Accident Investigation

Root Cause Analysis

 Root Cause Analysis
Objectives
• Identify three consistent and
systematic approaches to
investigating workplace
accidents.
• Understand how to apply
these approaches to a
workplace accident
investigation.
Root Cause Analysis
Overview
Data Collection

Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Data Collection

•Interviews
•Photographs
•Equipment Specs.
Data
Collection
•Equipment Manuals
Event Charting

•Safety Rules Change Causal Factor Barrier

Analysis Analysis Analysis

•Training Records Root Cause ID

Recommendations
 Root Cause Analysis
Event Charting

•Organizes collected data

for analysis
•Sequence diagram
Data
Collection
•May uncover needs for
Event Charting
additional data collection
Change Causal Factor Barrier
Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Event Charting
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen

Mary uses Mary Fire Mary

FE throws
fire ext. fails spreads calls
water on 911
fire Data
Collection

Kitchen Event Charting

Fire FD puts out destroyed
department fire Change Causal Factor Barrier
arrives Smoke damage Analysis Analysis Analysis
throughout
restaurant Root Cause ID

Recommendations
 Root Cause Analysis
Event Charting
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out

Mary Mary Fire Smoke Mary

starts leaves alarm enters
starts
cooking kitchen sounds kitchen

Mary sees FE not Grease

fire charged fire

Mary uses Mary Fire Mary Data

FE throws
fire ext. spreads calls Collection
fails water on 911
fire Event Charting

Kitchen Change Causal Factor Barrier

destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
 Root Cause Analysis
Causal Factor Analysis
Casual Factors:
1. Direct Cause: Immediate
event/ condition that caused
accident)
2. Contributing Cause: Data
Event/condition that increased Collection

probability or severity of the Event Charting

accident
Change Causal Factor Barrier
3. Root Cause: Event/condition Analysis Analysis Analysis

that, if corrected, will prevent Root Cause ID

recurrence
Recommendations
 Root Cause Analysis
Causal Factor Analysis

Potential Causal Factors:

• Lack of awareness
• Lack of safe work practices
• Lack of adherence/enforcement Data
to safe work practices Collection

• Improper/inadequate Event Charting

equipment/materials Change Causal Factor Barrier

• Improper/inadequate design Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Causal Factor Analysis
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out

Mary Mary Fire Smoke Mary

starts leaves alarm enters
starts
cooking kitchen sounds kitchen

Mary sees FE not Grease

fire charged fire

Mary Data
Mary uses FE Fire Mary
throws Collection
fire ext. fails spreads calls
water on
911
fire Event Charting

Kitchen Change Causal Factor Barrier

destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
 Root Cause Analysis
Change Analysis

Used to identify deviations from

the norm
• “What happened” vs. “What
should have happened”
Data
• Used mostly when operations Collection

and standardized Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Change Analysis

Common Changes and Differences:

• Personnel
• Plant
• Hardware Data

• Procedures Collection

• Managerial Controls Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Change Analysis
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out

Mary Mary Fire Smoke Mary

starts leaves alarm enters
starts
cooking kitchen sounds kitchen

Mary sees FE
FE not
not Grease
fire charged
charged fire

Mary Data
Mary uses FE Fire Mary
throws Collection
fire ext. fails spreads calls
water on
911
fire Event Charting

Kitchen Change Causal Factor Barrier

destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
 Root Cause Analysis
Barrier Analysis
Basic premise is that there is a
flow of energy associated with
all accidents
– Kinetic
– Potential
– Electric Data
Collection
– Thermal
Event Charting
– Steam
– Pressure Change Causal Factor Barrier
Analysis Analysis Analysis
Barriers are placed to reduce the
Root Cause ID
energy from people, property,
environment. Recommendations
 Root Cause Analysis
Barrier Analysis

Barrier Categories:
• Equipment
• Design
• Administration (procedures Data
processes) Collection

• Supervisory/Management Event Charting

• Warning Devices Change Causal Factor Barrier

Analysis Analysis Analysis
• Knowledge and Skills
Root Cause ID

Recommendations
 Root Cause Analysis
Barrier Analysis
Phone
rings in Grease
Greaseon AL pan Arcing Electric
front of ignites
burneron melts heats pan burner
restaurant ignites
burner shorts out

