OHS Accident & Incident Investigation Lecture 2 Root Cause Analysis.PDF

Root Cause Analysis OUR JOURNEY TODAY Review the difference between immediate cause and root cause Explain the various factors that can contribute to incidents Review various methods to conduct a Root Cause Analysis Incident Causation Model Why Analysis: 5 Why’s PEMEP...

Root Cause Analysis OUR JOURNEY TODAY Review the difference between immediate cause and root cause Explain the various factors that can contribute to incidents Review various methods to conduct a Root Cause Analysis Incident Causation Model Why Analysis: 5 Why’s PEMEP Ishikawa (Fishbone) Diagrams Workplace Incident Unplanned, unwanted, but preventable event which disrupts the work process and causes injury to people. Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is preventable might be a new concept. An incident/accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.  To prevent reoccurrence To determine the cost associated with an incident Why investigate To determine compliance with applicable safety regulations incidents? To process workers’ compensation claims Cornerstone for effective safety/ injury prevention program Why Investigate Workplace Incident/Accident Determining the cost of accidents Establish legal liability Identify trends and collect statistical data Minimize or prevent financial loss Show concern for employees & maintain worker morale Improve the health and safety system in the workplace Legal requirements (MLITSD & WSIB)  Direct Costs: Medical Compensation Costs Pension $1 Rehabilitation Building Damage { Tool and Equipement Damage Product and Material Damage Up to $70 Production Delays and Interruptions Legal Expenses Expenditure of Emergency Supplies and Equipment Interim Equipment Rental Investigation Time Hidden or Wages Paid For Time Lost { Cost of Hiring and/or Training Indirect Replacement Overtime Extra Supervisory Time Costs Clerical Time Decreased Output of Injured Worker Upon Return Loss of Business and Goodwill The Aim of the Investigation is NOT Exonerate individuals or management Satisfy insurance requirements Defend a position for legal argument Assign blame → Fact Finding! Incidents are Costing Us: A Few Statistics from the WSIB 2016 Fatalities: 221 Allowed Lost-Time Claims: 43,386 Allowed No Lost-Time Claims: 106,888 WSIB Payments: $2,252,000,000 An incident claim will likely affect a workplace’s WSIB rates Injury Events Causing Lost-Time Claims Impact of Accidents/Incidents Employee Work Place Community  What Would be the Impact?  What Would be the Impact? Causes of Adverse Events What is an The most obvious reason why an adverse event happens immediate cause? What is an The deeper, less obvious ‘system’ or underlying ‘root’ ’organizational’ reason for an adverse event happening cause? Tip of the Iceberg Immediate causes Apparent/obvious cause(s) of the injury; circumstances immediately Immediate surrounding an incident Causes Underlying (root) causes Deeper, systemic issues that contribute to incidents; Underlying real or underlying cause(s) of an event (Root) Causes Analysis The WHAT and WHY factors of accident/ incident investigation: WHAT happened? Identifying/determining the immediate cause(s) What were the conditions? What was the employee doing? WHY did it happen? Identifying/determining the root cause(s)  People What factors Equipment can contribute Material Environment to workplace Process/Method incident?  Incident Causes – People: Management Management holds the legal responsibility for safety in the workplace! Were safety rules communicated to and understood by all employees? Were written procedures available? Were the procedures/rules being enforced? Was there adequate supervision? Incident Causes – People: Employees The physical and mental conditions of those individuals directly involved in the accident must be explored. Was the employee experienced in the work he/she was doing? Was the employee adequately trained for the task being completed? Can the employee physically perform the work? What was the status of the employee’s health at the time of the incident? Was the employee tired at the time of the incident? Incident Causes - Equipment In this area, look for possible causes resulting from the equipment and materials used. Equipment failure? If so, what caused the failure? Was the machinery poorly designed? Was the equipment available but not used? Was the equipment inspected before use? Was the correct equipment used? Incident Causes - Material In this area, look for possible causes resulting from the equipment and materials used. Were hazardous substances involved? If yes, were they clearly identified and properly labeled? Was a less-hazardous alternative substance available? Was the raw material substandard in some way? Was PPE used? If yes, was it appropriate for the task being performed and was it in “serviceable condition?” Incident Causes - Environment The physical environment, including sudden changes to it, are factors that need to be identified. What were the conditions in the work area (example: cold, hot, damp, etc.)