Here are the steps to analyze an accident using root cause analysis:
1. Describe the direct cause of injury:
- The injury was a laceration to the right forearm caused by contact with a rotating saw blade.
- The accident type was "struck-by".
2. Identify primary surface causes:
- Conditions: Unguarded saw blade
- Behaviors: Working at the saw without guard
3. Identify secondary surface causes:
- Conditions: Missing fall protection equipment
- Behaviors: Supervisor not performing safety inspections
4. Determine system implementation weaknesses:
- Safety inspections were not being conducted consistently
- Safety rules were not being enforced
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
ABOUT THE TRAINING PROGRAM :-
Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented.
DESIGNED FOR :-
Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities.
OBJECTIVE :-
At the end of the training program, participants will be able
- To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process.
- To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools.
TRAINING PROGRAM COVERAGE :-
- Basic knowledge about RCA program.
- What are the RCA tools ?
- More about Why- Why analysis ?
- Videos and case studies on RCA
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
ABOUT THE TRAINING PROGRAM :-
Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented.
DESIGNED FOR :-
Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities.
OBJECTIVE :-
At the end of the training program, participants will be able
- To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process.
- To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools.
TRAINING PROGRAM COVERAGE :-
- Basic knowledge about RCA program.
- What are the RCA tools ?
- More about Why- Why analysis ?
- Videos and case studies on RCA
Root Cause Analysis - methods and best practiceMedgate Inc.
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.
The RCCA PPT is an excellent training tool to implement into your functional group or business.
It basically forces you to peel the onion on a failure as far back until you’ve reached the root cause whereas in some cases it could be several.
It incorporates the 5 whys and the problem solving technique.
Root cause analysis is a combination of the art and science used to find the underlying reasons for a given effect. One of the most widely used root cause analysis tools is the 5 Whys. It is a simple, effective method of problem solving that can help teams identify and eliminate the root cause of a problem
[To download this presentation, visit:
https://www.oeconsulting.com.sg/training-presentations]
Root Cause Analysis (RCA) is a problem-solving technique that seeks to identify the primary cause of a problem. By focusing on the root cause, organizations can prevent the problem from recurring and develop long-term solutions that improve efficiency, reduce costs, and increase customer satisfaction.
RCA uses tools such as the 5 Whys and Cause & Effect Diagram to identify the underlying causes of a problem. The 5 Whys technique involves asking "why" multiple times to dig deeper into the root cause. The Cause & Effect Diagram categorizes potential causes, such as people, process, and equipment, to identify root causes quickly.
This RCA presentation is designed to provide participants with a comprehensive understanding of Root Cause Analysis (RCA) as a problem-solving technique. The presentation highlights the importance of identifying the root cause of a problem and how RCA can be used to achieve this. Participants will learn how to apply common RCA tools such as the 5 Whys and Cause & Effect Diagram to identify the root cause of a problem. They will also gain knowledge on how to prioritize root causes using a Pareto Chart to focus on the most significant causes first. The presentation will also cover the pitfalls in root cause analysis, highlighting the importance of avoiding making assumptions, involving stakeholders, and making RCA an ongoing process. By the end of the presentation, participants will have a deep understanding of RCA and be equipped with the skills needed to identify and solve problems effectively.
LEARNING OBJECTIVES:
1. Understand the critical role of identifying root causes in effective problem-solving.
2. Apply 5 Whys and Cause & Effect Diagram for practical root cause analysis.
3. Learn to prioritize root causes using Pareto Charts for impactful solutions.
4. Recognize common pitfalls and strategies for overcoming them.
CONTENTS
1. Introduction to Root Cause Analysis
2. Overview of Problem Solving
3. 5 Whys
4. Cause & Effect Diagram
5. Root Cause Prioritization
6. Effective RCA Practices
Calibration Laboratory Audit Preparation Webinar presented on December 10, 2013 by Keith Bennett, Transcat's Directory of Metrology and Quality Systems
Root Cause Analysis - methods and best practiceMedgate Inc.
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.
The RCCA PPT is an excellent training tool to implement into your functional group or business.
