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Root Cause Analysis and Accident Investigation
- 2. Presented By Peter Zaidel KPA Product Manager pzaidel@kpaonline.com 303-228-2397
- 3. Questions • If you have questions during the presentation, please submit them using the “Questions” feature • Questions will be answered at the end of the webinar
- 4. KPA – Company Profile • Nationwide compliance expert on Safety, Environmental, H R • Colorado Headquarters • 23 Years Experience • 3000 + Clients – Dealerships, Service, Re pair • 20 Offices Serving 41 States • Compliance products and services – OSHA – DOT – EPA – Workers’ Comp – Background checking – Onboarding – Harassment – Red Flags – Onsite inspections – Online and onsite training and tracking – And many more…
- 5. Training Objectives • Accident Statistics and Costs • Accident Investigation • Root Cause Analysis Basics
- 6. Do your employees adopt your safety culture?
- 7. Is your workplace free from accidents?
- 8. Year Annual Daily 2003 5575 15 2004 5764 16 2005 5734 16 2006 5840 16 2007 5657 15 2008 5071 14 At Work Injury and Fatality Rates Year Annual Daily 2003 4365.2 11.9 2004 4257.3 11.6 2005 4214.2 11.5 2006 4085.4 11.2 2007 4002.7 11.0 2008 3696.1 10.1 (Thousands)
- 10. True Cost of an Accident Hidden Costs • Damaged to lot, autos or equipment • Unhappy customers • Clean-up time • Schedule delays • Training new employees • Overhead costs • Damage to reputation in community • Lost time by other employees Direct Costs • Insurance costs • Claim costs • Lost time • Medical bills • Legal fees
- 11. SAFETY PAYS Revenue required to Pay for an Accident… Accident Cost Business Profit Margin 1% 2% 3% 4% 5% $1,000 $100,000 $50,000 $33,333 $25,000 $20,000 $5,000 $500,000 $250,000 $166,667 $125,000 $100,000 $10,000 $1,000,000 $500,000 $333,333 $250,000 $200,000 $25,000 $2,500,000 $1,250,000 $833,333 $625,000 $500,000 $100,000 $10,000,000 $5,000,000 $3,333,333 $2,500,000 $2,000,000
- 12. Accident Pyramid 1 Major Accident 29 Minor Accidents 300 Near Misses
- 13. The Solution Incident Medical Attention Beyond First Aid? Equipment Damaged? No No Yes Yes Complete Accident Investigation Form Complete Incident Investigation Form
- 14. Root Cause Analysis • Complex Systems • People make mistakes
- 15. Goals of RCA • To prevent reoccurrence • As a process of continuous improvement • To find underlying physical and procedural problems • To guide organizational change • To promote safety culture
- 16. Phases of Root Cause Analysis
- 17. The Investigation • Beware of the Bias Trap • Timely Investigation • Pictures • Service Records
- 18. Analysis What is Root Cause Analysis? It is whatever YOU make it! Should focus on…. People!
- 19. Focus An evidence-based endeavor designed to help people discover how their behavior contributed to an incident... To such an extent that their behavior will change in the future.
- 20. Traps 3 Causes 1.Physical 2.Human 3.Latent Must be based on Evidence
- 21. Evidence
- 22. 0 10 20 30 40 50 60 January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July 2005 2006 2007 2008 Number of Claims By Month Evidence
- 23. Evidence
- 25. The 5 Whys The technician fell down He slipped on a coolant spill The spill was not cleaned up The technician was busy The technician makes money servicing cars, not cleaning up spills This is the pay structure at the dealership
- 26. “That’s Not My Job!” Latent Causes “I have to do this fast!” “What is influencing these thoughts?” Personal Root Cause Organizational Root Cause
- 27. Fishbone Analysis People Policies Procedures Plant In a hurry Slippery Floors Pay Structure Grit is worn out
- 28. Decision • Issue Tracking System – Deadlines – Feedback Loops • Safety Committee Participation – Management Involvement • Written Policies and Procedures • Positive Reinforcement • Getting Started
- 30. FACILITY COMPLIANCE & SAFETY EVALUATION Evaluation By KPA • Written Programs • Training Records • Compliance Issues • Shop Issues 90 Minutes Formal Report • Summarizing Areas of Opportunity
- 32. www.kpaonline.com info@kpaonline.com 866-356-1735 32 A copy of the recorded webinar and presentation will be emailed to you today.
Editor's Notes
- Let’s discuss a little accident theory and then we’ll move onto what to do about it.
- We form organizations to get work done. As the work we want to do gets larger and more complex, so do our organizations. As these organizations grow, we develop various systems to manage our organizations. Since we as humans regularly make mistakes, often our systems fail due to mistakes in process or system design flaws. Root Cause Analysis is a process of continuous improvement, it is used to find faults with our systems and make them better in the future. It is used whenever there is a gap between actual and desired performance. If you want your problems to go away, your best option is to kill them at the root. Hence the root cause analysis!
- Paper evidence includes trends from the past, training rosters, incident investigation forms and even our minutes.
- Finally you gather people evidence by interviewing the people involved, and looking for what motivated them to behave the way they did.