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 Progressive Safety Services LLC - All Rights Reserved 2 The analysis of an incident or event to identify causal factors and the root cause. Key piece of a successful safety process. Progressive Safety Services LLC - All Rights Reserved 3 Identify causal factors Identify the root cause(s) Take actions to prevent reoccurrence Progressive Safety Services LLC - All Rights Reserved 4 Rather than treating the symptoms we identify the root cause Gather information surrounding the event Take action to prevent future occurrence Progressive Safety Services LLC - All Rights Reserved 5 Causal Factors - an action or lack of action that caused an Incident or made the incident worse. ◦ 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) Progressive Safety Services LLC - All Rights Reserved 6 Root Cause ◦ 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 7 Effective Strategies for Gathering Information After the Incident Progressive Safety Services LLC - All Rights Reserved 8 Injury Near Miss Property Damage Environmental Release Security Quality Equipment Breakdown Others??? 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 Progressive Safety Services LLC - All Rights Reserved 10 As soon as possible after the incident occurred. “Do It Now” mentality Progressive Safety Services LLC - All Rights Reserved 11 At the scene of the incident if the analysis can be done safely. 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? Progressive Safety Services LLC - All Rights Reserved 13 The degree of analysis is determined by the severity or potential severity of the incident. Regardless of the severity/potential severity of an incident, thorough analysis will provide a valuable learning opportunity for all involved. Progressive Safety Services LLC - All Rights Reserved 14 Secure and Preserve the Scene 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 18 Helpful to ask preliminary questions of those involved directly or indirectly in the incident. 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? Progressive Safety Services LLC - All Rights Reserved 22 What long term or permanent action could have prevented the incident or minimized its effect? 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 Progressive Safety Services LLC - All Rights Reserved 24 Tips for Conducting a successful interview ◦ 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 Progressive Safety Services LLC - All Rights Reserved 25 Discuss possible ways to prevent future incident Have the interviewee provide a written statement Incident Statement Form Progressive Safety Services LLC - All Rights Reserved 26 Incident Analysis Progressive Safety Services LLC - All Rights Reserved 27 Many factors trigger the sequence of events that lead to an incident. 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 Progressive Safety Services LLC - All Rights Reserved 28 What is it? ◦ 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. Progressive Safety Services LLC - All Rights Reserved 29 Assemble the Analysis Team 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 Ensure that Action is Taken. Progressive Safety Services LLC - All Rights Reserved 30 Should consist of persons knowledgeable of the incident, work being done, general area, etc. Beneficial to involve managers, supervisors, and front- line employees. Progressive Safety Services LLC - All Rights Reserved 31 Give detail on the incident or issue that needs further analysis. Problem Example: Employees continue to slip and fall on the exterior walkway between warehouses #1 and #2. Progressive Safety Services LLC - All Rights Reserved 32 Example: Why are employees slipping on the exterior walkway between warehouse #1 and #2. Answer: Rain or water from snow melt is draining to this area, settling and freezing during cold weather. Progressive Safety Services LLC - All Rights Reserved 33 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. Progressive Safety Services LLC - All Rights Reserved 34 Example: Why have the gutters deteriorated? Answer: The gutters are over forty years old and have not been replaced. Progressive Safety Services LLC - All Rights Reserved 35 Why haven’t the gutters been replaced? Answer: Currently no program exists for evaluating roof areas and gutters. Money was not budgeted for replacement. Progressive Safety Services LLC - All Rights Reserved 36 Why hasn’t a program been developed to evaluate roofs, gutters, etc. on a consistent basis? 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. Progressive Safety Services LLC - All Rights Reserved 38 1st Why (is that)? Water is accumulating in this area and freezing during cold weather. 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