The document outlines the process of incident investigation and root cause analysis, emphasizing the importance of learning from experiences to prevent future incidents. It details steps for gathering evidence, interviewing involved parties, and analyzing data to identify root causes, ultimately leading to corrective actions. Moreover, it highlights the necessity of effective communication, notification requirements under the Nova Scotia OHS Act, and the management of change during the implementation of solutions.

1. Introduction to IncidentIntroduction to Incident
Investigation & Root CauseInvestigation & Root Cause
Analysis: Learning FromAnalysis: Learning From
ExperienceExperience

2. Introduction
• Incident Investigation & NS Safety Legislation
• Incident Investigation Steps
• Individual and Group Activities
• Action Plan
• Root Cause Analysis

3. Prevention Through Investigation
• Preventing another incident is a key reason for
investigations.
• Finding root causes of an
event means being able to
control the hazards in those
root causes
• Effective incident and injury investigation means fact-
finding not fault-finding. Fix the problem not the
blame!
• Importance of ‘near miss’ investigation

4. • What do you investigate now?
• How?
• For every incident, do you know who was involved,
what happened, how and why it happened?
• Are there any repeat incidents or near misses?
• Are all members of your workforce familiar with
past incidents so that they might recognize and
avoid the same situations?
In Your Environment

5. Investigating
Incident/Injury
• Time sensitive
• Objective and clear
• Analyzes potential for harm, even where actual
harm was less
• Investigates near-misses, asks “What if?”
• Fact-finding, not fault-finding
• Makes recommendations and plans for change
• Implement and Evaluate
• Communicates!

6. Under what
circumstances,
when and how
must you notify
the OHS Division
of an incident in
your workplace?
,

7. NS OH&S Act
• Nova Scotia Labour and Workforce Development
24 hour notice:
– workplace incident resulting in death
– explosion involving injuries or not.
• 7 days written notice:
– a fire resulting in injury
– an incident resulting in serious injury
– Examples: unconsciousness; loss of substantial blood;
fractures; amputation; major burns; loss of sight; any life
threatening injury).

8. NS OHS Act
• S. 28 Program Requirements
• S. 63 ‘Notice of Accidents at the Workplace’
- Serious bodily injury
- Accidental explosion
- Fatality
• S. 64 ‘Disturbance of Accident Scene’
• S. 65 ‘Duty to Disclose Accident Information’

9. No person shall disturb the scene of an incident that
results in serious injury or death except to:
• attend to persons injured or killed;
• prevent further injuries; or
• protect property that is endangered as a result
of the incident.
Except as directed by an officer
N.S. OH&S Act

10. The Bad Thing happens.
What’s next?

11. • Report the event to a designated person (usually
supervisor first).
• Provide first aid and medical care to injured
person(s); prevent further injuries or damage.
• Investigate to identify the causes.
• Report the findings.
• Develop a plan for corrective action.
• Implement plan and then evaluate the
effectiveness of the plan.
Investigation Steps

12. • The investigation steps are simple: gather
information, analyze it, draw conclusions,
make recommendations, evaluate planning
and implementation of recommendations.
• An open objective mind is necessary.
• Preconceived notions can lead us down the
wrong path, leaving significant observations
and facts uncovered.
Collect Data

13. There are two main types of evidence:
• physical evidence such as ….
• documentary such as….
• Physical evidence should be gathered as
witnesses are being interviewed.
• Be thorough and inquisitive when collecting
evidence but do not contaminate it.
Collect Data

14. • Need to interview client
and/or worker sooner
rather than later. Why?
• Interview as soon as
possible after.
Interview

15. Do...
put the worker at ease;
emphasize reason for the investigation (what
happened and why);
let the worker talk, listen carefully;
confirm understanding of statements;
make short notes only during the interview.
Data Collection
Interviewing:

16. •“Tell me what you were doing at the time.”
•“Tell me what you saw, and/or what you heard.”
•“Describe the conditions (weather, housekeeping,
light, noise, etc.) at the time.”
Interviewing:
Ask open-ended questions...

