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Root Cause Analysis ??????

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Root Cause Analysis Objectives Best Practice techniques for conducting effective root cause analysis ... – PowerPoint PPT presentation

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Title: Root Cause Analysis ??????


1
Root Cause Analysis??????
2
Objectives ??
  • Best Practice techniques for conducting effective
    root cause analysis
  • ??????????????
  • Identifying Countermeasures, Hierarchy of Control
  • ??????????????????
  • Examples of how techniques can be applied to
    incidents and near misses.
  • ??????????????????????

3
Why Investigate Incidents????????????
  • Find the causes
  • ??????
  • There will typically be several causes to an
    incident.
  • ?????????????????
  • Prevent similar incidents
  • ?????????
  • Performing an incident investigation, and
    communicating the results, will prevent similar
    incidents.
  • ????????????????????????????
  • Protect company interests
  • ???????(????????????????)
  • Every Imerys employee is a valuable asset.
  • ??Imerys????????????

4
Getting hurt is not generally a conscious
decision...???????,?????
  • ...Working Safely Is!
  • ?????????????!

5
  • Why Investigate Incidents and Near misses?
  • ??????????????

3,000 FIRST AID ?? (Minor ??)
  • ????

1 FATAL ??
  • Because we dont get to pick where we land
  • ??????????????

30 DISABLING ?? (Severe ??)
300 MEDICAL
???? (Serious ??)
30,000 NEAR MISSES
???? (Unsafe acts-Unsafe
conditions ?????????)
6
  • Why Investigate Incidents and Near misses?
  • ??????????????

3,000 FIRST AID ?? (Minor ??)
1 FATAL ??
  • But we can pick where we focus
  • ?????????????

30 DISABLING ?? (Severe ??)
300 MEDICAL
?? (Serious ??)
  • Effort ????

30,000 NEAR MISSES
???? (Unsafe acts-Unsafe
conditions ?????????)
7
Group Exercise ????
  • Discuss other reasons we should investigate near
    misses and close calls
  • ???????????????
  • 5 minutes
  • 5????

8
Responsibility ??
  • Ensure employees understand what an accident is.
  • ????????????
  • Ensure that all associates understand why they
    must report accidents.
  • ???????????????????

9
Responsibility ??
  • Investigate every accident!
  • ?????????
  • Major
  • ????
  • Minor
  • ???
  • Property
  • ????
  • Near Miss
  • ????

10
KEY INVESTIGATION POINT?????
  • Do Not Look for Someone to Blame!
  • ??????????!

11
Things that make you go Hmmm???????
Cause Corrective Action ?????? Employee
failed to notice protrusion of table in line of
path ???????????????? Discipline employee to be
aware of walking path ??????????
12
Before You Discipline (5 Questions)?????????
(???5???)
  • Leadership requires discipline when justified!
  • ??????,?????????!
  • Before you discipline ask yourself Have I
  • ?????????,????????
  • set an example by following safety rules/policies
  • ??????
  • provided adequate resources and support
  • ?????????????????????

13
Before You Discipline (5 Questions)?????????
(???5???)
  • provided adequate training
  • ??????????
  • insisted on compliance by enforcing safety rules
    in the past
  • ?????????????
  • provided adequate supervision by identifying and
    correcting hazards before someone got hurt
  • ?????????????????,?????????

14
Incident Investigation Process??????
Notification ??
Response ??
Analysis ??????
Follow-Up ????
Corrective Action ????
Fact-Finding ????
15
Before the Interview?????
  • Preparation
  • ??
  • Who should do the interview?
  • ??????????
  • Interviewer should have credibility with the
    interviewee
  • ???????????????
  • Interviewer should be aware of group dynamics
  • ???????????????????????

16
Before the Interview?????
  • Have prepared questions, just in case
  • ?????????,????
  • Meet on interviewees turf or neutral location
  • ?????????????????
  • Preferably were the incident occurred
  • ?????????????(????)

17
Who Should be Interviewed?????????
  • Injured and others directly involved
  • ???????????
  • Witnesses
  • ????
  • Others who do the same job
  • ????????
  • Maintenance personnel
  • ??????
  • Engineering
  • ????
  • Those who set up the equipment
  • ??????
  • Other experts
  • ????