It basically forces you to peel the onion on a failure as far back until you’ve reached the root cause whereas in some cases it could be several.
It incorporates the 5 whys and the problem solving technique.
Root cause analysis is a combination of the art and science used to find the underlying reasons for a given effect. One of the most widely used root cause analysis tools is the 5 Whys. It is a simple, effective method of problem solving that can help teams identify and eliminate the root cause of a problem
[To download this presentation, visit:
https://www.oeconsulting.com.sg/training-presentations]
Root Cause Analysis (RCA) is a problem-solving technique that seeks to identify the primary cause of a problem. By focusing on the root cause, organizations can prevent the problem from recurring and develop long-term solutions that improve efficiency, reduce costs, and increase customer satisfaction.
RCA uses tools such as the 5 Whys and Cause & Effect Diagram to identify the underlying causes of a problem. The 5 Whys technique involves asking "why" multiple times to dig deeper into the root cause. The Cause & Effect Diagram categorizes potential causes, such as people, process, and equipment, to identify root causes quickly.
This RCA presentation is designed to provide participants with a comprehensive understanding of Root Cause Analysis (RCA) as a problem-solving technique. The presentation highlights the importance of identifying the root cause of a problem and how RCA can be used to achieve this. Participants will learn how to apply common RCA tools such as the 5 Whys and Cause & Effect Diagram to identify the root cause of a problem. They will also gain knowledge on how to prioritize root causes using a Pareto Chart to focus on the most significant causes first. The presentation will also cover the pitfalls in root cause analysis, highlighting the importance of avoiding making assumptions, involving stakeholders, and making RCA an ongoing process. By the end of the presentation, participants will have a deep understanding of RCA and be equipped with the skills needed to identify and solve problems effectively.
LEARNING OBJECTIVES:
1. Understand the critical role of identifying root causes in effective problem-solving.
2. Apply 5 Whys and Cause & Effect Diagram for practical root cause analysis.
3. Learn to prioritize root causes using Pareto Charts for impactful solutions.
4. Recognize common pitfalls and strategies for overcoming them.
CONTENTS
1. Introduction to Root Cause Analysis
2. Overview of Problem Solving
3. 5 Whys
4. Cause & Effect Diagram
5. Root Cause Prioritization
6. Effective RCA Practices
Calibration Laboratory Audit Preparation Webinar presented on December 10, 2013 by Keith Bennett, Transcat's Directory of Metrology and Quality Systems
Transcat's "Calibration's Role in the Manufacturing Jigsaw Puzzle" PresentationTranscat
Howard Zion, Transcat's Director of Service Application Engineering, discusses how calibration fits into manufacturing or the jigsaw puzzle we call manufacturing. Whether relying on an external commercial calibration supplier or an internal calibration laboratory, there are a number of disconnects that can inadvertently cause problems for the end product and that can be costly!
Here are some facts associated with correct battery handling and the related hazards and safety concerns that users of battery encounter while using batteries. This also tells us about some best practices in handling battery.
Battery Testing 101 by Megger and TranscatTranscat
In this informative webinar, Andrew Sagl of Megger presents an overview of the various battery testing technologies available as well as how to properly maintain VRLA and VLA batteries.
Learn about practical solutions for automating temperature calibration in the field and at the bench. Transcat and Fluke Calibration cover how to set-up each solution and the pros and cons of each.
A pressure gauge is a crucial tool used for monitoring pressure levels in a plant or a organization.. It is also used with switches and moreover other instruments. To keep the tool in working order, you'll have to calibrate it from time to time. Pressure Gauge Calibration is usually essential when you purchase the instrument newly.
An Incident is the final event in an unplanned process that results in near-miss, injury or illness to an employee and possibly property damage. It is the final result or effect of a number of surface and root causes.
This model was developped by me in the same period of, a ndindependant from, Reason's Swiss Cheese Model Although it isa far more dynamic model, closer to reality it had never the success the SCM had. I am no professor and simply a SIBEENG (SIlly BElgian ENGineer).
CHAPTER15 Leaming from Accidents While no company want.docxmccormicknadine86
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo ...
