Incident Analysis (On-Site)

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 Discuss:

◦ Methods for conducting an effective incident analysis (on-site)

◦ Become familiar with the “5 Why” analysis process

◦ Become familiar with the “Fishbone Diagram” analysis process

 Key piece of a successful safety process.

 Identify the root cause(s)

 Take actions to prevent reoccurrence

 Gather information surrounding the event

 Take action to prevent future occurrence

◦ An action someone performed ◦ An action, a piece of equipment, component or process transaction performed ◦ An action not performed by someone ◦ An action not performed by piece of equipment, component or process transaction (TapRooT)

◦ is an initiating cause of a causal chain which leads to an outcome or effect of interest (Webster).

 Goal: Seek to identify and address root causes rather than causal factors.

Progressive Safety Services LLC - All Rights Reserved 9  Managers/supervisors of the employees involved or those who work in the area where the incident took place  Employees involved or witness to incident  Employees who have expertise with the work being performed or area where the incident took place  Facility safety committee  Corporate Safety Department  Third party experts

 “Do It Now” mentality

 Are there instances which may make it a challenge to conduct the analysis at the scene of the incident?

Progressive Safety Services LLC - All Rights Reserved 12  Appropriate PPE  Digital Camera/Video Capability  Tape Measure/Measuring Wheel  Flashlight  Caution/Danger Tape  Lockout/Tagout Equipment (locks/tags)  Pens, paper, legal pads, etc.  Others?

 Regardless of the severity/potential severity of an incident, thorough analysis will provide a valuable learning opportunity for all involved.

Gather the Facts

Conduct Employee/Witness Interviews

Prepare the Incident Report

Identify Root Causes/Corrective Actions

Progressive Safety Services LLC - All Rights Reserved 15  Secure the scene immediately after the incident: ◦ Caution/Danger Tape ◦ Barricades ◦ Divert Traffic ◦ Keep employees/media away from the scene

 Safety is the number one concern!

Progressive Safety Services LLC - All Rights Reserved 16  Identify, eliminate or reduce any hazards that may be present. This may include: ◦ Lockout/Tagout ◦ Bloodborne Pathogen Issues ◦ Ensuring Adequate Lighting ◦ Filling Out Applicable Permits

Note: These activities should be performed by qualified individuals.

Progressive Safety Services LLC - All Rights Reserved 17  All tools and equipment should be left in place until all critical information has been gathered.  Photos of the area should be taken to include: ◦ Equipment Involved ◦ Property damage ◦ Location of equipment/vehicles/employees ◦ Hazards/working conditions ◦ Others?

Progressive Safety Services LLC - All Rights Reserved 19  What was the exact location of the incident?  What time did the incident occur?  What was the person doing at the time of the incident (if applicable)?  What types of equipment were involved?  Was equipment involved in proper working order?  Was the employee qualified to perform the task?

Progressive Safety Services LLC - All Rights Reserved 20  Was proper equipment available and in use during the task?  Do operating procedures or JSA exist for the task?  Was the employee trained on the SOP or JSA?  Was the person following established procedures?  Others?

Progressive Safety Services LLC - All Rights Reserved 21  What were the physical conditions of the area prior to and during the events leading to the incident? ◦ Light/Dark ◦ Wet ◦ Cold ◦ Noise Level ◦ Weather Conditions ◦ Others?

 Had corrective actions been recommended in the past, but not implemented?

Progressive Safety Services LLC - All Rights Reserved 23  Provide information critical to the analysis  Help identify causal factors  Should involve anyone directly involved and witness to the incident  Should take place ASAP after the event

◦ Conduct in a neutral area where interviewee will feel comfortable ◦ Establish the purpose of the interview as fact finding, not for placing blame or finding fault ◦ Have interviewee give their version of the incident and the sequence of events ◦ Repeat the chain of events to the interviewee to ensure that they are accurate

 Have the interviewee provide a written statement

 Incident Statement Form

 In order to effectively identify the causal factors and root causes we will explore two tools:

◦ Five Why Analysis

◦ The Fishbone (Cause and Effect) Diagram

◦ Systematic technique used to identify the causal factors and root cause of a problem.

 Can be used for all incidents regardless of severity.

 Preferred for injuries, or near misses with low potential for causing injury, environmental releases, property damage, etc.

Define the Problem

Ask the First Why

Ask Why at Least Four More Times in Succession

Identify the Root Cause

Develop an Action Plan to Identify the Root Cause

 Beneficial to involve managers, supervisors, and front- line employees.