17. • Most incidents are multi-causal even when they
seem straight forward!
• Was the worker trained? If not, why not?
• Was the worker distracted? If yes, why was the
worker distracted?
• Was a safe work procedure being followed? If
not, why not?
• Were safety devices in order? If not, why not?
Need to reveal conditions that are open to
correction rather than attempts to prevent
"carelessness".
Analyzing Facts

18. • Look for supporting facts in:
• People
• Equipment
• Materials
• Environment
Analyzing contributing
factors

19. Before During After
People
Staff arriving for
work 30 minutes
early
7:30am
Slipped on
ice, breaking
wrist
Additional staff attended to
injured party, called
ambulance
Equipment Salt spreading
equipment available not used Salt spread
Materials Salt available not used Salt effective in controlling
hazard
Environment
Ice on parking lot,
Cold weather;
Lighting poor
(before sunrise)
same as
before
Temperature higher, salt
effective, sunrise brightened
area
Processes Maintenance not on
until 8:00am
Called in
early to
control
situation
Shift changed to have one
member of crew arrive ½
hour early to salt and one to
stay ½ hour later

20. Broken
Wrist Fall
Icy
Surface
Incident
Investigation
No Salt
Worker’s
Statement

21. Broken
Wrist Fall
Icy
Surface
Incident
Investigation
No Salt
Worker’s
Statement

22. Broken
Wrist Fall
Icy
Surface
Improper
Winter
Footwear
Rushing
No Salt
Victim
Statement
Observation
Observation
Observation
Witness
Statement
Victim
Statement
Observation
Incident
Investigation

23. Broken
Wrist Fall
Icy
Surface
Improper
Winter
Footwear
Rushing
Late
For work
Fashion
Choice
No Salt
Fear
Of
Penalty
Personnel
Off
Temp
Dropped
Victim
Statement
Observation
Victim
Statement
Observation
Victim
Statement
Interview
Incident
Investigation

24. Final Analysis
• Each conclusion should be checked to
see if:
• it is supported by evidence
• the evidence is direct (physical or documentary)
• based on eyewitness accounts
• Not based on assumptions!

25. Many models
• ISO 9001 Corrective Action
• Six Sigma DMAIC
• PLAN-Do-Check-Act(PDCA)
• DO IT2 problem solving model (10 step model)
– Focus on getting the problem statement right
– This model fits the PDCA-more in-depth on the plan
• Steps 1-7 PLAN
• Step 8 DO
• Step 9 CHECK
• Step 10 ACT
DO IT2…Root Cause Analysis( the core of problem solving and
corrective actions) Duke Okes 2009
Root Cause Analysis

26. Find it(cause of the problem)
Diagnostic phase
1. Define the problem
2. Understand the process
3. Identify possible causes
4. Collect the data
5. Analyze the data
Fix it(cause of problem)
Solution phase
6. Identify possible solution
7. Select solution(s)
8. Implement the solution(s)
9. Evaluate the effect(s)
10. Institutionalize the change
DO IT2
Problem
statement

27. Find it(cause of the problem)
Diagnostic phase
1. Define the problem
2. Understand the process
3. Identify possible causes
4. Collect the data
5. Analyze the data
Fix it(cause of problem)
Solution phase
6. Identify possible solution
7. Select solution(s)
8. Implement the solution(s)
9. Evaluate the effect(s)
10. Institutionalize the change
DO IT2
10

28. “ A problem well stated is a problem half solved”
Former GM executive Charles Kettering
THE PROBLEM STATEMENT
WHAT: a description of what happened
WHERE: where specifically the problem was found
WHO: If the problem directly affected an individual or a group of people , “who’’
often becomes an expansion of or replaces for , “where”
WHEN: when the problem was first found or began
HOW MUCH: the frequency and/or magnitude of the problem
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 1: Define the Problem

29. Understanding the process is all about stepping back and
taking a broad view of the problem before jumping to
possible causes.
SETTING PROCESS BOUNDARIES
• Keep it internal to your organization
• What’s logical from a relative timing perspective?
FLOWCHARTING THE PROCESS
• Flowcharting can be constructed to understand steps between them
WHY IS PROCESS SO IMPORTANT
• There is a prescribed or natural time order in which things get done, where
something is transferred from one step to another . When the out put of the
process isn’t satisfactory(objective not met),something probably went wrong
within the process.
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 2: Understanding the Process

