Injury Investigation Process Using Root Cause Analysis 1
Objectives Review why injury investigations & multiple root cause analysis are important. Discuss the elements of an effective injury investigation that not only gathers the relevant facts but uncovers and corrects the root causes of injuries. Dissect the injury investigation process. Apply several multiple root cause analysis tools.
Injury Investigation Procedures Investigate all injuries. Investigate immediately. Investigation led by Supervisor & Safety Team. Include appropriate people on the investigation team (immediate supervisor, Safety Team member, Maintenance/Engineering, etc.). Manager needs to be involved. Use the injury prevention report S070a. 3
Injury Investigation Procedures Seven steps Step 1 manage the incident scene Step 2 gather facts about what happened Step 3 conduct interviews Step 4 determine the sequence of events Step 5 determine root causes Step 6 plan prevention activities Step 7 complete injury prevention report 4
Step 1 Manage the Scene Ensure care and treatment of the injured Eliminate remaining hazards (i.e. clean- up spill, secure electrical), don t wait for investigation process to control a known hazard. Preserve and secure the scene of the Injury Maintain site as it was at the time of the incident. Secure for the duration of the investigation. Photograph, videotape, or diagram scene. Does critical evidence needs to be preserved? Possible third party involvement? 5
Step 2 Gather Facts Identify stakeholders that will need to be involved and how investigation will be done. Recognize when additional expertise is needed to evaluate complex operations or equipment. Observe weather and environmental conditions Observe control settings Review documents Evaluate the same operation in other areas to look at possible differences. 6
Step 3 Interview Conduct the interview as soon after the incident as possible. Keep the interview private to avoid group biases. Identify yourself. Put the person at ease, create a relaxed atmosphere. Focus on fact-finding finding not fault-finding. finding. Let the employee know from the start the purpose is not to find blame. Get all sides and request ideas for prevention. Don t jump to conclusions and recommendations too quickly. Ask known witnesses to identify others who were in the area (additional witnesses). Interview everyone who heard or knows something about the event. 7
Step 3 Interview Ask for description in their own words. Ask open ended questions. Allow them to tell their own story. Conduct interviews using Simple Approaches Who, What, Where, When, Why, How. Look for facts, beware of smoke screen. Listen, test, investigate and validate all evidence. Repeat the story back, probe into all aspects of the incident, get all sides of the story. Keep probing for more information. What else can you tell me that might have been a factor? Close the interview on a positive note. 8
Step 4 Determine the Sequence of Events There will be more than one contributing factor present in all incidents. Therefore, it is essential to determine how the situation developed to the point where an incident occurs. Who did what? What happened before that? Who was involved? When? Why did that happen? Ask why, why, why, why, why 9
Step 4 Determine Sequence of Events Pulley crushes finger Injury -1-2 -3-4 -5-6 -7-8 Bob works adjacent to unguarded pulley Bob behind schedule Doesn t want to make supervisor mad Production running behind 10
Step 4 - Sequence of Events No one is disciplined Others working by the unguarded pulley Replacing guard would slow work Pulley crushes finger Bob decides to ignore missing guard Injury -1-2 -3-4 -5-6 -7-8 Bob works adjacent to unguarded pulley Bob behind schedule Doesn t want to make Production supervisor mad running behind 11
Pulley crushes finger Bob decides to ignore missing guard Pulley is noisy Step 4 - Sequence of Events No one is disciplined Others working by the unguarded pulley Replacing guard would slow work Lubricate pulley Maintenance removes guard Injury -1-2 -3-4 -5-6 -7-8 Bob works adjacent to unguarded pulley Bob behind schedule Doesn t want to make Production supervisor mad running behind 12
Pulley crushes finger Bob decides to ignore missing guard Pulley is noisy Step 4 - Sequence of Events No one is disciplined Others working by the unguarded pulley Replacing guard would slow work Lubricate pulley Maintenance removes guard Injury -1-2 -3-4 -5-6 -7-8 Bob works adjacent to unguarded pulley Bob behind schedule Doesn t want to make supervisor mad Production running behind Maintenance doesn t replace guard Maintenance directed to stop and fix other equipment High priority emergency repair In other area of operation 13
Step 5 Determine Root Causes Weeding Out The Causes Of Injuries And Illnesses Direct Causes Surface Causes Root Causes 14
Step 5 Determine Root Causes Direct Cause of Injury Harmful transfer of energy - kinetic, thermal, chemical, etc. Contact with, exposure too, etc. Burns Strains Cuts 15
Primary Surface Causes Directly causes the injury event Unique hazardous conditions Individual unsafe behaviors Events occur close to the injury event Controllable or uncontrollable factors Failure to perform safety practices, procedures, processes Involves the victim, others Burns Unguarded machine Broken tools Chemical spill Defective PPE Untrained worker Lack of time To much work Strains Step 5 Determine Root Causes Secondary Surface Causes Indirectly causes the injury event Specific hazardous conditions Individual unsafe behaviors Events occur distant to the injury event Controllable or uncontrollable factors Failure to perform safety practices, procedures, processes Co-workers, supervisors anytime, anywhere Cuts Horseplay Create a hazard Ignore a hazard Fails to report injury Fails to inspect Fails to enforce Fails to train 16
