Objectives

Students will be able to:

Differentiate between Surface and Root Causes

Define Change Analysis, Barrier Analysis, MORT, Kepner-Tregoe Problem Solving and Decision Making.

Identifying Causes of Accidents Surface vs. Root Causes Surface causes are:

the hazardous conditions or unsafe work practices that directly or indirectly contributed to the accident.

Root causes are: the safety or loss control system weaknesses

that allow the existence of hazardous conditions and unsafe work practices.

Most accident investigations only identify the surface causes of accidents.

Major Concept tonight

Investigation Methodical Analytical Systematic process

Events and Causal Factor Analysis Events and Causal Factor Analysis

identifies the time sequence of a series of tasks and/or actions and the surrounding conditions leading to an occurrence.

The results are displayed in an Events and Causal Factor chart that gives a picture of the relationships of the events and causal factors.

Example chartshttp://www.docstoc.com/docs/43977209/Event-and-Causal-Factor-Chart

Participation opportunity

Name some “Surface Causes.”

Name some “Root Causes”

Change Analysis (DOE SSDC-4 1983)

Change Analysis is used when the problem is obscure.

It is a systematic process that is generally used for a single occurrence and focuses on elements that have changed.

Example: worker comes in early and starts work therefore didn’t get a safety briefing

Barrier Analysis (DOE SSD-4 1983)

systematic process that can be used to identify physical, administrative, and procedural barriers or controls that should have prevented the occurrence.

Barrier Defined: A construct between a hazard and a target, intended to prevent undesired effects to the target

http://www.bill-wilson.net/b52.html

Management Oversight and Risk Tree (MORT) Analysis

MORT and Mini-MORT are used to identify inadequacies in barriers/controls, specific barrier and support functions, and management functions.

It identifies specific factors relating to an occurrence and identifies the management factors that permitted these factors to exist.

(Vincoli, p.190)

Human Performance Evaluation Human Performance Evaluation

identifies those factors that influence task performance.

The focus of this analysis method is on operability, work environment, and management factors.

Man-machine interface studies to improve performance take precedence over disciplinary measures.

Kepner-Tregoe Problem Solving and Decision Making management consulting firm systematic framework for gathering, organizing,

and evaluating information and applies to all phases of the occurrence investigation process. Phases:

Situation appraisal: Identify concerns Problem analysis: Define the problem (Similar to Change

Analysis) Decision Analysis: Evaluate alternatives, assess risks Potential Problem Analysis: What new problems may be

introduced by the alternatives?

http://www.kepner-tregoe.com/AboutKT/AboutKT.cfm

Accident Investigation Process The accident investigation process involves the

following steps: Report the accident occurrence to a designated

person within the organization Provide first aid and medical care to injured person(s)

and prevent further injuries or damage Investigate the accident Identify the causes Report the findings Develop a plan for corrective action Implement the plan Evaluate the effectiveness of the corrective action Make changes for continuous improvement

Participation Opportunity

How do you evaluate the effectiveness of any of your programs?

Retrospective Investigations Retrospective investigations are

accident investigations that look back in time at a situation. Most investigations conducted in the workplace can be classified as a retrospective investigation.

Statistical Investigations Statistical investigations utilize data

collected over a period of time to determine causes and develop prevention measures.

Statistical investigations utilize mathematical techniques that identify the causes for accidents in terms of statistical probabilities.

Give some examples from your organization of statistical investigations (post accident)

Large Loss Investigations in-depth investigations directed at an

accident that resulted in a larger than usual loss of life, money, or property damage.

Examples of large loss investigations include large industrial fires, plant explosions, and airplane crashes

Chemical Safety Board http://

www.youtube.com/watch?v=ob7OM3v5zXo&list=UUXIkr0SRTnZO4_QpZozvCCA&index=1&feature=plcp

Systems Investigations

Systems investigations utilize a systems approach to the identification of causal factors.

There are a variety of systems investigation techniques available including root cause analysis, Fault Tree Analysis (FTA), and Failure Modes and Effects analysis (FMEA).

Conclusions

Differentiate between Surface and Root Causes

Define Change Analysis, Barrier Analysis, MORT, Kepner-Tregoe Problem Solving and Decision Making

Questions?

Sources

http://www.hss.energy.gov/sesa/analysis/orps/taskgroup/HPI_Investigation_Slides_for_EFCOG.pdf

Los Alamos Human Performance Investigations training (informative)

http://www.kepner-tregoe.com/NewsArtPub/InTheMedia.cfm

Additional reading

http://fmea-fmeca.com/how-is-fmea-done.html How to conduct FMEA