Christopher J. Colburn, MEng, CSP, CHMM

Manager, Environmental, Health and Safety – North America

Incident Investigation using Incident Trisection Techniques / Lean / Six Sigma Tools

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Session Objectives

Define and Discuss Safety I versus Safety II thinking and its application to Incident Investigations

Define and Discuss Incident Trisection, Causal and Contributing Factors

Demonstrate the application of Ishikawa Diagrams, Root Cause Analysis, Countermeasure Identification and Implementation

Discuss the concept of organizational drift and methods to Manage to Smart, Sustainable Solutions

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Safety – What it is really?

What is the definition of “Safety?”

– “Freedom from Unacceptable Levels of Risk” – ISO Guide 51:1999E / ANSI Z10-2012

– “Safety is not the absence of events; safety is the presence of defenses” – Todd Conklin, Pre-Accident Investigation

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Hazards – Have the potential to cause harm

Swiss Cheese Model James Reason

Swiss Cheese Model

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Accident Pyramid

Hazardous Energy

Threat/Target Initiating Mechanism

“If you wish to understand the Universe, think of energy, frequency and vibration”

~ Nikola Tesla

“Energy can be neither created nor destroyed. However, energy can change forms, and energy can flow from one place to another.” – First Law of Thermodynamics

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Accident Pyramid

Hazardous Energy

Threat/Target Initiating Mechanism

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Accident Pyramid

Hazardous Energy

Threat/Target Initiating Mechanism

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Accident Pyramid

Hazardous Energy

Threat/Target Initiating Mechanism

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…safety is not something you have, it’s something you do.

Change Adaptation

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Safety I Vs. Safety II 9

Intervene by changing people

Safety is best measured by its absence

Safety is a bureaucratic accountability

up

People are a problem to

control

Safety I Safety II

Versus

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Operational Mismatch

Blunt End – MGT/ Support

Sharp End – Operations

Work Imagined Work Completed

VP/GM Director Manager Supervisor Crew Chief Line Worker

Resource Availability

Resource Effect

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Incident Trisection

What is an Incident? – Simply Stated and Incident is a “Unexpected Outcome” as

the result of an event or sequence of events

What is Incident Trisection – Breaking the incident down into three distinctive and

digestible portions in order to learn and grow 1. Context 2. Consequence 3. Retrospect

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Incident Trisection

Context Consequence Retrospect

Incident

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Context

All the “Stuff” that occurred leading up to the incident – Consider everything that occurred up to 72 hours before the

incident – Identify and categorize these things as either:

– Causal Factors – Contributing Factors

Context

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Key Definitions

Causal Factor: “A condition or an event that results in an effect (anything that shapes or influences the outcome).”

Causal Factor Chain: “A cause and effect sequence in which a specific action creates a condition that contributes to or results in an event. Earlier events in a sequence are called “upstream” factors”

Direct Cause: “The cause that directly resulted in the occurrence.”

Contributing Cause: “A cause that contributed to an occurrence but, by itself, would not have caused the occurrence.”

Root Cause: “The cause that, if corrected, would prevent recurrence of this and similar occurrences. It is the most fundamental aspect of the cause that can logically be identified and corrected.”

Source: DOE-NE-STD-1004-92

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Consequence

Rarely that interesting

Consequence

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Retrospect

There is rarely the opportunity that a good worker made a bad decision that led to error. In retrospect, every error appears to be a choice but that is often incorrect. The outcome is agnostic to the cause when variability

manifests itself in the system Confirmation Bias

Retrospect

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Accident Investigation

1.Focus on understanding the context of the incident • Understand how things normally work

to understand how it didn’t work this time

• Why do the decisions make sense in context? (local rationality)

2.Remove blame from the process • Accountability should be forward-

looking 3. Learning Teams

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Learn and Grow

“Once you begin to Blame and Punish, you forfeit the opportunity to Learn and Grow.”

~ Todd Conklin

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Step 1 - Clarify the Problem

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Step 2 – Short Term Containment

Need to identify if there are any short term containment actions that need to be put in place to protect employees. When creating the short term containment plan, be sure to clearly identify who, will do what, and when.

Short Term Containment:

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Steps 3 & 4 – POC & CS Determine the Point of Cause & State the Current Situation

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Steps 3 & 4 – POC & CS Determine the Point of Cause & State the Current Situation

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Step 5 – Prioritized Problem Investigation

Without any prejudice:

Examine the Point of Cause and determine possible causes without prejudice

• Utilize your experiences and intuition as a reference when you make considerations.

