Incident Investigation and Root Cause Analysis Training - PowerPoint

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					 Incident Investigation and
Root Cause Analysis Training

         Rad Manning
       Safety Consultant

       September 15, 2005
What Brought this Class Forward

• Quality of the Root Causes Identified

• Building Consistency in Findings

• Provide a Basic Tool

• Provide Quality Statistics

• Pre-planning for investigations.

• Performing an investigation.

• Developing a timeline.

• Identifying the direct cause(s).

• Identifying root cause(s).

• Corrective actions.
First Training Session
Goals of an Investigation

• Identify the cause(s).

• Develop and implement corrective actions.

• Prevent recurrence.

• Foster a safe workplace.

• Improve morale.

• Demonstrate leadership.

• Improve a work process.
Preparing for an Investigation

• Putting together an investigation kit.

• Practicing techniques.

• Setting up an investigation team.

• Develop a checklist.

• Develop basic questions.

• Identify standard interviewees.

• Gathering information.
Challenges to Investigating

• The culture – company, project, and client.

• Severity of the incident.

• Parties involved.

• Legal issues.

• Gathering information.

• Lack of training or experience in investigating
The Importance of Focusing on Just the FACTS

• Leads to a clear understanding of what happened.

• Keeps from persecuting the innocent.

• Identifies the right cause.

• Identifies the appropriate corrective actions.
Developing a Timeline

• Put down “key” moments.

• Determine when to start.

• Everything is important, at first.

• Include known information, facts, assumptions,
  questions, and need for further research.

• Alone versus Team.

• Adding detail to key moments.

• Weeding out period.
Timeline of Actions
Identify the Direct Cause

• Agree on a definition.

• Do not limit yourself.

• Identify the links in the chain.

• Look for direct effects.
Digging for the Root Causes
Root Cause Definition

The most basic cause (or causes) that can reasonably be
  identified that management has control to fix and, when
 fixed, will prevent (or significantly reduce the likelihood or
        consequences of) the problem's recurrence.

         TapRooT®; System Improvements, Inc.
Root Cause Focus Areas

• Management

• Front Line Supervision

• Training

• Administrative Controls (Policies and Procedures)

• Enforcement

• Accountability

• Employees
Finding the Root Cause

• Keep asking why.

• Review systems/processes.

• Review management direction and involvement.

• Look at the training and the quality of the training.

• Crew make-up and assignment of a task.

• Qualification of personnel.

• Task review (hazard analysis).

• Existence, quality, and thoroughness of
Identified Typical Root Causes

• Lack of focus/awareness.
• Lack of attention.
• Complacency.
• Did not follow policy/procedure.
• Use of incorrect tool.
• Not wearing proper PPE.
• Not tied off.
• Tripped on uneven surface.
• Employee in a hurry.
• Act of God/uncontrolled event.
Root Cause Examples

•   Poorly written procedure.

•   Lack of enforcement.

•   Lack of accountability.

•   Poorly qualified personnel.

•   Lack of instruction.

•   Poor administrative control.

•   Pre-planning of task.

•   Lack of training/poor quality training.

•   Work schedule.

•   Communication needs improvement.
Example of Finding Root Cause
   Root Cause Flowchart


                                                                                                        Interface with
   Policies/                                                    Preparation                              Equipment
                        Training          Management               And             Instructions
  Procedures                                                                                                 and
                                                                Supervision                               Work Area
Wrong Revision      Not Provided          No Policy             No Preparation   No Communication        Hot Environment
Typo                Did Not Attend        Lack of Enforcement   Pre-Job Brief    Turnover                Cold Environment
No Procedure        Teaching Lacking      Lack of               Walk Thru        Complex Instructions    Display Poor
Not Available       No Testing            Accountability        Lock-Out/Tag-Out Terminology             Slippery Surface
Steps Wrong         Continuing Training   Employee Relations    Employees        Timely Instruction      Cramped Position
Instruction Wrong                         Commitment            Assigned                                 Body Position
Ambiguous Instruction                     Policy Not Strict     No Supervision
Three Standard Corrective Actions

1. Discipline

2. Training

3. Procedures
Regression to the Mean

   1st   2nd 3rd   4th   1st   2nd 3rd   4th   1st   2nd 3rd   4th   1st   2nd 3rd   4th
   Qtr   Qtr Qtr   Qtr   Qtr   Qtr Qtr   Qtr   Qtr   Qtr Qtr   Qtr   Qtr   Qtr Qtr   Qtr
Developing Corrective Actions

• Deal only with the root cause.

• Make it something that can be accomplished.

• Make it measurable.

• Assign to a specific person or group.

• Review periodically.
Loss Analysis Form (LAF)
Loss Analysis Form (LAF) Continued

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