CHAPTER15 Leaming from Accidents While no company want.docxspoonerneddy
CHAPTER15
Leaming from Accidents
While no company wants to have accidents, once they occur, it is
important to learn from these accidents. One of the worst mistakes to make
for a company is to repeat an accident. Accidents are opportunities to fix the
safety program, correct hazardous situations, train employees on the correct
behavior, and ensure systemic problems are corrected. While an accident is
dreadful, we must learn from them.
The key concept of a safety program and the accident investigation program
15 ro prevent accidents and/ or prevent recurrence of an accident. No one
wants to get hurt, but actions/inactions and conditions will dictate an accident.
All 'd aca ents are caused, and there are many consequences of accidents. The
heallh and safety of personnel is the utmost priority, but other issues include
funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -
g 0oss of sales), and also civil or criminal legal action.
Lessons Learned
"If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s
ncept of 1 ' essons learned. One of the most important elements of
159
Parl IV: Pmornting Arddmls
160
accident in vcs t.igat.ion that ha s been discussed is to fi
an . . gure Out Wh
happened and how to prevent It. One of the bigge st mistakes of an . at
. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt
. h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·
' ent recurren
b)' correcting the problems, but actually develop a system to lea f ce
. rn rorn th
accidents. A lesso ns learned program will ensure that accidents a e
, . . re corrected
not just at o ne locat1on, but at all locations. Also a lessons lea d f
. . rne rorn a
smaller accident can hdp avoid a larger accident from happening. "If ~-e
were really good at learrung from o ur mistakes, two similar accidents would
never occur" Qanson 2009) .
One of the biggest failures of companies is not communicating the
problems, causes , issues, rrustakes, and / or failures of an accident to the other
divisions of the company. If a company has multiple locations, then these
issues could cause an accident anywhere. Communication is the key. Luckily,
communication is much easier now, and accident information can be e-mailed
immediately to other off-s ite locations.
There are many different ways to disseminate lessons learned information,
and many companies e-mail out each cause and corrective actions to all.
Others put together a weekly or monthly newsletter to disseminate the
accident information. Communication is the key component.
Review Board
Another important aspect is to have an accident review board to review
the accide nt report to check for quality, consistency, and ensure the faccs ,
causal factors, and corrective actio n s are correct. There are many types
of re view board s. The be st review bo.
An accident is an event that has unintentionally happened, that results in damage, injury or harm. An incident is an event that has unintentionally happened, but this may not result in damage, harm or injury. Therefore, every accident can be an incident. However not all incidents can be termed as an accident.
المرحلة الأولي من برنامج التوعية بأنظمة الصحة والسلامة المهنية والبيئة والتى إقيمت بموقع مستودعات البترول براس غارب بمحافظة البحر الأحمر بحضور ممثلي شركات تنفيذ المشروع وهي PETROJET، Enppi ، ALREHAB ، HILAL ، OETROMINT ، ENERGYA ، IEMSA ، MMC وذلك خلال شهر سبتمبر 2020 الجاري وقد حضر البرنامج أكثر من 180 مشارك من الشركات المنفذة للمشروع
اليكم دليل
توقع ما هو غير متوقع - ما يجب مراعاته عند التخطيط لمكان العمل
حالات الطوارئ هو قسم المعايير والموارد الفنية باللغة الانجليزية OR-OSHA
What to consider in planning for workplace
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
1. Copyright statement. This educational information is provided by the Public Education and Conferences Section of the Oregon
Occupational Safety and Health Division (Oregon OSHA), Salem, Oregon, USA. Unless a copyright is indicated, information herein is
in the public domain and may be copied and distributed without permission. Citation of Oregon OSHA as source of the information is
appreciated. This document is originally published in Microsoft PowerPoint. Permission to use PowerPoint graphics must be obtained
from Microsoft Inc. If a copyright is otherwise indicated on a photo, graphic, or other material, permission to copy these materials
must be obtained from the original source.
Disclaimer. This information provides suggested methods for presenting various safety and health related topics. This material, or any
other material used to inform employers of compliance requirements of Oregon OSHA standards through simplification of the
regulations should not be considered a substitute for any provisions of the Oregon Safe Employment Act or for any standards issued by
Oregon OSHA.