? Was poor housekeeping a problem? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts or fumes present? Incident Causes – Process In this category, the actual work procedure being performed at the time of the incident is looked at. Was a safe work procedure used? Did conditions change to make the normal procedure unsafe? Were the appropriate tools and materials available and used? Were safety devices (example: machine guards) in place and working properly? Root Cause Analysis Look beyond the obvious cause(s) Analyze both the immediate and the underlying or root causes of the incident There are multiple causes which interact with each other and the work Realize that some injuries or illnesses may take years to become obvious A root cause is the cause that, if corrected, should prevent recurrence of this and similar occurrences  Incident Causation Model Inadequate Underlying Immediate Event Loss Control Causes Causes (Incident) Substandard Inadequate: Acts/Practices/ Individual At-risk Behaviours Potential Unintended System Factors Loss Harm Substandard R&R Conditions Producing or Compliance Work Damage Event Factors Problem-Solving Model Example: Lac-Mégantic Train Disaster Parked, unattended oil train cars rolled downhill and derailed 47 killed, town destroyed Why? Lac-Mégantic Train Disaster Causes Investigation identified 18 distinct causes and contributing factors Company not effectively managing risks Transport Canada not effectively monitoring Eight months earlier locomotive improperly repaired leading to fire on night of accident, lead to brake failure Employee training, testing, and supervision were not sufficient Ineffective training and oversite on train securement Insufficient hand brakes set and not tested Why Analysis: 5 Why’s 5 Whys Example Why did your car stop? Because it ran out of gas. Why did it run out of gas? Because I didn’t buy gas on my way to work. Why didn’t you buy gas on your way to work? Because I didn’t have any money. Why didn’t you have any money? Because I lost it all during a poker game last night. Why did you lose at poker? Because I’m terrible at bluffing.  5 Whys Example Worker felt ill after exiting space 1. Why did the worker feel ill? Noxious air 2. Why was their noxious air? Sludge residue in tank 3. Why was there sludge residue in the tank? Tank not cleaned, ventilated, or tested before entry 4. Why wasn’t the tank cleaned, ventilated or tested? Worker not trained in hazards and controls 5. Why wasn’t the worker trained? No policy, or procedure for entering and cleaning tanks  PEMEP Factors Contributing to Incidents e.g., equipment that is not available, e.g. what people do adequate or maintained or not do Was there equipment failure? Were they appropriately People Equipment trained? Incident Hazard Material Environment Process e.g., defective materials, not e.g., poor work place layout and e.g., repetitive and monotonous enough materials, wrong housekeeping, noise, hot/ tasks, overtime, working alone instructions temperatures, poor lighting Is there a safe working Was the material clearly Workplace layout appropriate? procedure? labelled? Ishikawa (Fishbone) Diagrams Fishbone Diagram Fishbone Analysis - Video Root Cause – Team work It is almost impossible for an individual to not rely on their personal experiences, background and knowledge when analyzing root cause facts and information. It is best to perform Root Cause Analyses in a team or group setting. Multiple view points will increase the likelihood of an objective analysis. Example Incident Parking Lot Pothole Incident In early spring a worker reports that he cannot work because he twisted his ankle in a pothole on the main path of the parking lot as he was walking to the building before his shift. What is the hazard in the story? What are the contributing factors? What is the immediate cause? What is the underlying root cause? What can be done to prevent injuries in the future? Recommendations Summary Recommendations Date Oct 1, 2024 After a Winter thaw and based on a recent employee injury, potholes in the Hazard ▪ Potholes in employee parking lot parking lot are a high risk and need to Risk ▪ High traffic, deep holes, many be a priority. It is very likely other older workers, high risks with injuries will occur in the future. The immediate danger JHSC recommends that the –report of injury (twisted ankle) maintenance survey the entire parking lot and clearly mark large potholes; and the employer resurface the parking Future ▪ Do an assessment of the parking lot lot as soon as possible. Actions ▪ Mark large potholes with pylon cones ▪ resource, quote and hire paving company to resurface entire parking lot QUESTIONS?