RCAFContractor Training

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Questionable Item,Near Loss, Loss Occurs

WHY?

Questionable Item,Near Loss, Loss Occurs

WHY?

Personal FactorsPersonal Factors External FactorsExternal FactorsOrganizational FactorsOrganizational Factors

Root Cause Analysis Flowchart (RCAF)

Personal FactorsPersonal Factors

Did not follow procedures or acceptable practices because . . .Did not follow procedures or acceptable practices because . . .

4. In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equip damage, regulatory

assessment or production delay).

4. In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equip damage, regulatory

assessment or production delay).

2. Doing the job according to procedures or acceptable practices takes more time/effort2. Doing the job according to procedures or acceptable practices takes more time/effort

3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated

1. Lack of skill or knowledge1. Lack of skill or knowledge

5. Lack of or inadequate procedures 5. Lack of or inadequate procedures

6. Inadequate communication of expectations regarding procedures or acceptable practices.

6. Inadequate communication of expectations regarding procedures or acceptable practices.

Development of solutionsDevelopment of solutions

Implementation of solutionsImplementation of solutions

Organizational FactorsOrganizational Factors 8. External Factors8. External Factors

Verification and validation of solutionsVerification and validation of solutions

Questionable Item, Near Loss, Loss Occurs . . . WHY?Questionable Item, Near Loss, Loss Occurs . . . WHY?

7. Inadequate tools or equipment7. Inadequate tools or equipment

When to Use RCAF

JHA and SAI Level 3’s

Observations and WalkthroughsNear Loss Incidents (NLIs) when IRAT <400Loss Incidents when IRAT <400

STEP #1 - Use 5-Why Process to Identify Logical Root Causes

Questionable Item,Near Loss, Loss Occurs

WHY?

Questionable Item,Near Loss, Loss Occurs

WHY?

Root Causes

Incident: Worker’s hand was cut by a fan on running rig welder

Questionable Item,Near Loss, Loss Occurs

WHY?

Questionable Item,Near Loss, Loss Occurs

WHY?

Personal FactorsPersonal Factors External FactorsExternal FactorsOrganizational FactorsOrganizational Factors

STEP #2 – Use RCAF Flowchart to Determine Factors

Because we didn’t have an inspection checklist to verify that rig welders’ equipment is in safe operating condition before being allowed into

the plant.

Personal FactorsPersonal Factors

Did not follow procedures or acceptable practices because . . .Did not follow procedures or acceptable practices because . . .

In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equipment damage,regulatory assessment or production delay).

In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equipment damage,regulatory assessment or production delay).

Doing the job according to procedures or acceptable practices takes more time/effort. Doing the job according to procedures or acceptable practices takes more time/effort.

Short-cutting procedures or acceptable practices is positively reinforced or tolerated. Short-cutting procedures or acceptable practices is positively reinforced or tolerated.

Lack of skill or knowledgeLack of skill or knowledge

Factors and Solutions Flowchart

Lack of or inadequate proceduresLack of or inadequate procedures

Inadequate tools or equipment (available, operable & safely maintained; proper task & workplace design)Inadequate tools or equipment (available, operable & safely maintained; proper task & workplace design)

Inadequate communication of expectations regarding procedures or acceptable practices Inadequate communication of expectations regarding procedures or acceptable practices

Development of solutionsDevelopment of solutions

Implementation of solutionsImplementation of solutions

Organizational FactorsOrganizational Factors External FactorsExternal Factors

Verification and validation of solutionsVerification and validation of solutions

Factors and Solutions Flowchart

STEP #3 – Develop Solutions to Address Factor

Factor Identified

Solution(s) 1) Develop procedure with checklist form to inspect all rig welders as they come into the plant to ensure they are in safe working condition before being sent to the jobsite

2) Communicate new procedure to the affected workforce3) Train personnel that will be performing the inspections

STEP #4 – Implement Solutions

STEP #5 – Verify and Validate Solutions

Track solutions to completion, ensure they are implemented in agreed upon timeframe

Must verify that the Solution(s) worked. Test it to be sure it is fully implemented and doing what it was supposed to do.

1 - Lack of Skill or Knowledgeo Training not conducted or not availableo Worker missed required trainingo Training completed but not understood (no

validation)

o Task completed/attempted by unqualified workero Training inadequate or ineffectiveo Training not required but is necessary to do job

properly

2 - Doing the job according to accepted practice takes more time/efforto Worker took unapproved shortcut in order to save time

or effort o PPE available but not utilized in order to save time,

make task simpler, or for worker comfort

o Work team(s) did not adequately discuss job roles or requirements in an effort to save time (includes shift turnover)

o Worker(s) did not prepare for task in order to save time (includes LPSA, SJHA's, Daily Addendum, Permits, Safety standards, other work planning)