Mary Mary Fire Smoke Mary

starts leaves alarm enters
starts
cooking kitchen sounds kitchen

Mary sees FE not Grease

fire charged fire

Mary Mary Data

Mary uses FE Fire
fire ext. throws spreads calls Collection
fails water on 911
fire Event Charting

Kitchen Change Causal Factor Barrier

destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
 Root Cause Analysis
Root Cause Identification

Root causes
– Derived from the facts
and analysis conducted
– Should answer two Data
Collection

questions: Event Charting

1. What happened? Change Causal Factor Barrier

Analysis Analysis Analysis
2. Why it happened?
Root Cause ID

Recommendations
 Root Cause Analysis
Root Cause Identification

• Root causes should identify

reasons for each casual factor
identified by the analysis.
• Root causes which can not be
Data
completely supported by fact Collection
should identified in the report.
Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Root Cause Identification

• Unattended stove
– Facility design less than adequate
– Lack of operational policy
• Heating element failure Data
Collection

– Lack of preventative maintenance Event Charting

program
Change Causal Factor Barrier
– Facility design less than adequate Analysis Analysis Analysis

(auto-suppression system) Root Cause ID

Recommendations
 Root Cause Analysis
Root Cause Identification

• Fire Extinguisher failure

– Inadequate inspection program
• Water on grease fire
Data
– Inadequate training (abnormal events) Collection

Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Recommendations
Identify the corrective actions for each
cause.
Ensure the corrective action is viable by
answering:
• Will the corrective action prevent Data
recurrence? Collection

• Is the corrective action feasible? Event Charting

• Does the corrective action introduce Change Causal Factor Barrier

Analysis Analysis Analysis
new hazards/risks?
Root Cause ID

Recommendations
 Root Cause Analysis
Recommendations

• What are the consequences of

not implementing the
recommendations?
• What time frame is adequate to
Data
implement the Collection
recommendations?
Event Charting
• Is the implementation of the
Change Causal Factor Barrier
recommendations measurable? Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Recommendations - Direct/Contributing Cause #1

• Unattended stove
RC #1: Facility design less than
adequate
RC #2: Lack of operation policy
• Install phone in kitchen Data
Collection
• Implement policy that hot oil is never
left unattended (any other Event Charting
operations?)
• Modify procedure development Change Causal Factor Barrier
Analysis Analysis Analysis
process to identify and address
potential emergencies and hazards
(JSA). Root Cause ID

Recommendations
 Root Cause Analysis
Recommendations - Direct/Contributing Cause #2

• Heating element failure

RC #3: Lack of preventative maintenance
program
• Develop preventative maintenance strategy
to periodically replace burner elements. Data
RC #4: Facility design less than adequate Collection

(auto-suppression system)
Event Charting
• Consider alternative preparation methods
(baking) or alternative equipment (gas Change Causal Factor Barrier
stove). Consider additional hazards these Analysis Analysis Analysis
my introduce.
• Install commercial kitchen fire suppression Root Cause ID
system per building code.
Recommendations
 Root Cause Analysis
Recommendations - Direct/Contributing Cause #3

• Fire Extinguisher failure

RC #5: Inadequate inspection program
• Refill/replace extinguisher.
• Inspect all extinguishers
Data
monthly/annually. Collection
• Report incidences using extinguishers to
owner to trigger refilling (training). Event Charting

Change Causal Factor Barrier

Analysis Analysis Analysis

Root Cause ID

Recommendations
 Root Cause Analysis
Recommendations - Direct/Contributing Cause #4
• Water on grease fire
RC #7: Inadequate training
• Review training program for
adequacy (contingency plan in case
of extinguisher failure). Data
Collection
• Provide hands-on training on fire
extinguishers. Event Charting

• Review other skill-based activities Change Causal Factor Barrier

to ensure level of hands-on training Analysis Analysis Analysis

is adequate.
Root Cause ID

Recommendations
 Root Cause Analysis
Objectives
• Identify three consistent and
systematic approaches to
investigating workplace
accidents.
• Understand how to apply
these approaches to a
workplace accident
investigation.