Chapter 13: Analysis

1. MINA Handbook Chapter 13: Analysis

2. The 5M Model Time

3. Cause and Effect Diagramming • What it is: • A graphic illustration of the relationship between a given outcome and all the factors that influence this outcome. • May be depicted as a “Fishbone” diagram • What it does: • To determine factors that cause a positive or negative effect. • To focus on specific issues while avoiding irrelevant discussion. • To identify areas where there is a lack of data.

4. Cause and Effect Diagramming • How to use it: • Specify the effect to be analyzed (positive or negative) • List major categories of factors that influence the effects being studied (The 5M’s for a start) • Use an idea-gathering technique to identify factors and sub factors. • Look for repeaters or root causes. • Prioritize the list of causes.

5. Fishbone Diagram

6. Fishbone Diagram

7. Hazard Analysis • The basic tool of the Safety Analyst • To list the elements of the system • To identify the hazards for each system’ • To assess the consequences of each hazard • To determine appropriate corrective action • The value of the hazard analysis is that it drives corrective actions for critical safety problems • Its weakness is that it is not comprehensive

8. Hazard Analysis • Identify Hazards for Each Element • List all known potential accident conditions • Organization’s historical data • Standard accident history • Look for unwanted energy transfer • Mechanical, electrical, chemical, radiological • Determine effect of function • Loss of function • Malfunction • Interfacing systems • Human error, external event

9. Job Safety Analysis • What it is: • JSA is the application of the HA technique to specific job tasks. • What it does: • JSA identifies risks associated with individual jobs and tasks. • JSA helps focus on proper safety and health countermeasures. • JSA aids in identifying training needs. • JSA can be used as an investigation tool: • Evaluate job as it was done in the mishap • Identify uncontrolled hazards (causes)

10. Local Mishap Analysis • Sports and Rec, off-duty, slips, trips & falls • Not cost-effective to analyze each one using a system safety analysis technique, but, • Need a method to determine if there is a problem • Use statistical methods to alert • Use change analysis to identify problem

11. Statistical Control for Safety • Based on concepts of statistical process control • Establish “average” number of events • Define upper and lower control limits • Monitor and plot actual experience • Take action if significant deviation occurs

12. Statistical Control Chart

13. Statistical Control ChartDeviations

14. Statistical Analysis • When deviations occur, shift from monitor to analyze. • Use any analysis tool. • Most useful is probably Change Analysis

15. Change Analysis • What it is: • A method of identifying hazards resulting from changes. • A tool for investigation as well as analysis of future events. • What it does: • Identifies high risk areas introduced to an operation as a result of changes in environment, personnel, tasks, equipment, etc.

16. Change Analysis Mishap Situation Set down differences Analyze Differences For effect on mishap Compare Comparable Mishap-free Situation Integrate information into mishap investigation process

17. Fault Tree and Logic Diagrams • What it is: • A graphical depiction of the relationship between various elements of a system. • Similar to cause and effect diagram but can be quantified using Boolean logic. • Can combine hardware and human elements. • What it does: • Shows combinations of failures • Identifies the “weak link” (critical path)

18. Fault Tree and Logic Diagrams • How to do it: • Select top event (Source: hazard analysis or accident) • Identify all events leading to top event. • Follow this logic down to the basic or root events. • Assign probabilities • Sum probabilities using Boolean Algebra • Establish top event probability

19. Fault Tree and Logic Diagrams • How to do it: • Select top event (Source: hazard analysis or accident) • Identify all events leading to top event. • Follow this logic down to the basic or root events. • Assign probabilities • Sum probabilities using Boolean Algebra • Establish top event probability

20. Root Cause Analysis • A subset of fault tree analysis • Keep breaking down the precipitating factors into smaller and smaller units until you reach the basic cause factor. • Like a child does, keep asking why • Example: • Human error is a common cause for accidents. People don’t deliberately make mistakes. Find the underlying reason for the mistakes and you prevent future accidents.

21. Project Evaluation Tree (PET) • Project Evaluation Tree (PET) developed in 1989 • Based on management oversight risk technique (MORT) • Purpose • To provide a simple and efficient tool for performing an in-depth evaluation or analysis of a project, system or operation. • Now called mishap factors evaluation tree (MFET) in MINA text.

22. Mishap Factors Evaluation Tree (MFET) Operationally Ready Facilities/ Hardware Procedures Personnel Contents Authorized Design Criteria Mission Ready Construction & Validation Assigned Fabrication Currency Human Factors Testing Used (Psychological & Inspection Writer’s Qualification Physiological) Maintenance Update Provisions Change Control

23. PROCEDURES

24. PERSONNEL

25. HUMAN FACTORS

26. FACILITIES/HARDWARE

27. MFET Exercise • Severe thunderstorms pummel the base resulting in widespread damage. • CE damage control center established • Electric shop tasked to restore electrical service to the base. • Augmentee to electric shop seriously injured during recovery efforts • Use MFET as the analysis tool • Present your team’s proposed findings, causes and recommendations

28. Develop an AnalysisProblem Solving Procedures As you get into the analysis of facts you might want to consider using one of the most common procedures applied during mishap investigations: Change Analysis Hazard Analysis

29. Problem Solving WHY? Person slips on oil on floor WHY? Oil was spilled on floor Person stepped in oil WHY? WHY? Person walked through work area When machine was serviced, oil spilled WHY? WHY? Person Worked in department Improper procedures used Spill not prevented

30. Analysis Once you have causes, look for solutions Watch for the “Can’t” Look for creative options Recommend Corrective Measures You may be asked for cost benefit analysis Don’t let the cost limit your analysis Provide options Let the boss determine realities