18
Fact Finding The Interview??????
  • Interview Tips (put the interviewee at ease)
  • ???? (???????????)
  • Create a positive environment
  • ???????????
  • Ask questions without being aggressive
  • ?????????????
  • Be patient, do not talk too much
  • ????,???????
  • Show interest in the interviewee
  • ????????????
  • Avoid criticism
  • ???????

You are investigating the incident/accident, not
the person ???????,??????
19
Interview Questions ????
Primary and Secondary ???????
Open ??? vs. Closed ???
Individual ?? vs. Group ??
Leading ??? vs. Neutral ???
20
During the Interview????
What techniques can you use for more effective
interviews? ?????????????
  • As soon as possible and at the scene
  • ????????
  • Put at ease
  • ???????
  • fact finding, not fault finding
  • ??????,??????????
  • start with easily answered questions (conditions,
    etc.)
  • ????????????(??????)
  • seek privacy
  • ???????
  • ask for prevention ideas
  • ???????????

21
During the Interview????
  • Ask open questions (what, when, where)
  • ????????(??????,??,???)
  • One-on-One and One at a time
  • ?????????????

22
Fact Finding Interview Questions?????????
  • Ask open ended questions (not yes/no)
  • ???????(??????/?????????)
  • No
  • ???
  • Have you received safety training?
  • ??????????
  • Yes
  • ???
  • What safety training have you received?
  • ???????????

23
Fact Finding Interview Questions?????????
  • Dont ask leading questions
  • ????????????
  • No
  • ??
  • Does your supervisor discuss safety with you?
  • ???????????????????
  • Yes
  • ??
  • Who discusses safety with you?
  • ?????????????

24
During the Interview?????
  • Phrases to remember
  • ????????
  • Please help me understand what happened
  • ??????????????
  • Go on
  • ???
  • What does that mean to you
  • ??????????
  • Can you explain that further
  • ??????????
  • dead air
  • dead air

25
Interview Quiz ???????
  • Is this a good question?
  • ???????????
  • In which direction was the John running when he
    tripped on the pallet?
  • ?John???????,?????????
  • Leading question that assumes
  • ??????
  • John was running John??
  • John fell on a pallet John??????
  • What would be a better question?
  • ????????
  • What was John doing before he fell?
    John??????????
  • Why do you think John was fell down?
    ???John?????????

26
Interview Quiz ???????
  • Is this a good question?
  • ??????????
  • Did you see Jane reach past the guard and stick
    her hand inside the machine?
  • ???Jane????????????????
  • Leading question that assumes
  • ?????????
  • Jane did reach past the guard Jane????????
  • What would be a better question?
  • ????????
  • What did you see the operator do?
  • ??????????????

27
Interview Quiz ???????
  • Is this a good question?
  • ??????????
  • Did you realize that Ed was angry before he got
    the fork truck?
  • ???? Ed???????????
  • Leading question that assumes
  • ?????????
  • Ed was angry Ed???
  • What would be a better question?
  • ????????
  • How would you describe Eds behavior before he
    got the fork truck? ??????Ed???????????

