root cause analysis

Enterprise EHS Software Solutions

USING ROOT CAUSE ANALYSIS TO IMPROVE SAFETY

Mike JacksonModerator

PART 1: WHAT HAPPENEDPART 2: WHY DID IT HAPPENPART 3: HOW TO STOP IT HAPPENING AGAIN

Shannon Crinklaw, CRSP, CHRPEHS Client Service Consultant

SHANNON INTRODUCTION

• CRSP, CHRP• Over 10 years’ experience

in safety and risk

• Led & developed risk assessments as part of Toyota SMS including industrial, emergency response and construction models.

• Consultant in the implementation of OH&S software for various clients across industries

WHAT HAPPENED

OSHA'S 2013 TOP 10 SERIOUS VIOLATIONS1. Fall protection2. Hazard communication 3. Scaffolding4. Respiratory protection5. Electrical: wiring 6. Powered industrial trucks7. Ladders8. Lockout/Tagout9. Electrical systems design10. Machines

TOO MANY INCIDENTS… (2012 FIGURES)• Nonfatal injuries & illnesses: 3 million• Deaths: 4,628 workers = 89/week = 12/day• Construction: The "Fatal Four" were

responsible for 54.2% of fatalities1. Falls2. Struck by object3. Electrocution4. Caught-in/between

Eliminating the Fatal Four would save 437 workers' lives in America every year.

Source: OSHA Commonly Used Statistics

…AND MOST INCIDENTS ARE PREVENTABLE• Herbert William Heinrich – 1920s

Fatality

Severe injury

Minor injury

Near miss

Unsafe acts & conditions

Only 2% of all accidents are unpreventable (or "acts of God")

The other 98% are preventable: 88%: unsafe acts 10%: unsafe conditions

RESULT

BEHAVIOR

To avoid fatalities at the top of the pyramid, start doing analysis at the bottom

Fatality

Severe injury

Minor injury

Near miss

Unsafe acts & conditions

Near miss

Minor injury

Severe injury

Fatality

• Who• When• Where• What

Gather known facts before asking WHY

HOW TO START INVESTIGATE?

WHAT YOU SHOULD INVESTIGATE

All "near miss" situations = risk for accidents

All accidents = risk for injuries

All injuries, even the minor ones

INVESTIGATION IS NOT ENOUGH• Inspections:

Identification & correction of hazards on a case-by-case basis

• Audits:Deeper investigation to identify systematic /

process issues• Risk assessment:

Ongoing analysis to continuously evaluate and mitigate risk to prevent it from happening

WHY IT HAPPENED

ROOT CAUSE ANALYSIS - DEFINITION• Root cause: “The fundamental reason for the

occurrence of a problem” [The Collins English Dictionary]

Root cause analysis: A process, method or procedure that helps discover and understand the initiating fundamental reason for the occurrence of a problem

ROOT CAUSE ANALYSIS - DEFINITION• Root cause analyses are used in various

domains and sectors:

*-based RCA Domain SectorProduction Quality control Industrial manufacturingProcess Business processes Industrial manufacturingFailure Failure analysis Engineering, MaintenanceSafety Accident analysis Occupational Health & Safety

SAFETY-BASED ROOT CAUSE ANALYSIS

Taiichi Ohno, Former Executive Vice President of Toyota Motor Corporation

Goal: Reduce the chance of recurrence of incidents to improve the safety of all employees over time.

The root cause of any problem is the key to a lasting solution

Source: Toyota Production System: Beyond Large-Scale Production - Taiichi Ohno

PROCESS-BASED ROOT CAUSE ANALYSIS

Why can one person at Toyota Motors operate only one machine when one person can operate 40-45

looms at the Toyota textile plant?

Because machines at Toyota Motor didn't stop when machining was done.

The birth of automation.

• Repeatedly asking WHY is the scientific basis of the Toyota system.

Source: Toyota Production System: Beyond Large-Scale Production - Taiichi Ohno

ALWAYS LOOK FOR DEEP CAUSES• Two categories of accident causes:

1. Immediate causes employee error lack of concentration, stress, fatigue non-use of personal protective equipment

– WHY? – Do not stop at immediate cause – Don’t blame people, look at facts

2. Underlying or root causes

When accidents are investigated, the emphasis should be concentrated on

finding the root cause of the accident rather than

the investigation procedure itself so you can prevent it

from happening again.

Source: Canadian Centre for Occupational Health and Safety

WHY IT HAPPENED

- ROOT CAUSE MODELS -

BASIC ELEMENTS OF ROOT CAUSEManMethodMachineMaterialEnvironment Blaming the Man is the

easiest explanation to accidents, but also the most unlikely one…

BRAINSTORMING / AFFINITY DIAGRAM

Machine

Defective equipment

Wrong tool for the job

Not enough PPE

Environment

Excessive noise

Crowding workers into one area

Lack of skills due to inadequate

training

Physical limitations

CAUSE-AND-EFFECT (FISHBONE) DIAGRAM

MACHINE

MAN ENVIRONMENT

Crowding workers into one area

Excessive noise

Physical limitations

Lack of skills due to inadequate training

Defective equipment

Wrong tool for the job

Not enough PPE

HIGHER NUMBER OF INCIDENTS

5 WHY ANALYSIS

Fix the root cause, not the symptoms

5 WHY ANALYSIS – COMMON MISTAKES• Rely on opinion vs. investigation • Pin blame on an individual vs.

identify the system pain points• Cure the symptoms (short-term)

vs. the root cause (long-term)• Restrict the analysis to 5 steps• Misconduct analysis resulting in

an illogical outcome

5 WHY ANALYSIS – BAD EXAMPLE

5 WHY ANALYSIS – GOOD EXAMPLE

HOW TO STOP IT HAPPENING

WHAT YOU DO WITH THE 5 WHY ANALYSIS• Fix the problem:

More efficiently: Identify a single, central root cause and improve resource allocation

Faster: Document your thought process and fix incidents faster over time

WHAT YOU DO WITH THE 5 WHY ANALYSIS• Work on continuous improvement (Kaizen)

As the process of your analysis is documented, both the root cause and the corrective action can be applied to other areas of the organization

Share your findings with other areas

WHAT YOU DO WITH THE 5 WHY ANALYSIS• Track for trends and reporting

Analyze trendsIdentify pain pointsContinuously educate people

HOW CAN A SAFETY SOFTWARE HELP?

Collect comprehensive incident data

Create an accurate picture of the event

Identify root causes and learning points

Implement corrective actions

Ensure proper incident notification up the chain of command

ROOT CAUSE ANALYSIS QUALITY

Ability to review quality of root cause analysis: Safety professionals can review root cause created by personnel at the site/location

SHARING INFORMATION

Roll-out to other areas

REPORTING AND TRENDING

DECISION TREE MODEL

DO NOT STOP QUESTIONING

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