incident exploration - ifsqn.com
TRANSCRIPT
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Incident Exploration
Dr. David Rosenblatt, Sher Consulting and Training, ltd.
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https://www.youtube.com/watch?v=tA-nvkN7UaI&t=1s
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incident analysis vs. investigation
No blame
No shame
No fear
No guilt
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incident analysis vs. investigation
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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Incident exploration sequence decide
plan
collect evidence
analyze
corrective action
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decide
plan
collect evidence
analyze
corrective action
step 1
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
step 2 – the big question
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
step 2 – the big question
step 3 – revisit the risk assessment
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
step 2 – the big question
step 4 – major faults
step 3 – revisit the risk assessment
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
step 2 – the big question
step 4 – major faults
step 3 – revisit the risk assessment
step 5 – Root Cause Analysis
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step 2 – the big question
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step 2 – the big question
Did our risk assessment fail?
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Identify
Evaluate
Control
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was the potential
hazard identified?
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was the potential
hazard identified?
back to the risk
assessment
no
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was the potential
hazard identified?
was it ranked as significant?
back to the risk
assessment
no
yes
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was the potential
hazard identified?
was it ranked as significant?
back to the risk
assessment
no
yes
no
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
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back to the risk
assessment
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back to the risk
assessment
Revise risk assessment
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back to the risk
assessment
Revise risk assessment
Re-evaluate food safety team competence
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back to the risk
assessment
Revise risk assessment
Re-evaluate food safety team competence
Look for similar blind spots
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back to the risk
assessment
Revise risk assessment
Re-evaluate food safety team competence
Look for similar blind spots
Communicate to all food safety teams
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
validation fault
yes
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
validation fault
yes
human factors
no
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
validation fault
yes
human factors
no
motivation competencehuman error forgetfulness
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
validation fault
yes
human factors
no
motivation competencehuman error forgetfulness
knowledgecapability (personal /
organizational)
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was the potential
hazard identified?
was it ranked as significant?
were control measures (PCs)
chosen?
back to the risk
assessment
no
yes
yes
no
no
were CMs implemented as planned?
yes
validation fault
yes
human factors
no
motivation competencehuman error forgetfulness
knowledgecapability (personal /
organizational)
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decide
plan
collect evidence
analyze
corrective action
step 1 – chain of events
step 2 – the big question
step 4 – major faults
step 3 – revisit the risk assessment
step 5 – Root Cause Analysis
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Root Cause Analysis
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct causes
fault
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct causes
fault
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct causes
fault
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct causes
fault
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct cause
fault
salmonella contamination
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct cause
fault
salmonella contamination
leaky ceiling
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct cause
fault
salmonella contamination
leaky ceiling
clogged rain gutters
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct cause
fault
salmonella contamination
leaky ceiling
clogged rain gutters
5M (machine, man, method,
material, measurement)
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The traditional RCA methodology involves asking the question “why?” until we reach the root causes.
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HOWEVER…
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HOWEVER…
If the organization has a management system, it MUST split the “why?” into two RCAs
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HOWEVER…
If the organization has a management system, it MUST split the “why?” into two RCAs
A) Why did it happen?
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HOWEVER…
If the organization has a management system, it MUST split the “why?” into two RCAs
A) Why did it happen?B) Why wasn’t it prevented?
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A non conforming situation (fault) always has underlying
contributing causes:
root causes
indirect causes
direct cause
fault
salmonella contamination
leaky ceiling
clogged rain gutters
gutter cleaning not performed according to
procedure…
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Why wasn’t it prevented or detected?
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Why wasn’t it prevented or detected?
Why didn’t the maintenance team report that they had a capacity problem?
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Why wasn’t it prevented or detected?
Why didn’t the maintenance team report that they had a capacity problem?
Why did nobody discover that a crucial maintenance task was overdue?
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Why wasn’t it prevented or detected?
Why didn’t the maintenance team report that they had a capacity problem?
Why did nobody discover that a crucial maintenance task was overdue?
Why did nobody notice that the gutter was clogged?
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Why wasn’t it prevented or detected?
Why didn’t the maintenance team report that they had a capacity problem?
Why did nobody discover that a crucial maintenance task was overdue?
Why did nobody notice that the gutter was clogged?
Why did nobody notice that the ceiling was leaking?
Is the product sampling procedure sufficient?
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take home points
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Effective learning from undesirable incidents requires:
take home points
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Effective learning from undesirable incidents requires:
• a corporate culture of tolerance: no blame, no shame, no fear, no guilt
take home points
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Effective learning from undesirable incidents requires:
• a corporate culture of tolerance: no blame, no shame, no fear, no guilt
• questioning and improving our risk assessments
take home points
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Effective learning from undesirable incidents requires:
• a corporate culture of tolerance: no blame, no shame, no fear, no guilt
• questioning and improving our risk assessments
• identifying human factors with surgical precision
take home points
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Effective learning from undesirable incidents requires:
• a corporate culture of tolerance: no blame, no shame, no fear, no guilt
• questioning and improving our risk assessments
• identifying human factors with surgical precision
• splitting the “why?”
take home points
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Effective learning from undesirable incidents requires:
• a corporate culture of tolerance: no blame, no shame, no fear, no guilt
• questioning and improving our risk assessments
• identifying human factors with surgical precision
• splitting the “why?”
• understanding that taking calculated risks is acceptable
take home points
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Thank you!
Dr. David Rosenblatt, Sher Consulting and Training, ltd.