30. Here are some reasons processes fail:
• If there are no defined standards for how the
process is to be carried out , people will do what
they perceive as necessary or sufficient .
• The process definition is incorrect.
• Sometimes the process definition is not followed.
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 2: Understanding the Process

31. Understanding the process(Step2)provides problem solvers
with a broad view of the system that has failed.
Step 3 is then about identifying what factors are more or less
likely to have caused the problem.
3 APPROACHES FOR IDENTIFING POSSIBLE CAUSES:
• Treat each step of the flowchart as a possible cause
• Use a logic tree (why-why)to identify possible causes
• Brainstorm a list of possible causes
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 3: Identify Possible Causes

32. Use a logic tree (why-why)to identify possible causes
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 3: Identify Possible Causes

33. The basic steps for data collection involve the following:
1. Knowing what theories are to be tested, that is, what cause
and affect relationship are to be evaluated? This is the
purpose of Step 3.
2. Knowing what variable are involved and where they can be or
should be measured
3. Knowing what form the data will be in and deciding when and
how they should be gathered
4. Predicting what form the data will be in and deciding when
and how they should be gathered
5. Preparing for and carrying the data collection process.
Step 4: Collect Data

34. The basic steps for data analysis include the following:
1.Being clear about the theory to be tested and the data
acquired(step 4) to test it
2.Predicting what the data would look like if the theory
were true
3.Analyzing and interpreting the data to see whether they
support or deny the theory being tested
4.Considering other conclusions the data might support,
other ways to slice the same data, and other data that
might confirm or deny the same conclusion
Step 5:Analyze the Data

35. In Step 5 we have identified what has failed now we
identify possible solutions
Techniques
• Scale up or scale down
• Mind maps
• What would X Do?
• No limits( brainstorming)
• Mistake proofing
• Benchmarking
Step 6: Identify possible Solution

36. Now that you have your list of possible solutions.
Two major issues to be considered relative to the
decision-making process:
1) Who should make the decision?
2) What criteria should be used to make it?
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 7: Identify and Select Solution

37. There is no one correct method, but it will instead
depend on the particular situation;
1) Who should make the decision?
a) Autonomous-makes the decision on the basis of what he or she knows
and/or believes to be best
b) Consultative-makes the decision, but only after first getting inputs from
other who may have knowledge about the situation
c) Consensus-shares the decision-making process equally with
knowledge of or responsibility for the change.
1) Issues that impact which approach is best
includes the following:
a) How much knowledge does the individual have relative to others who
might be involved?
b) How much time is available for making the decision? That is how
critical is it to take action quickly
c) How much will lack of input impact willingness of others to support the
change?
Step 7: Identify and Select Solution

38. 1) What criteria should be used to make it?
Typical criteria include the following:
•Potential technical gains to be achieved, such as reduction in
errors, improvement of throughput, and so forth
•Financial return such as benefit/cost ratio or payback period
•How long will it take
•How well will it fit in to the organizational system and culture
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 7: Identify and Select Solution

39. Finding a good solution is one thing, but effectively implementing it is
another
Implementation calls for management of three knowledge areas:
• Technology
• Project management
• Organizational change management
-How well will it fit in to the organizational system and culture
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 8: Implement the solution(s)

40. Taking action without checking to see whether the process
improvement worked is like shooting in the dark.
During the follow-up you need to check two things:
• To see whether performance of the process is back to
what is normal or expected
• Check to ensure that the changes have been properly
implemented
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 9: Evaluative the effects

41. Some ways of doing this are as follows:
• Make it impossible to do it the old way
• Include adoption of change as a component of personnel
evaluation
• Revise the reward system to include consideration of
flexibility
• Have personnel who work in changed process assess the
degree of success and then report on the successes,
difficulties and perceived barriers
• Shape organizational culture and norms to support the
change
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Step 10: Institutionalize the change

42. The key reasons people resist change:
• People are familiar and often comfortable with the way
things are
• They fear change they believe might negative impact them
• The process of change is poorly managed by organization
• Everett Rodgers(1995) classified people into 5 groups
• 1)innovators
• 2) early adopters
• 3)early majority
• 4) late majority
• 5)laggards
DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009
Resistance to change

43. Questions