root cause analysis - methods and best practice
DESCRIPTION
A critical part of any safety management system comes after incidents occur. Effective incident investigation including root cause analysis can provide many answers for your organization regarding why an incident or event has occurred. Even if your safety department excels at completing investigations and undertaking corrective actions, your SMS will not be effective if you fail to identify root causes quickly and accurately. Safety teams that make Root Cause Analysis central to their day-to-day activities will significantly improve their ability to better the safety of the workplace and ensure that incidents do no reoccur. In these slides, Medgate Safety expert Shannon Crinklaw discusses Root Cause Analysis, outlining its potential impact, covering different analysis methodologies and outlining best practices. To view the accompanying webinar, go to http://bit.ly/X518oY where you will learn: What type of incidents are most common. Mistakes that organizations should avoid when carrying out root cause analysis. Different models of root cause analysis, such as Five Why and Cause-and-Effect diagrams. The long term benefits of root cause analysis efforts.TRANSCRIPT
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Enterprise EHS Software Solutions
USING ROOT CAUSE ANALYSIS TO IMPROVE SAFETY
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Mike JacksonModerator
PART 1: WHAT HAPPENEDPART 2: WHY DID IT HAPPENPART 3: HOW TO STOP IT HAPPENING AGAIN
Shannon Crinklaw, CRSP, CHRPEHS Client Service Consultant
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SHANNON INTRODUCTION
• CRSP, CHRP• Over 10 years’ experience
in safety and risk
• Led & developed risk assessments as part of Toyota SMS including industrial, emergency response and construction models.
• Consultant in the implementation of OH&S software for various clients across industries
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WHAT HAPPENED
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OSHA'S 2013 TOP 10 SERIOUS VIOLATIONS1. Fall protection2. Hazard communication 3. Scaffolding4. Respiratory protection5. Electrical: wiring 6. Powered industrial trucks7. Ladders8. Lockout/Tagout9. Electrical systems design10. Machines
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TOO MANY INCIDENTS… (2012 FIGURES)• Nonfatal injuries & illnesses: 3 million• Deaths: 4,628 workers = 89/week = 12/day• Construction: The "Fatal Four" were
responsible for 54.2% of fatalities1. Falls2. Struck by object3. Electrocution4. Caught-in/between
Eliminating the Fatal Four would save 437 workers' lives in America every year.
Source: OSHA Commonly Used Statistics
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…AND MOST INCIDENTS ARE PREVENTABLE• Herbert William Heinrich – 1920s
Fatality
Severe injury
Minor injury
Near miss
Unsafe acts & conditions
Only 2% of all accidents are unpreventable (or "acts of God")
The other 98% are preventable: 88%: unsafe acts 10%: unsafe conditions
RESULT
BEHAVIOR
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To avoid fatalities at the top of the pyramid, start doing analysis at the bottom
Fatality
Severe injury
Minor injury
Near miss
Unsafe acts & conditions
Unsafe acts & conditions
Near miss
Minor injury
Severe injury
Fatality
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• Who• When• Where• What
Gather known facts before asking WHY
HOW TO START INVESTIGATE?
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WHAT YOU SHOULD INVESTIGATE
All "near miss" situations = risk for accidents
All accidents = risk for injuries
All injuries, even the minor ones
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INVESTIGATION IS NOT ENOUGH• Inspections:
Identification & correction of hazards on a case-by-case basis
• Audits:Deeper investigation to identify systematic /
process issues• Risk assessment:
Ongoing analysis to continuously evaluate and mitigate risk to prevent it from happening
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WHY IT HAPPENED
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ROOT CAUSE ANALYSIS - DEFINITION• Root cause: “The fundamental reason for the
occurrence of a problem” [The Collins English Dictionary]
Root cause analysis: A process, method or procedure that helps discover and understand the initiating fundamental reason for the occurrence of a problem
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ROOT CAUSE ANALYSIS - DEFINITION• Root cause analyses are used in various
domains and sectors:
*-based RCA Domain SectorProduction Quality control Industrial manufacturingProcess Business processes Industrial manufacturingFailure Failure analysis Engineering, MaintenanceSafety Accident analysis Occupational Health & Safety
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SAFETY-BASED ROOT CAUSE ANALYSIS
Taiichi Ohno, Former Executive Vice President of Toyota Motor Corporation
Goal: Reduce the chance of recurrence of incidents to improve the safety of all employees over time.