 Problem Example: Employees continue to slip and fall on the exterior walkway between warehouses #1 and #2.

 Answer: Rain or water from snow melt is draining to this area, settling and freezing during cold weather.

 Example: Why is water draining from the roof and settling in this area rather than being diverted to a drain.

 Answer: The condition of the warehouse gutters has deteriorated. Water from the roof is not being directed away from the area.

 Example: Why have the gutters deteriorated?

 Answer: The gutters are over forty years old and have not been replaced.

 Answer: Currently no program exists for evaluating roof areas and gutters. Money was not budgeted for replacement.

 Answer: Management/Maintenance had not identified the gutter condition as an issue/concern.

Progressive Safety Services LLC - All Rights Reserved 37  Management will require an annual inspection process for roofs, gutters, etc. Deteriorated gutters will be replaced within the next four weeks.

 “In the meantime” all employees will be briefed on the hazard and instructed to use other routes if possible, ice-melt will be applied to the area as needed.

2nd Why (is that)? Water from warehouse roofs is draining to this area and settling. During cold weather the water freezes. Remember that sometimes the process may involve 3rd Why (is that)? asking why more than five The condition of the gutters has deteriorated. Water from roofs is not directed away from the area. times.

4th Why (is that)? Gutters are over forty years old and have not been replaced.

5th Why (is that)? Building roofs and gutters are not being evaluated consistently and Corrective Action Level replaced as needed. of Why

Corrective Action: Develop an annual inspection process for roofs/gutters. Replace deteriorated gutters. Short term ensure that all employees are aware of the hazard and apply ice melting products as needed. Progressive Safety Services LLC - All Rights Reserved 39 Cause and Effect

Progressive Safety Services LLC - All Rights Reserved 40  Tool that can be used to identify causal factors/root causes and corrective actions  Recommended use: All incidents, injuries or near misses or those with significant potential  A greater level of analysis than The Five Why’s  Performed with a diagram that looks like the skeletal system of a fish

◦ Large flip chart or dry erase board ◦ Tape ◦ Markers (dry erase, other), pens, etc. ◦ Persons knowledgeable with the problem or process being analyzed. ◦ Post-its ◦ Facilitator

Decide on Problem and Write it Down

Draw a Fishbone Diagram

Identify the Major Causal Factors and Connect them to the Backbone of the Fish

Brainstorm for Each Major Causal Factor.

Place the Causal Factors of the Major Causes in Their Appropriate Place.

Identify Potential Root Causes

◦ Managers

◦ Supervisors

◦ Operations Employees

◦ Near Miss ◦ Property Damage ◦ Injury ◦ Quality ◦ Production Bottlenecks ◦ Others?

Problem

Causal Factors Effect

◦ Man (people, physical work, etc.) ◦ Machine (technology, machinery, etc.) ◦ Materials (raw materials) ◦ Method (process) ◦ Management (leadership, supervision, etc.) ◦ Mother Nature (weather, environmental factors, condition, time, etc.)

Problem

Materials Methods Management

Progressive Safety Services LLC - All Rights Reserved 48  Brainstorm for causes for each of the major causal factors (major bones).  Think of an area that contributes to the problem.  Example: A faulty tool would be a causal factor under the equipment section.  For each identified cause ask: ◦ Why does this happen? ◦ What could happen? ◦ Can also implement the 5 why approach to each causal factor.

Cause Cause

Problem

Materials Methods Management

 Circle each factor that strongly effects the problem.

 The circled items are the root causes.

Cause

Problem

Cause

Materials Methods Management

 Corrective actions should eliminate or further reduce the exposure.

 Helpful to use the hierarchy of controls to help eliminate or reduce exposure.

Start Here Elimination Eliminate the hazard all together. Example: good housekeeping

Substitution Using a less hazardous means Of accomplishing the task. Example: safe chemical

Engineering Design to eliminate hazards. Controls Example: Installing guards, interlocks, barriers, ventilation, etc.

Organize work in a way to Administrative or minimize hazards. Process Controls Example: job rotation

Personal Protective The last resort when trying to Equipment eliminate or decrease exposure

 Each individual action should be tracked until completion.

 Follow up until corrective actions are implemented, the problem has been eliminated or its exposure reduced.

◦ Conduct an on-scene incident analysis.

◦ The use of two tools to conduct and incident analysis.

 Implement improved incident analysis for incidents

 Invest time to identify the root causes and causal factors

Any good investment provides solid returns

 “Five Why” Analysis Worksheet

 Fishbone Diagram Example