Fixing the System with
Root Cause Analysis
2. Get to the roots to fix the system
The hazardous conditions and unsafe behaviors we identify as contributing to the accident are called
the surface causes of the accident. After we identify surface causes, we'll need to determine if
inadequate safety system components contributed to the accident by allowing the hazardous
conditions and unsafe behaviors to develop or occur. These system inadequacies are called the root
causes of accidents. Let's take a closer look at these two very important concepts.
The surface causes of accidents
The surfaces causes of accidents are those hazardous conditions and unsafe employee/manager
behaviors and activities that have directly caused or contributed in some way to the accident.
Hazardous conditions:
• are basically things or objects that cause injury or illness
• may also be thought to be defects in a process
• may exist at any level of the organization
Hazardous conditions may exist in any of the following categories:
Materials Machinery Equipment Environment Chemicals
Tools Workstations Facilities People Workload
Time
It's important to know that most hazardous conditions in the workplace are the result of an unsafe
behaviors that produced them.
Unsafe behaviors:
• are actions we take or don't take that increase risk of injury or illness.
• may also be thought to be errors in a process
• may occur at any level of the organization.
Some example of unsafe employee/manager behaviors include:
Failing to comply with rules Using unsafe methods Taking shortcuts
Failing to report injuries Failing to report hazards Horseplay
Allowing unsafe behaviors Failing to train Failing to supervise
Scheduling too much work Ignoring worker stress Failing to correct
3. The direct cause of injury is not the cause of the accident
If we examine the surface cause categories above, we find that each may somehow produce a
harmful level of energy that may be transferred to our body directly causing an injury. The harmful
transfer of energy is the direct cause of injury. Let's take a look at three examples:
• If a harsh acid splashes on our face, we may suffer a chemical burn because our skin has been
exposed to a chemical form of energy that destroys tissue. In this instance, the direct cause of
the injury is harmful a chemical reaction. The related surface cause might be the acid
(condition) or working without proper face protection (unsafe behavior).
• If our workload is to too strenuous, force requirements on our body may cause a muscle strain.
Here, the direct cause of injury is a harmful level of kinetic energy (energy resulting from
motion), causing injury muscle tissue. A related surface cause of the accident might be fatigue
(hazardous condition) or improper lifting techniques (unsafe behavior).
The important point to remember here is that the "direct cause of injury" is not the same as
the surface cause of the accident. To summarize:
• The surface cause of the accident describes a condition or behavior. The result of the condition
and/or behavior is the direct cause of injury...a harmful transfer of energy.
• The direct cause of injury is the harmful transfer of energy. The direct result is injury.
Safety Engineering & Safety Management…two different roles
Safety "engineers" closely analyze all the surface cause categories and attempt to (1) eliminate the
harmful energy, (2) reduce the harmful energy transfer, or (3) reduce exposure to harmful energy
transfer. They do this by designing safety features directly into tools, machinery, equipment,
facilities, etc.
On the other hand, safety “managers” identify and analyze the safety management system to evaluate
the effectiveness of its subsystem components. They improve the system to eliminate or reduce the
common or root causes producing the hazardous conditions and behaviors.
Workplace safety is most successful when engineering controls and management system
improvement compliment each other.
4. The root causes of accidents
The root causes for accidents are the underlying safety system weaknesses that have somehow
contributed to the existence of hazardous conditions and unsafe behaviors that represent surfaces
causes of accidents.
It's important to understand that root causes always pre-exist surface causes. Indeed, inadequately
designed system components have the potential to feed and nurture hazardous conditions and unsafe
behaviors. If root causes are left unchecked, surface causes will flourish!
Examples of safety system functions and the components common to all systems
include:
Safety systems: Systems are developed to:
Promote Commitment/leadership Increase employee involvement
Establish accountability Identify and control hazards
Investigate incidents/accidents Educate and train
Evaluate the safety program
System components:
Policies Programs Plans Processes
Procedures Budgets Reports Rules
Safety managers work with safety engineers to eliminate or reduce exposure to hazards through
effectively improving safety system components. Because systems design work common throughout
the workplace, eliminating any single root cause may simultaneously eliminate many hazardous
conditions and unsafe behaviors.