28
Bucket of Bricks?????
29
A Series of Unfortunate Events????????
THE BUCKET OF BRICKS STORY (Interviewing
Technique Reinforcer) The following letter is a
reprint of an actual letter sent by an employee
to the Petrolane-Utah Gas Service. I am writing
in response to your request for additional
information. In the accident reporting form, I
put trying to do the job alone as the cause of
the accident. You said in your letter that I
should explain more fully and I trust that the
following information will be sufficient. I am a
bricklayer by trade. On the date of the
accident, I was working alone on the roof of a
new six story building. When I completed my
work, I discovered that I had about 500 pounds of
bricks left over. Rather than carry the bricks
by hand, I decided to lower them in a barrel by
using a pulley which fortunately was attached to
the side of the building at the sixth
floor. Securing the rope at ground level, I went
up to the roof, swung the barrel out and loaded
the bricks into it. Then I went back to the
ground and untied the rope, holding it tightly to
ensure a slow descent of the 500 pounds of brick.
You will note in the accident report that I
weigh 165 pounds. Due to my surprise at being
jerked off the ground so suddenly, I lost my
present state of mind and forgot to let go of the
rope. Needless to say, I proceeded at a rather
rapid rate up the side of the building. In the
vicinity of the third floor, I met the barrel
coming down. This explains the fractured skull
and broken collarbone. Slowed only slightly, I
continued my rapid ascent, not stopping until the
fingers of my right hand were two knuckles deep
into the pulley. Fortunately, by this time, I
had regained my present state of mind and was
able to hold tightly to the rope in spite of my
pain. At approximately the same time, however,
the barrel of bricks hit the ground and the
bottom fell out of the barrel. Devoid of the
weight of the bricks, the barrel now weighed
approximately 50 pounds. I refer you again to my
weight. As you might imagine, I began a rapid
descent of the building. In the vicinity of the
third floor, I met the barrel coming up. This
accounts for the two fractured ankles and the
lacerations of my legs and lower body. The
encounter with the barrel slowed me enough to
lessen my injuries when I fell on the pile of
bricks. Fortunately, only three vertebrae were
cracked. I am sorry to report, however, that as I
lay there on the bricks in pain, unable to stand,
and watching the empty barrel six stories above
me, I again lost my present state of mind and let
go of the rope. The empty barrel weighed more
than the rope, so it came back down. And that
accounts for my two broken legs. I hope I have
furnished the information you required as to how
the accident occurred. Sincerely, Joe Schmoe
30
A Series of Unfortunate Events????????
  • ?????
  • (??????)
  • ????????Petrolane-Utah Gas Service?????????
  • ?????,???????,????????????????????????,??????????
    ??????????????????????????????????,??????????,???
    ????????
  • ????????????,????????????????????????????,???????5
    00??????????????????????????????????,?????????????
    ?????????????????
  • ??????????????,?????????,??????????,??????????,???
    ???,????500???????????????????????????165??
  • ????????????????,???????????,?????????????????????
    ???,??????????????
  • ?????????????,??????????????????????????,?????
  • ???????,??????????,?????????????????????????????,?
    ???????,????????,?????????????????,??????????,????
    ?????????????????50??
  • ??????????????????,???????????????????,???????????
    ????????????????????,??????????????????????????,??
    ?????????????????
  • ????????,??????????,??????????,???????????????????
    ??????????,???????????????,?????????????
  • ???????????????????????
  • ???
  • Joe Schmoe

31
The Interview??
  • You have 5 minutes to
  • ??5??
  • Create an non controversial atmosphere
  • ???????????
  • Gather additional facts
  • ??????
  • Ask open ended questions
  • ??????
  • Actively listen
  • ????
  • Ask Primary and Secondary Questions
  • ??????????

32
Incident Investigation Process??????
Notification ??
Response ??
Follow-Up ????
Analysis ??????
Corrective Action ????
Fact-Finding ????
33
Analyse Data????
  • Concentrate on the underlying causes, the Root
    Causes, not the symptoms.
  • ??????????,????????
  • Accidents rarely result from a single cause, but
    occur because of a network of Multiple Causes.
  • ?????????????,????????????????
  • Direct causes (energy sources hazardous
    materials)
  • ????(?????)
  • Indirect causes (unsafe acts and conditions)
  • ????(?????????????????)
  • Basic causes (management policies personal or
    environmental factors)
  • ????(?????????????)

34
Unsafe Acts and Conditions??????????
  • Unsafe acts
  • ????????????
  • Operating Procedure Deviation
  • ?????????
  • Running - Horse Play
  • ??
  • By-passing safety devices
  • ?????????
  • Not using protective equipment
  • ???????
  • Under influence of drugs or alcohol
  • ????????
  • Unsafe conditions
  • ????????????
  • Defective Tools/Equipment
  • ?????????????
  • Line Speed
  • ??????????
  • Inadequate guard barrier
  • ?????????
  • Illumination
  • ????
  • Inadequate/Improper PPE
  • ??????????????
  • Inadequate machine guarding
  • ????????

35
Multiple Root Cause Analysis Technique???????????
  • Five Whys
  • ?????

36
Why Analysis ?????
Why? ???? Why? ???? Why? ???? Why?
???? Why? ????
The why questions drive to the system root
causes. Identify root causes through simple,
precise, objective, statements that describe why
the factors identified in the discrepancy
analyses exist. ????????????????????????? ?????
???????????????????
37
Why Analysis ?????
  • Done after fact-finding has developed the
    objective information on events, conditions and
    contributing factors.
  • ??????????,?????????????????????????
  • State the occurrence simple, precise, and
    objective terms to describe what happened without
    stating, or implying, why it happened
  • ?????????????????,?????????????
  • Then ask WHY to identify why these conditions,
    factors and discrepancies exist.
  • ??????,??????????????????
  • Repeat the WHY to drive back to real the system
    issues that are at the source.
  • ????????????????

