&H Prcedures (F) S&H Training (G) 8.03 (E) 8.04 (D) (E) 8.07 (A) Inadequate crrectin f wrksite/jb hazards Inadequate identificatin f wrksite/jb hazards Inadequate management f change system Inadequate incident reprting/investigatin system Inadequate r lack f safety meetings (A) 9.05 (D) 9.06 (D) Inadequate cntractr selectin Inadequate technical design: design input nt crrect Use f nn-apprved cntractr Inadequate technical design: design input nt available Lack f jb versight Inadequate technical design: design input infeasible Inadequate versight Inadequate technical design: design utput inadequate Inadequate technical design: design utput unclear (D) Inadequate Preventive maintenance: assessment f needs Inadequate Preventive (E) maintenance: lubricatin/servicing Inadequate Preventive (E) maintenance: adjustment/assembly Inadequate Preventive (E) maintenance: cleaning/resurfacing (E) Inadequate repair maintenance S&H Resurces (H) 8.08 Inadequate perfrmance measurement and assessment Inadequate technical design: design utput nt crrect (E) Inadequate repair maintenance: cmmunicatin f needed repair S&H Metrics and Data Analysis (I) 6

7 Target Areas 1-BEGINNING Sample Prtin f a Maturity Path 2- MEETING MINIMUM STANDARD 4- SUCCEEDING 5-LEADING SHE Integratin int all ISC Prcesses (ps, engineering, maintenance, prcurement, etc ) Safety impacts are cnsidered in the management f change prcess, but nt n a rutine basis and nt always early enugh in the prcess. Safety issues are nt incrprated at all r timely enugh int ther ISC peratinal, planning, r decisin prcesses. Operatinal wrk practices and prcedures are dcumented fr all significant wrk dne n the site. MOC prcess, including nting and addressing safety impacts, is understd and dcumented in all regulated change management events Other ISC prcesses and Cmmercial decisins incrprate SHE issues timely in the prcess Mst peratinal wrk practices and prcedures include a descriptin f the safety hazards, and precautins f ding the prescribed wrk. The MOC prcess, including nting and addressing safety impacts, is cmmn at all sites with identical terminlgy. A safety review is dcumented fr all prjects & majr maintenance events (verhauls, turnarunds) Cmmercial planning (new prduct develpment, etc ) includes a dcumented safety review early in the decisin-making prcess. All ISC and Cmmercial prcesses facilitate safety risk reductin strategies in all decisins made. Operatinal wrk practices and prcedures are peridically reviewed fr changes frm actual practice, prcedures are updated as needed, and gap training is cmpleted t ensure all emplyees knw the best, current prcedures, safety risks and safeguards.. MOC prcess best practices are shared acrss all sites. Leadership ensures that safety cnsideratins are prperly integrated int all business prcesses, tls and decisins. Leadership ensures that envirnmental, security and health (ESH) cnsideratins are als prperly integrated int all business prcesses, tls and decisins. Safety and ESH are cnsidered a strategic cmpnent f business and wrkfrce planning. Business prcesses effectively wrk tgether t reduce risks and expsure t hazards and make sund safety and SHE decisins, as early as pssible. A prcess is in place t benchmark peratinal wrk practices and prcedures with all five plants and with best in class cmpanies frm safety and SHE perspectives. Crrective actin-refer t maturity path r management system Shrt term crrectins fr immediate causes Lng term preventative crrectins fr rt cause Gd crrective actins will change a prcess r accepted way f wrking r behaving. Track, mnitr, audit Crrective Actin - TIPS AND STEPS Cntinue the imprvement prcess Select immediate causes and cntributing factrs t slve ther immediate prblems: shrt -term slutins. A gd rt cause is ne where we can change r influence a prcess r system t remve the reasn r influence fr an unsafe act r cnditin fr gd. 7

8 Nw what?... Think pr-actively Uses f RCAT Accident Incidents Risk Analysis hazards and expsures Current Safety Prgrams RCAT is a structured way t analyze why did this happen? r better why d we d things this way nw? Can it be changed t be safer? Tips Preparatin : 1. Maturity path r management system 2. Educatin bust ld myths 3. Templates make it easy 4. Review and mnitr the prcess 5. Track clsure f crrective actins 6. Track effectiveness f crrective actins 8