3 - Deviating from accepted practices is reinforced or tolerated (short cutting)o Supervisor implied need for shortcuto Supervisor or peer influence for "friendly competition"

including the use of shortcuts or deviations from procedures

o Inadequate reinforcement or compliance with policy or procedure by the supervisor, even though management expectations are clear

o Inadequate verification of proper use of policy or procedure by supervisor (management presence in the field)

o Required job supervision and/or intervention not provided

o Supervisor allowed unqualified or impaired worker(s) to perform task, despite indications of worker deficiencies

4 - Past deviations from procedures or acceptable practices produced no negative resultso SPSA not performed regularlyo Procedures and/or work standards not consulted

regularlyo Job habits/common practices have deviated from

procedures or acceptable standards

o Routine task performed without prior planning or preparation

o SHE risks, and decision to not minimize them, were understood and accepted by worker(s)

o Worker(s) knowingly deviated from accepted practice based on similar instances in the past that yielded favorable results

Decision Support Tools Personal Factors

5 - Lack of/or inadequate Procedures/Policies o Policy/Procedure is needed; but does not exist or is

not availableo Policy/Procedure not required; but should beo Policy/Procedure not updated when changes madeo Policy/Procedure content does not address hazards

leading to incident

o Policy/Procedure is confusing, incomplete, or incorrect

o Policy/Procedure contains errors (sequence wrong, typos, wrong calculations/conversions, wrong names/identifications…)

o No way to implement Policy/Procedure as writteno Policy/Procedure creates unnecessary risks,

difficulties, or inefficiencies (ergonomics, fatigue, repetition, etc.)

6 - Inadequate Communication of Critical Information or Expectationso Inadequate communication of expectations by

managemento Management actions appear to contradict stated

expectationso New or modified Policy/Procedure or job standard not

received by worker (not communicated by management or central staff)

o Special task requirements (procedure, SJHA, work permit, PPE, etc.) identified, but not communicated to workers

o Inadequate communication between work teams or key individuals

o Communications incorrect or misunderstood

7 - Inadequate Tools, Equipment, Facilitieso Correct tools, equipment, or PPE not available or

inadequate (includes communication equipment)o Inadequate human/machine interface

(alarms,displays,controls,layout)o Labeling, signs, or identification non-existent or

incorrect o Inadequate work environment (lights, noise,

housekeeping, barriers)o Ergonomics of task need improvement (excessive

physical activity,etc)o Task too complex (too many actions or decisions

required))

o Inadequate design or specification of equipment for purpose

o Defective equipment fabrication/constructiono Equipment damaged prior to installation/useo Wrong equipment ordered or installedo Inadequate inspection and/or preventive

maintenanceo Hazards or errors not detectable prior to incidento Equipment repaired, but failure repeatedo Fault identified but not yet repaired

8 - External Factorso Natural disastero Act of vandalism

o War/Sabotageo Other

Decision Support Tools Operational /External Factors

Incident: Worker was observed running impact w/o a faceshield

Incident: Worker was observed transitioning w/o maintaining 100% tie-off

Using the 5-Why Process it was determined that:

• Worker had started task with faceshield on• He was in a very tight congested area• When he repositioned his body, the faceshield was knocked off and fell 30’ to grade• He had less than a minute left to finish tightening one nut and the task was complete

Using the 5-Why Process it was determined that:

• Job had been in progress for ~ 2hours• Worker had all proper fall arrest equipment on, dismantling scaffold• Workcrew was on the next to last level, they had already dismantled 3 levels• When moving on the same level the worker often moved w/o 100% tie-off • The Crew’s Foreman had been on the jobsite all morning observing the work

What is the Root Cause & Factor?

Root Cause Analysis Flowchart (RCAF)

Personal FactorsPersonal Factors

Did not follow procedures or acceptable practices because . . .Did not follow procedures or acceptable practices because . . .

4. In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equip damage, regulatory

assessment or production delay).

4. In past, did not follow procedures or acceptable practices and no incident occurred(injury, product quality incident, equip damage, regulatory

assessment or production delay).

2. Doing the job according to procedures or acceptable practices takes more time/effort2. Doing the job according to procedures or acceptable practices takes more time/effort

3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated

1. Lack of skill or knowledge1. Lack of skill or knowledge

5. Lack of or inadequate procedures 5. Lack of or inadequate procedures

6. Inadequate communication of expectations regarding procedures or acceptable practices.

6. Inadequate communication of expectations regarding procedures or acceptable practices.

Development of solutionsDevelopment of solutions

Implementation of solutionsImplementation of solutions

Organizational FactorsOrganizational Factors 8. External Factors8. External Factors

Verification and validation of solutionsVerification and validation of solutions

Questionable Item, Near Loss, Loss Occurs . . . WHY?Questionable Item, Near Loss, Loss Occurs . . . WHY?

7. Inadequate tools or equipment7. Inadequate tools or equipment