Incident Investigation - Grainnet

1 Copyright © 2012 Sologic, LLC. All Rights Reserved.

Incident Investigation What should I do?

Chris Eckert, President

Sologic, LLC

989-835-3402

[email protected]

www.sologic.com

2 Copyright © 2011 Sologic, LLC. All Rights Reserved. 2 Copyright © 2012 Sologic, LLC. All Rights Reserved.

Incident Investigation-Overview

• Why Investigate?

• Steps for an Incident Investigation

• Example


About Sologic • Root Cause Analysis

– Training – Software – Incident Investigations

• Offices Locations

– North America (Midland, MI-- Home office) – London – Hong Kong – Sao Paulo – Sweden – Australia – Buenos Aires – S. Africa – Al Khobar, Saudi Arabia

▲

x x

x

x

x

x x

x

Languages: English, Spanish, Dutch, Portuguese, Chinese (Mandarin & Cantonese),

Swedish, French, German


Have you heard these before? Root Cause: “Employee didn’t recognize the hazard” “Employee was not paying attention” “Employee didn’t follow procedure”

Popular Solutions: “Reinforce the need for Employees to be aware of their surroundings” “Communicate importance being alert at all times” “Retrain on procedure”

How Effective are these Solutions??


Incident Investigation

If your purpose is: – Basic Compliance?

• Fill out & file OSHA/regulatory compliant form

Nothing changes. You continue with the same risk.

– Prevention? • Perform an Investigations. Dig deeper. Determine causes

– Actionable issues will be uncovered

– Sustainable improvement opportunities will be found

Risk will be reduced setting you on the path to prevention!


When you investigate incidents…

Operational deficiencies

Procedure gaps

Quality problems

Maintenance oversights


When an Incident Occurs……. • Implement Emergency Plan (if applicable) • Obtain medical/ER assistance • Secure the site • Begin Notifications

– Internal • Leadership • Site Personnel • Legal • PR

– External • Law Enforcement • Regulatory

• Start gathering data (or direct others to do so) – Site Photos – Interviews – Broken equipment – PPE – Process control data

Incident Management

Incident Investigation


Gather & Manage Data

Create the Problem

Statement

Analyze Cause & Effect

Generate Solutions

The first step in an

investigation is to

gather and manage

data.

The data gathered

supports the

investigation.

After initial data

gathering, the next

step is to create the

problem statement.

This is done by the

investigation team

and stakeholders.

The third step is to

analyze the causes

of the problem.

Causes need to be

supported with

evidence.

Causal relationships

need to be validated.

Once causes are

identified, supported,

and validated,

corrective and

preventive actions

need to be identified.

Final recommendations

are determined and an

implementation plan

developed.

Produce the Final Report

The report is the

final deliverable of

the investigation.

We need to share

what has been

learned with others.

Without a report, the

investigation is

incomplete.

1 2 3 4 5

Incident Investigation/Root Cause Analysis (RCA)- 5 Steps




Create the Problem

Statement


Generate Solutions


investigation is to

gather and manage

data.

The data gathered

supports the

investigation.

After initial data

gathering, the next


problem statement.

This is done by the

investigation team

and stakeholders.


analyze the causes

of the problem.

Causes need to be

supported with

evidence.



Once causes are


and validated,

corrective and

preventive actions




implementation plan

developed.


The report is the


the investigation.

We need to share

what has been



investigation is

incomplete.

1 2 3 4 5


What Data do I look for? People: Procedures & Documentation:

• Who was involved in the incident?

• What roles did they play? • Who else is knowledgeable

about the process and/or incident?

• What procedures were involved? • Formal or informal?

• What kind of documentation is available?

• What training was involved? • How are procedures audited?

Hardware, Software, & Systems: Environment:

• What kinds of hardware / software were involved?

• What is the purpose of the hardware / software?

• How does it fit into the overall system?

• What were the environmental conditions?

• What role did the environment play?

• Inside or outside? • Summer or winter?


Data (Examples) People: Procedures & Documentation:

• Witnesses • Operators • Maintenance techs • Supervisors • Managers • Suppliers • Customers

• Standard Operating Procedures • Hazard Assessments • Maintenance procedures • Work order history • Server log files • Training & attendance records • Audits

Hardware, Software, & Systems: Environment:

• Control logic • Broken equipment • Material specs • Tools • PPE • Software

• Indoor vs outdoor • Weather • Airborne dust • Lighting • Temperature • Humidity

12 Copyright © 2011 Sologic, LLC. All Rights Reserved. 12 Copyright © 2011 – 2012 Lyncsolve Publishing, LLC. All Rights Reserved.