9 Tips Usually a Culture-Business integratin rt cause 1. Unplanned events r tasks 2. Nt d a pre-jb r pre-task review, n JSA r JSHA 3. Insufficient manning, planning, equipment, time 4. Jb design with inherent hazards r risks nt remved r nt mitigated 5. Rutine jb turns nn-rutine and n MOC dne 6. Unit r plant des nt see the risk---wrk is rutine, usual way this leads t n prcedures, n training, n enfrced pre-jb reviews, undefined ppe, different ways t d the jb Cultural Leadership 1. Unsafe acts cndned 2. Unsafe tls, equipment and prcesses cndned Tips Mtivatins...strng influences, as cntributing factrs, but are usually nt rt causes: 1. Nt ask fr help 2. Rushed 3. New-reluctant t ask fr help 4. Seasned vet-cmplacent with lng-standing wrk tasks and inherent risks; established wrk-arunds 5. Unsafe Peers actins r caching 6. Unsafe Supervisr actins 9

10 Sample Data Analysis Injury Rt Causes - All Emplyees in % NOTE: SHE Integratin (56%) cmbines SHE included in wrk tasks and design, AND wrk supprt, like planning, prejb reviews, scheduling and manning ESSH Integratin Risk assessment Emplyee decisin/actin Inadequate Prcedure Inadequate Training Traps 1. Nt digging deep enugh stpping t sn 2. Blaming the injured persn, instead f examining wrk dne and cntributing factrs 3. Fcusing n immediate causes, like ppe r training 4. Cnsider the influencers (cntributing factrs) Usually nt the rt cause Must be addressed they increase prbability, frequency and wrsen effects 5. Leadership Skills needed t imprve engagement and caching thers 6. Technical Skills needed t reduce hazards r risks f expsures 7. Needed peple are nt invlved in investigatin and analysis 10

11 Case Study Machine was recently mved frm ne building t anther On cmpletin f her wrk, the emplyee intended t shut dwn the machine. Fr this purpse she climbed n the rear side f the system. In the prcess she placed her ft n a bundle f cables that was fastened t the middle f the cntrl cabinet. After a shrt mment, the cntrl cabinet tilted tward the system s access staircase and hit the emplyee in the back. Nw define the Effect. Metrics/Measurement Manpwer Machines Climbing n equipment unsafe psitin, n ne stpped Pr access t machine cntrls Cntrl panel nt blted t the flr Effect Back injury frm being struck by Cntrl Panel Rt Cause Maintenance did nt receive a wrk rder Dept. did nt issue wrk rder Machine mve was perfrmed by Dept. Dept did nt fllw prcess change prcedure (MOC) Cngested wrk area Materials Methds Mther Nature/Envirnment Referring t the RCAT Chart.. 11

12 Use the selected rt cause t identify the System cause: 1. Target the pssible underlying cause fr further analysis. 2. Refer t the Rt Cause Analysis Tl (RCAT) Chart Is the identified rt cause a persnal r jb factr? Lk acrss the Rt Cause Chart Clumns fr the ne that best describes the pssible rt cause. Lk dwn the clumn fr the best descriptin f the underlying rt cause a system issue. Link t a maturity path/management system Rt Cause Analysis Tl (RCAT) - Chart, Hw des that wrk? Under Jb Factrs categries: 7. Training / Knwledge transfer 8. Management/Emplyee Leadership 9. Cntractr selectin and versight 10. Engineering design 11. Wrk planning 12. Purchasing, Material handling and Cntrl 13. Tls and equipment (ergnmics) 14. Prcedures, plicies, rules, 15. Cmmunicatin 8.05 Management f Change 12

13 Jb Factr: 8. Management/Emplyee Leadership Under Management/Emplyee Leadership we find: Inadequate Management f Change System 1. This is linked by clr cde and letter t the Maturity Path/Management System element S&H Business Integratin. 2. We ve nw linked the rt cause t the Maturity Path element that needs imprvement t prevent this rt cause frm negatively influencing the riginal prcess. 3. Further analysis f the affected Maturity Path/Management System element must ccur t identify systemic crrective actin(s). SUMMARY - The 4 Twists Prcess and Influencers REMINDER: Critical t gather infrmatin - cmpletely, penly, neutrally 1. Underlying Belief: Emplyees are influenced by wrk, prcesses, supervisrs and peers that surrund them...t the pint f creating a rt cause 2. Examine wrk prcess steps, equipment, envirnment, supprt prcesses FIRST 3. Influencers at wrk Peple Knw influencing minds Peple See influencing hands Peple Feel influencing heart 4. Persnal influencers Wrk histry, physical cnditin, gegraphic lcatin 13