Strains Step 5 Determine Root Burns Implementation Root Causes Common conditions & behaviors Inadequate implementation of safety policies, programs, plans Inadequate design of processes & procedures Pre-exist exist the surfaces causes Controllable Middle management anytime, anywhere System Design Root Causes Inadequate design of safety policies, programs, plans Pre-exist exist all other causes Controllable CEO, Top management anytime, anywhere Causes Unguarded machine Broken tools Chemical spill Defective PPE Untrained worker Lack of time To much work Inadequate training No discipline procedures No orientation process Inadequate training plan No accountability policy No mission statement Lack of vision Cuts Horseplay Create a hazard Ignore a hazard Fails to report injury Fails to inspect Fails to enforce Fails to train No recognition Inadequate labeling Outdated hazcom program No recognition plan No inspection policy 17
Step 5 Determine Root Causes Common Methods There are simple tools for visualization and knowledge organization: 1. Cause & Effect, Fishbone Diagram 2. Process Map 3. Five Why s Diagram All attempt to diagram cause and effect relationships between known facts and possible causes. All rely on brainstorming by investigation team. 18
Step 5 Determine Root Causes Common Methods 19
Step 5 Determine Root Causes Common Methods 20
Step 5 Determine Root Causes 5-Why s Diagram Cause Cause Cause Cause Injury 21
Step 5 Determine Root Causes An employee in the shop steps over a beam onto a flat surface. The beam shifts and the employee loses his balance and falls. He sprains his ankle and has a small cut on his hand from hitting the table nearby as he was falling. The employee in the adjacent work area hears the employee yell and helps him up. The second employee finds the supervisor and the injured employee is taken for medical treatment. 22
Step 5 Determine Root Causes 1.Employee/Behavior 2.Materials/Equipment 3.Environment 4.Methods 23
Step 5 Determine Root Causes 1. Employee/Behavior How long has the employee been doing the job? How familiar is the employee with this working area? How long has the employee been employed with the Company? Has the employee been trained in this type of work? Was another employee involved? 24
1. Employee/Behavior 1. Step 5 Determine Root Causes Was the employee observed as being fatigued or injured before work? Did the employee feel that they sufficiently prepared the job before starting? Does the employee have a good work record and attendance? Were there any prior events that initiated the behavior? Did the employee have any previous injuries? 25
Step 5 Determine Root Causes 2. Materials/Equipment What equipment was involved? Was the equipment used as designed? Was there a known equipment concern prior to the incident? Was the equipment in good working order? 26
Step 5 Determine Root Causes 2. Materials/Equipment Was the equipment available to complete the job? Was there equipment available but not used? Was the equipment used properly? Was the employee trained in how to use the equipment? Was the area congested with excess materials, tools or equipment? Was proper PPE available and utilized? 27
Step 5 Determine Root 3. Environment Was it dark? Causes Was the area sufficiently illuminated? Was it hot? Cold? Raining? Was the surface slippery, wet or icy? Was the walking surface even? Was housekeeping an issue? Noise? 28
Step 5 Determine Root Causes 4. Methods/Work Processes Was there adequate staffing for task/job? What methods were used in and in what sequence? Are there routine concerns (blocked walk ways, equipment breakdowns, etc.) in this area? Was there a pre-planning planning inspection in this area? What defects were noted in the pre- planning inspection of the area? 29
Step 6 Plan Prevention Activities Treat the cause not the symptom Determine corrective actions that will eliminate or reduce root causes Follow the Hierarchy of Control: 1. Engineering Control Eliminate or isolate the risk most effective. 2. Administrative Control Control the risk through education, training, warnings, signs, rules, work methods, etc. 3. Personal Protective Equipment Last resort and least effective. Assign responsibility for action plans and set target dates. Determine ways to measure progress in process and outcomes. 30
Step 7 Complete Injury Prevention Report 31
Root Causal Analysis Review facts related to the problem Group facts into 5 categories People Material Method Machine Environmental Derived from Safety Committee information, Accident Investigation, etc
Why ask Why? Ask Why? at least 5 times for each cause Intent is to move from casual causes to root causes Typical Example: Employee slips, falls and breaks wrist Why #1 Employee not scanning his/her work area, not looking ahead of work. End of story
Why ask Why? Ask Why? at least 5 times for each cause Intent is to move from casual causes to root causes Correct Example: Employee slips, falls and breaks wrist Why #1 Why did employee slip? Water on floor Why #2 Why was there water? Water cooler leaking. Why #3 Why was cooler leaking? No WO ever completed and sent to Maint. Why #4 Why was WO never completed? Sup never trained on how to complete WO. Why #5 Why was supv never trained? Controls not in place to ensure all mgmt is trained on filling out WO.