38
  • ????
  • ????
  • ????
  • ????
  • ????

39
5????
  • ????

40
Incident Investigation Process ???????
Notification ??
Follow-Up ????
Response ??
Analysis ??
Corrective Action ????
Fact-Finding ????
41
Developing Countermeasures ????
  • Identify and address multiple root causes - not
    just the indirect, apparent causes.
    ????????,??????,??????
  • 60 seconds till the world ends
  • Multiple root causes will need multiple controls
    so dont focus on a single solution.??????????????
    ????????????
  • Develop simple, precise, objective, statements of
    what could be done to remove the root causes
    ????,??,????????????
  • This list should be as comprehensive as possible
    ??????????
  • Brainstorming will be an effective technique
    ????????????
  • Address all identified multiple root causes.
    ?????????

42
Controls and Countermeasures ???????
  • Identify those persons who are responsible for
    corrective/preventive actions. ?????????
  • Set corrective/preventive action target dates,
    and follow up to ensure action is completed and
    effective. ??????????,?????????????????
  • Share results with similar operations within
    plant and across plants. Video Reenactment
    excellent tool to accomplish this.???????????????
    ????,??????

43
Hierarchy of Controls ???????????
  • Elimination/Substitution- removing or reducing
    the hazard
  • ??/?? ???????
  • Engineering Controls workstation design,
    machine guards, safety controls, isolation of
    hazardous areas, monitoring devices, etc.
  • ?????? ????,????,????,??????,?????
  • Administrative Controls - procedures,
    assessments, inspection, records to monitor and
    ensure safe practices and environments are
    maintained.
  • ?????? ????,??,??,?????????????????
  • Training Controls - initial new hire safety
    orientation, job specific safety training and
    periodic refresher training.
  • ?? ????????,????????????
  • Personal Protective Equipment
  • ??????

44
Accident Investigation Process???????
Notification ??
Follow-Up ????
Response ??
Analysis ??
Corrective Action ????
Fact-Finding ????
45
Track Countermeasures ????
  • Complete Incident Investigation Forms with CM,
    responsible persons, completion date and status.
  • ?CM,?????????????,???????
  • Follow your guidelines
  • ??????
  • Ask Affected Parties
  • ?????????
  • Regular Review by Sr. Management
  • ?????????

46
Summary forEffective Root Cause Analysis
?????????????
  • Techniques are merely tools and can be misused
    and/or misapplied.
  • ???????,??????
  • Techniques inherently overlap and should be used
    together to check or confirm facts.
  • ??????,??????????????
  • Integrate findings from various techniques and
    use parts from all tools.
  • ?????????????
  • Scale the scope of the analysis to suit the
    severity or complexity of the accident.
  • ??????????????????????
  • Active management role is critical.
  • ?????????????

47
??????????
48
?????????
SHANMUGANATHAN (OTC SUPEVISOR) 8 MORE OTC
WORKERS GOING UP ACCESS ROAD
TOP HAULAGE ROAD (2 sections)
OTC Vehicle
ACCESS ROAD
HOLLAND IS90 GEAR DOZING BUCKET BACK PUSHER
MACHINE DRIVEN BY GALA SINGH
TIPPING ACCCESS ROAD
BOTTOM HAULAGE ROAD (MCA1)
Susindaran drove Pajero WBP 50
GALA SINGH (OTC BACK PUSHER OPERATOR)
Molek Kinta Vehicle
DUWI BIN MUSA (MOLEK KINTA)
MOHD SAID (MOLEK KINTA)
MARBLE PLATFORM
EMERGENCY ROAD
Murugan drove excavator
KALAIYARASAN (OTC SIGNALMAN)
ARUMUGAM (OTC PROJECT MANAGER)
ZUBIR ABDULLAH (MOLEK KINTA)
RATHAKRISHNAN (OTC DIRECTOR)
BOTTOM HAULAGE ROAD (MCA0)
PAJERO BFH 9168
AZAMAN (IMERYS SAFETY OFFICER, inside of Pajero)
49
????
??????
?????
???????
??????
???????
?????
Imerys ???
Overview of the Rock-Fall Face
50
?????? Pajero
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