Incident Investigation and Root Cause Analysis Training

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Incident Investigation and Root Cause Analysis
Training

• Rad ManningSafety Consultant

September 15, 2005
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What Brought this Class Forward

• Quality of the Root Causes Identified
• Building Consistency in Findings
• Provide a Basic Tool
• Provide Quality Statistics

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Agenda

• Pre-planning for investigations.
• Performing an investigation.
• Developing a timeline.
• Identifying the direct cause(s).
• Identifying root cause(s).
• Corrective actions.

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First Training Session
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Goals of an Investigation

• Identify the cause(s).
• Develop and implement corrective actions.
• Prevent recurrence.
• Foster a safe workplace.
• Improve morale.
• Demonstrate leadership.
• Improve a work process.

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Preparing for an Investigation

• Putting together an investigation kit.
• Practicing techniques.
• Setting up an investigation team.
• Develop a checklist.
• Develop basic questions.
• Identify standard interviewees.
• Gathering information.

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Challenges to Investigating

• The culture company, project, and client.
• Severity of the incident.
• Parties involved.
• Legal issues.
• Gathering information.
• Lack of training or experience in investigating
  incidents.

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The Importance of Focusing on Just the FACTS

• Leads to a clear understanding of what happened.
• Keeps from persecuting the innocent.
• Identifies the right cause.
• Identifies the appropriate corrective actions.

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Developing a Timeline

• Put down key moments.
• Determine when to start.
• Everything is important, at first.
• Include known information, facts, assumptions,
  questions, and need for further research.
• Alone versus Team.
• Adding detail to key moments.
• Weeding out period.

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Timeline of Actions
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Identify the Direct Cause

• Agree on a definition.
• Do not limit yourself.
• Identify the links in the chain.
• Look for direct effects.

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Digging for the Root Causes
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Root Cause Definition

• The most basic cause (or causes) that can
  reasonably be identified that management has
  control to fix and, when fixed, will prevent (or
  significantly reduce the likelihood or
  consequences of) the problem's recurrence.
• TapRooT System Improvements, Inc.

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Root Cause Focus Areas

• Management
• Front Line Supervision
• Training
• Administrative Controls (Policies and Procedures)
• Enforcement
• Accountability
• Employees

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Finding the Root Cause

• Keep asking why.
• Review systems/processes.
• Review management direction and involvement.
• Look at the training and the quality of the
  training.
• Crew make-up and assignment of a task.
• Qualification of personnel.
• Task review (hazard analysis).
• Existence, quality, and thoroughness of
  policies/procedures.

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Identified Typical Root Causes

• Lack of focus/awareness.
• Lack of attention.
• Complacency.
• Did not follow policy/procedure.
• Use of incorrect tool.
• Not wearing proper PPE.
• Not tied off.
• Tripped on uneven surface.
• Employee in a hurry.
• Act of God/uncontrolled event.

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Root Cause Examples

• Poorly written procedure.
• Lack of enforcement.
• Lack of accountability.
• Poorly qualified personnel.
• Lack of instruction.
• Poor administrative control.
• Pre-planning of task.
• Lack of training/poor quality training.
• Work schedule.
• Communication needs improvement.

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Example of Finding Root Cause

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Root Cause Flowchart
Direct Cause
Interface with Equipment and Work Area
Preparation And Supervision
Policies/ Procedures
Instructions
Management
Training
Wrong Revision Typo No Procedure Not
Available Steps Wrong Instruction Wrong Ambiguous
Instruction
Not Provided Did Not Attend Teaching Lacking No
Testing Continuing Training
No Policy Lack of Enforcement Lack of
Accountability Employee Relations Commitment Poli
cy Not Strict
No Preparation Pre-Job Brief Walk
Thru Lock-Out/Tag-Out Employees Assigned No
Supervision Teamwork
No Communication Turnover Complex
Instructions Terminology Timely Instruction
Hot Environment Cold Environment Display
Poor Slippery Surface Cramped Position Body
Position
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Three Standard Corrective Actions

• Discipline
• Training
• Procedures

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Regression to the Mean
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Developing Corrective Actions

• Deal only with the root cause.
• Make it something that can be accomplished.
• Make it measurable.
• Assign to a specific person or group.
• Review periodically.

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Loss Analysis Form (LAF)
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Loss Analysis Form (LAF) Continued