Incident Exploration

Dr. David Rosenblatt, Sher Consulting and Training, ltd.

https://www.youtube.com/watch?v=tA-nvkN7UaI&t=1s

incident analysis vs. investigation

No blame

No shame

No fear

No guilt

incident analysis vs. investigation

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

Incident exploration sequence decide

plan

collect evidence

analyze

corrective action

decide

plan

collect evidence

analyze

corrective action

step 1

decide

plan

collect evidence

analyze

corrective action

step 1 – chain of events

decide

plan

collect evidence

analyze

corrective action

step 1 – chain of events

step 2 – the big question

decide

plan

collect evidence

analyze

corrective action

step 1 – chain of events

step 2 – the big question

step 3 – revisit the risk assessment

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

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

step 2 – the big question

step 2 – the big question

Did our risk assessment fail?

Identify

Evaluate

Control

was the potential

hazard identified?

was the potential

hazard identified?

back to the risk

assessment

no

was the potential

hazard identified?

was it ranked as significant?

back to the risk

assessment

no

yes

was the potential

hazard identified?

was it ranked as significant?

back to the risk

assessment

no

yes

no

was the potential

hazard identified?

was it ranked as significant?

were control measures (PCs)

chosen?

back to the risk

assessment

no

yes

yes

no

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

back to the risk

assessment

back to the risk

assessment

Revise risk assessment

back to the risk

assessment

Revise risk assessment

Re-evaluate food safety team competence

back to the risk

assessment

Revise risk assessment

Re-evaluate food safety team competence

Look for similar blind spots

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

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

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

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

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

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)

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)

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

Root Cause Analysis

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct causes

fault

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct causes

fault

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct causes

fault

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct causes

fault

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct cause

fault

salmonella contamination

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct cause

fault

salmonella contamination

leaky ceiling

A non conforming situation (fault) always has underlying

contributing causes:

root causes

indirect causes

direct cause

fault

salmonella contamination

leaky ceiling

clogged rain gutters

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)

The traditional RCA methodology involves asking the question “why?” until we reach the root causes.

HOWEVER…

HOWEVER…

If the organization has a management system, it MUST split the “why?” into two RCAs

HOWEVER…

If the organization has a management system, it MUST split the “why?” into two RCAs

A) Why did it happen?

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?

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…

Why wasn’t it prevented or detected?

Why wasn’t it prevented or detected?

Why didn’t the maintenance team report that they had a capacity problem?

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 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 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?

take home points

Effective learning from undesirable incidents requires:

take home points

Effective learning from undesirable incidents requires:

• a corporate culture of tolerance: no blame, no shame, no fear, no guilt

take home points

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

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

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

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

Thank you!

Dr. David Rosenblatt, Sher Consulting and Training, ltd.