The root cause of any problem is the key to a lasting solution
Source: Toyota Production System: Beyond Large-Scale Production - Taiichi Ohno
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PROCESS-BASED ROOT CAUSE ANALYSIS
Why can one person at Toyota Motors operate only one machine when one person can operate 40-45
looms at the Toyota textile plant?
Because machines at Toyota Motor didn't stop when machining was done.
The birth of automation.
• Repeatedly asking WHY is the scientific basis of the Toyota system.
Source: Toyota Production System: Beyond Large-Scale Production - Taiichi Ohno
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ALWAYS LOOK FOR DEEP CAUSES• Two categories of accident causes:
1. Immediate causes employee error lack of concentration, stress, fatigue non-use of personal protective equipment
– WHY? – Do not stop at immediate cause – Don’t blame people, look at facts
2. Underlying or root causes
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When accidents are investigated, the emphasis should be concentrated on
finding the root cause of the accident rather than
the investigation procedure itself so you can prevent it
from happening again.
Source: Canadian Centre for Occupational Health and Safety
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WHY IT HAPPENED
- ROOT CAUSE MODELS -
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BASIC ELEMENTS OF ROOT CAUSEManMethodMachineMaterialEnvironment Blaming the Man is the
easiest explanation to accidents, but also the most unlikely one…
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BRAINSTORMING / AFFINITY DIAGRAM
Machine
Defective equipment
Wrong tool for the job
Not enough PPE
Environment
Excessive noise
Crowding workers into one area
Man
Lack of skills due to inadequate
training
Physical limitations
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CAUSE-AND-EFFECT (FISHBONE) DIAGRAM
MACHINE
MAN ENVIRONMENT
Crowding workers into one area
Excessive noise
Physical limitations
Lack of skills due to inadequate training
Defective equipment
Wrong tool for the job
Not enough PPE
HIGHER NUMBER OF INCIDENTS
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5 WHY ANALYSIS
Why?
Fix the root cause, not the symptoms
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5 WHY ANALYSIS – COMMON MISTAKES• Rely on opinion vs. investigation • Pin blame on an individual vs.
identify the system pain points• Cure the symptoms (short-term)
vs. the root cause (long-term)• Restrict the analysis to 5 steps• Misconduct analysis resulting in
an illogical outcome
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5 WHY ANALYSIS – BAD EXAMPLE
Why?
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5 WHY ANALYSIS – GOOD EXAMPLE
Why?
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HOW TO STOP IT HAPPENING
AGAIN
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WHAT YOU DO WITH THE 5 WHY ANALYSIS• Fix the problem:
More efficiently: Identify a single, central root cause and improve resource allocation
Faster: Document your thought process and fix incidents faster over time
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WHAT YOU DO WITH THE 5 WHY ANALYSIS• Work on continuous improvement (Kaizen)
As the process of your analysis is documented, both the root cause and the corrective action can be applied to other areas of the organization
Share your findings with other areas
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WHAT YOU DO WITH THE 5 WHY ANALYSIS• Track for trends and reporting
Analyze trendsIdentify pain pointsContinuously educate people
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HOW CAN A SAFETY SOFTWARE HELP?
Collect comprehensive incident data
Create an accurate picture of the event
Identify root causes and learning points
Implement corrective actions
Ensure proper incident notification up the chain of command
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ROOT CAUSE ANALYSIS QUALITY
Ability to review quality of root cause analysis: Safety professionals can review root cause created by personnel at the site/location
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SHARING INFORMATION
Roll-out to other areas
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REPORTING AND TRENDING
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DECISION TREE MODEL
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DO NOT STOP QUESTIONING