Since root causes reside within safety management systems, upper management -- those who
formulate systems, are most likely going to be involved in making the necessary improvements.
When analyzing for system weaknesses, it may be beneficial to coordinate closely with those who
will be responsible for implementing system improvements.
5. Three levels of cause analysis
As mentioned earlier in the course, accidents are processes that culminate in an injury or illness. An
accident may be the result of many factors (simultaneous, interconnected, cross linked events) that
have interacted in some dynamic way. In an effective accident investigation, the investigator will
conduct three levels of of cause analysis:
Injury analysis. At this level of analysis, we do not attempt to determine what caused the accident,
but rather we focus on trying to determine how harmful energy transfer caused the injury.
Remember, the outcome of the accident process is an injury.
Event Analysis. Here we determine the surface cause(s) for the accident: Those hazardous
conditions and unsafe behaviors described throughout all events that dynamically interact to produce
the injury. All hazardous conditions and unsafe behaviors are clues pointing to possible system
weaknesses. This level of investigation is also called "special cause" analysis because the analyst can
point to a specific thing or behavior.
Systems analysis. At this level we're analyzing the root causes contributing to the accident. We
can usually trace surface causes to inadequate safety policies, programs, plans, processes, or
procedures. Root causes always pre-exist surface causes and may function through poor component
design to allow, promote, encourage, or even require systems that result in hazardous conditions and
unsafe behaviors. This level of investigation is also called "common cause" analysis because we
point to a system component that may contribute to common conditions and behaviors throughout the
company.
The biggest challenge to effective accident investigation is to transition from event
analysis to systems analysis.
One last important point to make is that most accident processes are far more complex than we might
originally think. Some experts believe at least 10 or more factors come together to cause a serious
injury. Other experts state that, on average, 27 factors directly and indirectly contribute to serious
accidents.
Only by thoroughly conducting all three levels of analysis can we design system improvements that
effectively eliminate hazardous conditions and unsafe behaviors at all levels of the organization. The
accident investigation can not serve as a proactive safety process unless system improvements
effectively prevent future accidents.
Fix the system…not the blame
6. Injury or
Illness
Direct Cause of Injury
• Harmful Energy Transfer
• Kinetic, thermal, chemical, etc.
Primary Surface Causes
• Directly cause of the injury event
• Unique hazardous condition(s)
• Individual unsafe behavior(s)
• Controllable or uncontrollable factors
• Events occur close to the injury event
• Failure to perform safety practices,
procedures, processes
• Involves the victim, others
Secondary Surface Causes
• Indirectly cause the injury event
• Specific hazardous condition(s)
• Individual unsafe behavior(s)
• Controllable and uncontrollable factors
• Events occur distant from the injury event
• Failure to perform safety practices,
procedures, processes
• Co-workers, supervisors, anytime, anywhere
Implementation Root Causes
• Common conditions and behaviors
• Inadequate implementation of safety policies,
programs, plans
• Inadequate design of processes, procedures
• Pre-exist surface causes
• Controllable
• Middle management, anytime, anywhere
System Design Root Causes
• Inadequate design of safety system policies,
programs, plans
• Pre-exist all other causes
• Controllable
• CEO, top management, anytime, anywhere
External Environmental Causes
• Government regulation
• Physical resources
• Human resources
• Capital
• Society
The Accident Weed
Fails to inspect
No recognition planInadequate training plan
No accountability policy No inspection policy
No discipline procedures
Outdated hazcom programNo orientation process
Unguarded
m
achine Horseplay
Fails to trainTo much work
Defective PPE Fails to report injury
Inadequate training
Create a hazard
Fails to enforce
Untrained worker
Broken tools
Ignore a hazard
Lack of time
Inadequate labeling
No recognition
Cuts
Burns
Lackofvision
Strains
Nomissionstatement
Chemical spill
7. Team Exercise: “Getting to the roots by asking why, why, why, why”
Purpose: Now that you have reconstructed the specific events prior to, during, and after the
accident, it’s time to analyze for cause by asking a series of "Whys."
