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 charts http://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 organizationof 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
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