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The document outlines three consistent approaches to investigating workplace accidents: data collection, event charting, and root cause identification. It then provides details on each approach and how to apply them to an investigation of a kitchen fire accident. Data collection involves gathering evidence like interviews, photos, and records. Event charting creates a timeline of the incident. Root cause identification determines the underlying causes that led to the accident through causal factor analysis, barrier analysis, and change analysis. The document uses the kitchen fire example to demonstrate how to apply these approaches to identify root causes and make recommendations to prevent future occurrences.
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- 1. COMPILED BY :VASANT OAK DGM EHSS WHAT”s UP- 9987592242
- 2. Identify threeconsistent and systematic approaches to investigating workplace accidents. Understand how to apply these approaches to a workplace accident investigation.
- 3. Data Collection Event Charting RootCause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 4. •Interviews •Photographs •Equipment Specs. •Equipment Manuals •SafetyRules •Training Records Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 5. •Organizes collected data foranalysis •Sequence diagram •May uncover needs for additional data collection Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 6. Mary starts cooking Mary leaves kitchen Smoke alarm sounds Mary enters kitchen Mary uses fire ext. FE fails Mary throws wateron fire Fire spreads Fire starts Mary calls 911 Fire department arrives FD puts out fire Kitchen destroyed Smoke damage throughout restaurant Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 7. Mary starts cooking Mary leaves kitchen Smoke alarm sounds Mary enters kitchen Mary uses fire ext. FE fails Mary throws wateron fire Fire spreads Fire starts Mary calls 911 Fire department arrives FD puts out fire Kitchen destroyed Smoke damage throughout restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out FE not charged Mary sees fire Grease fire Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Phone rings in front of restaurant
- 8. Casual Factors: 1. DirectCause: Immediate event/ condition that caused accident) 2. Contributing Cause: Event/condition that increased probability or severity of the accident 3. Root Cause: Event/condition that, if corrected, will prevent recurrence Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 9. Potential Causal Factors: •Lack of awareness • Lack of safe work practices • Lack of adherence/enforcement to safe work practices • Improper/inadequate equipment/materials • Improper/inadequate design Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 10. Mary starts cooking Mary leaves kitchen Smoke alarm sounds Mary enters kitchen Mary uses fire ext. FE fails Mary throws wateron fire Fire spreads Fire starts Mary calls 911 Fire department arrives FD puts out fire Kitchen destroyed Smoke damage throughout restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out FE not charged Mary sees fire Grease fire Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Electric burner shorts out Mary leaves kitchen FE not charged Mary throws water on fire Phone rings in front of restaurant
- 11. Used to identifydeviations from the norm • “What happened” vs. “What should have happened” • Used mostly when operations and standardized Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 12. Common Changes andDifferences: • Personnel • Plant • Hardware • Procedures • Managerial Controls Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 13. Mary starts cooking Mary leaves kitchen Smoke alarm sounds Mary enters kitchen Mary uses fire ext. FE fails Mary throws wateron fire Fire spreads Fire starts Mary calls 911 Fire department arrives FD puts out fire Kitchen destroyed Smoke damage throughout restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out FE not charged Mary sees fire Grease fire Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Electric burner shorts out Mary leaves kitchen FE not charged Mary throws water on fire Phone rings in front of restaurant
- 14. Basic premise isthat there is a flow of energy associated with all accidents – Kinetic – Potential – Electric – Thermal – Steam – Pressure Barriers are placed to reduce the energy from people, property, environment. Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 15. Barrier Categories: • Equipment •Design • Administration (procedures processes) • Supervisory/Management • Warning Devices • Knowledge and Skills Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 16. Mary starts cooking Mary leaves kitchen Smoke alarm sounds Mary enters kitchen Mary uses fire ext. FE fails Mary throws wateron fire Fire spreads Fire starts Mary calls 911 Fire department arrives FD puts out fire Kitchen destroyed Smoke damage throughout restaurant Grease ignites on burner AL pan melts Arcing heats pan Electric burner shorts out FE not charged Mary sees fire Grease fire Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis Electric burner shorts out Arcing heats pan FE fails Mary throws water on fire Electric burner shorts out Grease on burner ignites Fire spreads FD puts out fire Mary leaves kitchen Phone rings in front of restaurant Smoke alarm sounds Mary calls 911 Mary uses fire ext.
- 17. Root causes Derivedfrom the facts and analysis conducted Should answer two questions: 1. What happened? 2. Why it happened? Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 18. • Root causesshould identify reasons for each casual factor identified by the analysis. • Root causes which can not be completely supported by fact should identified in the report. Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 19. • Unattended stove –Facility design less than adequate – Lack of operational policy • Heating element failure – Lack of preventative maintenance program – Facility design less than adequate (auto-suppression system) Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 20. • Fire Extinguisherfailure – Inadequate inspection program • Water on grease fire – Inadequate training (abnormal events) Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 21. Identify the correctiveactions for each cause. Ensure the corrective action is viable by answering: Will the corrective action prevent recurrence? Is the corrective action feasible? Does the corrective action introduce new hazards/risks? Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 22. What arethe consequences of not implementing the recommendations? What time frame is adequate to implement the recommendations? Is the implementation of the recommendations measurable? Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 23. Unattended stove RC#1: Facility design less than adequate RC #2: Lack of operation policy Install phone in kitchen Implement policy that hot oil is never left unattended (any other operations?) Modify procedure development process to identify and address potential emergencies and hazards (JSA). Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 24. Heating elementfailure RC #3: Lack of preventative maintenance program Develop preventative maintenance strategy to periodically replace burner elements. RC #4: Facility design less than adequate (auto-suppression system) Consider alternative preparation methods (baking) or alternative equipment (gas stove). Consider additional hazards these my introduce. Install commercial kitchen fire suppression system per building code. Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 25. Fire Extinguisherfailure RC #5: Inadequate inspection program Refill/replace extinguisher. Inspect all extinguishers monthly/annually. Report incidences using extinguishers to owner to trigger refilling (training). Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 26. Water ongrease fire RC #7: Inadequate training Review training program for adequacy (contingency plan in case of extinguisher failure). Provide hands-on training on fire extinguishers. Review other skill-based activities to ensure level of hands-on training is adequate. Data Collection Event Charting Root Cause ID Recommendations Causal Factor Analysis Barrier Analysis Change Analysis
- 27. Identify threeconsistent and systematic approaches to investigating workplace accidents. Understand how to apply these approaches to a workplace accident investigation.
- 28. COMPILED BY :VASANT OAK DGM EHSS WHAT”s UP- 9987592242