objectives
DESCRIPTION
Objectives. Students will be able to: Differentiate between Surface and Root Causes Define Change Analysis, Barrier Analysis, MORT, Kepner-Tregoe Problem Solving and Decision Making. Identifying Causes of Accidents. Surface vs. Root Causes Surface causes are: - PowerPoint PPT PresentationTRANSCRIPT
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Objectives
Students will be able to:
Differentiate between Surface and Root Causes
Define Change Analysis, Barrier Analysis, MORT, Kepner-Tregoe Problem Solving and Decision Making.
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Identifying Causes of Accidents Surface vs. Root Causes Surface causes are:
the hazardous conditions or unsafe work practices that directly or indirectly contributed to the accident.
Root causes are: the safety or loss control system weaknesses
that allow the existence of hazardous conditions and unsafe work practices.
Most accident investigations only identify the surface causes of accidents.
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Major Concept tonight
Investigation Methodical Analytical Systematic process
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Events and Causal Factor Analysis Events and Causal Factor Analysis
identifies the time sequence of a series of tasks and/or actions and the surrounding conditions leading to an occurrence.
The results are displayed in an Events and Causal Factor chart that gives a picture of the relationships of the events and causal factors.
Example chartshttp://www.docstoc.com/docs/43977209/Event-and-Causal-Factor-Chart
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Participation opportunity
Name some “Surface Causes.”
Name some “Root Causes”
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Change Analysis (DOE SSDC-4 1983)
Change Analysis is used when the problem is obscure.
It is a systematic process that is generally used for a single occurrence and focuses on elements that have changed.
Example: worker comes in early and starts work therefore didn’t get a safety briefing
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Barrier Analysis (DOE SSD-4 1983)
systematic process that can be used to identify physical, administrative, and procedural barriers or controls that should have prevented the occurrence.
Barrier Defined: A construct between a hazard and a target, intended to prevent undesired effects to the target
http://www.bill-wilson.net/b52.html
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Management Oversight and Risk Tree (MORT) Analysis
MORT and Mini-MORT are used to identify inadequacies in barriers/controls, specific barrier and support functions, and management functions.
It identifies specific factors relating to an occurrence and identifies the management factors that permitted these factors to exist.
(Vincoli, p.190)
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Human Performance Evaluation Human Performance Evaluation
identifies those factors that influence task performance.
The focus of this analysis method is on operability, work environment, and management factors.
Man-machine interface studies to improve performance take precedence over disciplinary measures.
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Kepner-Tregoe Problem Solving and Decision Making management consulting firm systematic framework for gathering, organizing,
and evaluating information and applies to all phases of the occurrence investigation process. Phases:
Situation appraisal: Identify concerns Problem analysis: Define the problem (Similar to Change
Analysis) Decision Analysis: Evaluate alternatives, assess risks Potential Problem Analysis: What new problems may be
introduced by the alternatives?
http://www.kepner-tregoe.com/AboutKT/AboutKT.cfm
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Accident Investigation Process The accident investigation process involves the
following steps: Report the accident occurrence to a designated
person within the organization Provide first aid and medical care to injured person(s)
and prevent further injuries or damage Investigate the accident Identify the causes Report the findings Develop a plan for corrective action Implement the plan Evaluate the effectiveness of the corrective action Make changes for continuous improvement
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Participation Opportunity
How do you evaluate the effectiveness of any of your programs?
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Retrospective Investigations Retrospective investigations are
accident investigations that look back in time at a situation. Most investigations conducted in the workplace can be classified as a retrospective investigation.
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Statistical Investigations Statistical investigations utilize data
collected over a period of time to determine causes and develop prevention measures.
Statistical investigations utilize mathematical techniques that identify the causes for accidents in terms of statistical probabilities.
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Give some examples from your organization of statistical investigations (post accident)
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Large Loss Investigations in-depth investigations directed at an
accident that resulted in a larger than usual loss of life, money, or property damage.
Examples of large loss investigations include large industrial fires, plant explosions, and airplane crashes
Chemical Safety Board http://
www.youtube.com/watch?v=ob7OM3v5zXo&list=UUXIkr0SRTnZO4_QpZozvCCA&index=1&feature=plcp
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Systems Investigations
Systems investigations utilize a systems approach to the identification of causal factors.
There are a variety of systems investigation techniques available including root cause analysis, Fault Tree Analysis (FTA), and Failure Modes and Effects analysis (FMEA).
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Conclusions
Differentiate between Surface and Root Causes
Define Change Analysis, Barrier Analysis, MORT, Kepner-Tregoe Problem Solving and Decision Making
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Questions?
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Sources
http://www.hss.energy.gov/sesa/analysis/orps/taskgroup/HPI_Investigation_Slides_for_EFCOG.pdf
Los Alamos Human Performance Investigations training (informative)
http://www.kepner-tregoe.com/NewsArtPub/InTheMedia.cfm
Additional reading
http://fmea-fmeca.com/how-is-fmea-done.html How to conduct FMEA