Instructions.
1. Analyze the injury event to identify and describe the direct cause of injury. See
examples below.
a. Describe the injury and it’s cause.
• Laceration to right forearm resulting from contact with rotating saw blade.
• Contusion from head striking against/impacting concrete floor.
• Burn injury to right lower leg from contact by battery acid.
• Impact following a fall from platform to lower level caused dislocation of right shoulder.
b. Identify the accident type.
Struck-by Struck-against Contact-by Contact-with
Caught-on Caught-in Caught-between Fall-to-surface
Fall-to-below. Over-exertion Bodily reaction Exposure.
Write the direct cause for the injury below.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List the accident type.
_________________________________________________________________________________
8. Team Exercise: “Getting to the roots by asking why, why, why, why”
2. Analyze at least two events occurring just prior to the injury event to identify
surface causes for the accident.
a. Determine the primary surface causes. Look for specific hazardous conditions and
employee behaviors that caused the injury.
• Event x. Unguarded saw blade. (condition or behavior?)
• Event x. Working at elevation without proper fall protection. (condition or behavior?)
• Event x. Employee unaware of hazards of working with batteries. (condition or behavior?)
Condition(s)_______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Behavior(s) _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
a. Determine secondary surface causes. These are also specific conditions and behaviors.
• Supervisor not performing weekly area safety inspection. (condition or behavior?)
• Fall protection equipment missing. (condition or behavior?)
• Responsible person not training on how to hook up harness. (condition or behavior?)
Condition(s)_______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Behavior(s) _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
9. Team Exercise: “Getting to the roots by asking why, why, why, why”
3. Analyze each surface cause to identify potential root cause(s) that contributed to or
produced the accident.
a. Determine system implementation weaknesses. Look for the common behaviors that
represent inadequate implementation of safety programs and processes. It’s important to
understand that poor implementation of one program area may be the result of poor
implementation in another safety management program area:
Top management commitment Accountability
Employee involvement Hazard identification & control
Incident & Accident Investigation Education & Training
Safety system evaluation
• Safety inspections are being conducted inconsistently.
• Safety is not being adequately addressed during new employee orientation.
• Supervisors are not enforcing safety rules.
Implementation Root Causes ______________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
a. Determine system design weaknesses. Then ask why to determine the inadequate/missing
policies and plans that caused them. These are common conditions.
• Inspection policy does not clearly specify responsibility by name or position.
• No fall protection training plan or process in place.
• Procedures for administering corrective actions absent from the accountability plan.
System Design Root Causes ______________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
10. Determine the causes
Direct Cause of injury- A harmful transfer of
energy that produces injury or illness.
Surface Causes of accident - Specific
hazardous conditions or unsafe behaviors that
result in an accident.
Root Causes of the accident - Common
behaviors and conditions that ultimately result in an
accident.
11. Fails to inspect
No recognition planInadequate training plan
No accountability policy No inspection policy
No discipline procedures
Outdated hazcom programNo orientation process
Unguarded
m
achine Horseplay
Fails to trainTo much work
Defective PPE Fails to report injury
Inadequate training
Create a hazard
Fails to enforce
Untrained worker
Broken tools
Ignore a hazard
Lack of time
Inadequate labeling
No recognition
Cuts
Burns
Lackofvision
Strains
NomissionstatementChemical spill
12. Team Exercise: “Getting to the roots by
asking why, why, why, why”
1. Analyze the injury event to identify and describe the
direct cause of injury.
a. Describe the injury and it’s cause.
b. Identify the accident type.
13. Team Exercise: “Getting to the roots by
asking why, why, why, why”
2. Analyze at least two events occurring just prior to the
injury event to identify surface causes for the accident.
a. Determine the primary surface causes.
b. Determine secondary surface causes.
14. Team Exercise: “Getting to the roots by
asking why, why, why, why”
3. Analyze each surface cause to identify potential root
cause(s) that contribute to or produced the accident.
a. Determine system implementation weaknesses.
b. Determine system design weaknesses.