If first on the scene, what would you do? What evidence would you collect/preserve?

13 Copyright © 2011 Sologic, LLC. All Rights Reserved. 13 Copyright © 2011 – 2012 Lyncsolve Publishing, LLC. All Rights Reserved.

Interviewing

• Prepare a list of questions ahead of time

• What do you ask?

– Start with open-ended questions:

• “Please help me to understand what happened”

• “What did you see?” or “hear”, “feel”, “taste”, “smell”, etc.

• “Could you explain that process?”

• Listen closely. Take good notes. Be considerate

• Choose a quiet, private room near their work

– Don’t haul them up to the ‘front end’




Create the Problem

Statement


Generate Solutions


investigation is to

gather and manage

data.

The data gathered

supports the

investigation.

After initial data

gathering, the next


problem statement.

This is done by the

investigation team

and stakeholders.


analyze the causes

of the problem.

Causes need to be

supported with

evidence.



Once causes are


and validated,

corrective and

preventive actions




implementation plan

developed.


The report is the


the investigation.

We need to share

what has been



investigation is

incomplete.

1 2 3 4 5


Example Problem Statement Focal Point: Burned right hand to employee

When: Date: July 28, 2014; 10:30am

Unique: While disconnecting wiring inside breaker panel

Where: Facility: Steel recycling plant; Cleveland, OH

System: MCC for Overhead Crane

Component: Breaker box 204

Impact: Safety: 2nd degree burn to right hand. LTA/OSHA recordable.

60 day restricted duty

Revenue:

Plant shutdown for 4 hours

Cost:

$20,000 medical treatment

$4,000 OT

$3,000 to repair electrical damage from arc flash

$7,000 workers compensation

$34,000 Total

Frequency: 2nd electrical flash over burn this year

Potential

Impact: Potential Electrocution/Fatality


Problem

Cause & Effect

Relationships

Solutions

RCA--its most basic form

Because Solutions

eliminate Causes

Normally, people

jump right to

Solutions.

However, we

need to first

understand……




Create the Problem

Statement


Generate Solutions


investigation is to

gather and manage

data.

The data gathered

supports the

investigation.

After initial data

gathering, the next


problem statement.

This is done by the

investigation team

and stakeholders.


analyze the causes

of the problem.

Causes need to be

supported with

evidence.



Once causes are


and validated,

corrective and

preventive actions




implementation plan

developed.


The report is the


the investigation.

We need to share

what has been



investigation is

incomplete.

1 2 3 4 5


Cause and Effect

Spilled water

Upset container

Water in container

Open-top container

Focal Point

Transitory

Non-Transitory

Non-Transitory

Transitory causes represent a

changes. These include

movements, actions, decisions,

forces applied, etc

Non-Transitory causes

represent properties, status, or

conditions


Cause and Effect Example

Causelink® RCA software

Trial download: www.sologic.com


Cause and Effect Example






Create the Problem

Statement


Generate Solutions


investigation is to

gather and manage

data.

The data gathered

supports the

investigation.

After initial data

gathering, the next


problem statement.

This is done by the

investigation team

and stakeholders.


analyze the causes

of the problem.

Causes need to be

supported with

evidence.



Once causes are


and validated,

corrective and

preventive actions




implementation plan

developed.


The report is the


the investigation.

We need to share

what has been



investigation is

incomplete.

1 2 3 4 5


Solutions

Solutions eliminate Causes

Eliminating Causes = Breaking of Causal Chains

Breaking Causal Chains = Prevention of Repeat Events

This is the end game for why you investigate incidents


Solutions

Spilled water

Upset container

Water in container

Open-top container

Focal Point

Transitory

Non-Transitory

Non-Transitory


Solutions

Spilled water

Upset container

Water in container

Open-top container

Focal Point

Transitory

Non-Transitory

Non-Transitory


Solutions

Spilled water

Upset container

Water in container

Open-top container

Focal Point

Transitory

Non-Transitory

Non-Transitory


Solutions Example




Solutions Example


Wrap up/Questions

For more information on RCA training, software and incident

investigation support…….

www.sologic.com

Chris Eckert

989-835-3402

[email protected]

Documents

Incident Investigation - Grainnet