• Make determinations based on facts. • While listening to others clarify whether you are hearing an opinion or actual facts

How to Perform this Step: • Do the exercise twice, once on your own, and another at the Gemba w/

the Experts. • Avoid “Leading Questions”

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Step 5 – Prioritized Problem Investigation

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Step 5 – Prioritized Problem Investigation Examine the Point of Cause and determine possible causes without prejudice

Go and See to Confirm

Possible Causes

Problem to Pursue

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WHY

Potential Cause

Potential Cause

Actual Cause

Potential Cause

Actual Cause

Potential Cause

Potential Cause

Potential Cause

Actual Cause

Potential Cause

Root Cause

WHY

WHY

WHY

Possible Cause

Steps 6 & 7 – Root Cause Identification Gather facts through Go and See and keep asking “Why?”

Use GO and SEE … Eliminate when you can…prioritize…test the most likely if possible.

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Step 6 & 7 – Root Cause Identification

Maintenance team member did not properly secure Why?

Example : Bolts are loose

Why?

: Supervisor does not have good understanding : Supervisor lacks power of concentration

Specify the root cause

Team member did not follow standard work

Team member had not been trained on standard work

Why?

Why?

Why?

Maintenance supervisor forgot to train

No standard training checklist to follow

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Step 6 & 7 – Root Cause Identification

Check if it truly IS the root cause

Specify the root cause

• If Countermeasure is taken for the cause, we can expect the Problem to Pursue at the Point of Cause to be solved and the same result to be achieved consistently.

• The Possible Root Cause can be connected to the previous cause with the word “Therefore” eventually reaching the Prioritized Problem at the Point of Occurrence.

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Root Cause Identification

Problem

Possible Cause

Cause

Cause

Cause

Root Cause?

Why? Why?

Why?

Why?

Cause >> Effect Relationships

Therefore Test

Problem to Pursue @ the Point of

Cause

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Step 6 & 7 – Root Cause Identification

Too much

oil vapor in the air

Vents were removed

To prevent oil from dripping

AIB Requirements

Customers mandated

Root Cause?

Why?

Why?

Why?

Why? Therefore…

Therefore…

The question here maybe should be why is there oil dripping?

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Step 6 & 7 – Root Cause Identification

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Step 8 – Countermeasure Evaluation

Temporary Countermeasure Reverse a negative situation, establish containment

or temporarily return to normal or standard

Countermeasure By addressing Root Cause, prevents problem from

recurring

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Step 8 – Counter Measure - Hierarchy of Controls

1. Elimination 2. Substitution 3. Engineering Controls 4. Warnings 5. Administrative Controls 6. Personal Protective Equipment

• Design to eliminate hazards, such as falls, hazardous materials, noise, confined spaces, and manual material handling

• Substitute for less hazardous material • Reduce energy. For example: Lower speed, force,

amperage, pressure, temperature, and noise.

• Ventilation systems • Machine guarding • Sound enclosures • Circuit breakers • Platforms and guard railing • Interlocks • Lift tables, conveyors, and balancers

• Signs • Backup alarms • Beepers • Horns • Labels

Procedures

• Safe job procedures • Rotation of workers • Safety equipment inspections • Changing work schedule

Training • Hazard Communication Training • Confined Space Entry

• Safety glasses • Hearing protection • Face shields • Safety harnesses and lanyards • Gloves • Respirators

CONTROLS EXAMPLES

Most Effective

Least Effective

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Step 8 – Countermeasure Evaluation Build consensus with others

Build consensus with related people and departments to achieve an increased level of speed and smoothness. Share your findings and your problem solving report including target.

•Explain and discuss plans with all relevant people at the planning stage.

•Set up a committee for planning purpose.

•Hold the meeting to collect opinions.

•Always share latest status/information.

Build consensus with others

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Steps 8 & 9 – Countermeasure Implementation Plan

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Step 10 – Check Countermeasures

Evaluate whether or not the target was achieved

Evaluate the results

Was the target achieved?

Evaluate the process

Did we follow the 11 steps?

Did we follow the process outlined in our countermeasure?

Confirm positive and negative effects incidental to results

Evaluate results and processes, and share it with members involved

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Step 11 - Standardize and Share

Examples of standardization

Forms Manual Checklists Flow-chart

If possible, the standard should clarify all relevant factors so that anyone, at anytime, without waste can implement the standard

Set successful processes as new standards

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In Conclusion….

“No question is so difficult to answer as that to which the answer is obvious.”

~ George Bernard Shaw 1856-1950

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Christopher J. Colburn, MEng, CSP, CHMM

AGCO Corporation Manager, EHS – North America

Region IV VPPPA Board of Directors – Treasurer Elect Christopher.colburn@agcocorp.com

Cell: 404-353-4626