Root causes.Accident investigation

Each accident/incident should be methodically analyzed using an accident investigation/root cause analysis approach. Because many root cause analysis methods exist, it will be the investigator s responsibility to select the appropriate analysis approach (e.g., barrier analysis). Use of proper accident/incident investigation methods and tracking will lead to intervention, which will successfully prevent further occurrence of these occupational accidents and incidents. 

Oregon OSHA. 2013. Accident Investigation—Root Causes Instructor Guide. 1207. Department of Consumer and Business Services Public Education Section. http //www.cbs.state.or.us/external/osha/educate/mateals/Accident-Investigation-llO/l-llOi.pdf. Accessed February 12,2014. 

Root cause analysis is used when there are multiple problems with a number of causes of an accident. A root cause analysis is a sequence of events that shows, step by step, the events that took place in order for the accident to occur. Root cause analysis puts all the necessary and sufficient events and causal factors for an accident in a logical, chronological sequence. It analyzes the accident and evaluates evidence during an investigation. It is also used to help prevent similar accidents in the future and to validate the accuracy of preaccidental system analysis. It is used to help identify an accident s causal factors, which, once identified, can be fixed to eliminate future accidents of the same or of similar nature. 

The first case study describes the application of the sequentially timed event plotting (STEP) technique to the incident investigation of a hydrocarbon leak accident. Following the analysis of the event sequence using STEP, the critical event causes are then analyzed using the root cause tree. 

An EPA-OSHA accident investigation at Napp Technologies Inc. in Lodi, New Jersey, developed the root causes and recommendations to address the root causes. Describe the accident, and develop layered recommendations for this specific accident. See http // www.epa.gov/ceppo/pubs/lodiintr.htm. 

An apparently high level of effort is required to report and investigate near misses. The costs of this effort are quantifiable. The benefits of these investigations are not as easy to tabulate. The actual number of accidents that have been prevented by improved near miss reporting may never be known. However, organizations that have seen dramatic increases in near miss reporting have also seen dramatic reductions in losses. The root causes of near misses of safety consequences may be the same management system weaknesses that adversely affect operability, quality, and profitability. 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

The Type A investigation of a sodium potassium (NaK) accident that occurred at the Y-12 plant on December 8, 1999, identified a lack of understanding of the hazard from NaK and its reactive byproducts as one of the root causes of the accident. The investigation found that personnel involved in planning the task, the safety documentation for the facility, the procedure for the task, and the procedures supporting hazard identification and analysis did not address the complete NaK hazard. The investigation also determined that detailed hazard identification data supported by accident analysis and appropriate control information was readily available. 

An accident model should encourage a broad view of accident mechanisms that expands the investigation beyond the proximate events A narrow focus on operator actions, physical component failures, and technology may lead to ignoring some of the most important factors in terms of preventing future accidents. The whole concept of root cause needs to be reconsidered. 

I often inform the person about the technique before I press them a bit to get to the root cause. Five is not a magic number the number of times you ask the question is situational. It is very effective at framing the conversation and engaging all involved In root cause analysis. Therefore, it is a very useful technique when conducting incident or accident investigations. Chapter 7 will be devoted to that important aspect of world-class safety. 

Problem solving Asking why five times can be used in accident investigations to get to root causes. A PDCA problem-solving loop can be used to redefine safety processes. 

A future chapter will be devoted to effective incident/accident investigations. Every incident (near miss) or accident provides a continuous improvement opportunity that should result in root cause analysis and corrective actions. Here is a chance to utilize someone with a passion for lean, and his/her problem-solving skill sets, to fill this safety team position. Eilling this role provides another opportunity to develop a future business leader. 

Accident/incident investigation subteam This team is accountable for the continuous improvement of safety by using every incident and accident as a vehicle to get to root causes and corrective actions. The... 

Lead all accident investigations using lean tools to get to root cause and corrective actions. 

Root cause The one cause that leads all of the others when conducting an investigation of an outcome. In accident or safety incident investigations, the pursuit of effective corrective actions is dependent on defining the root cause of the accident or incident. 

Removes fear from the accident investigation process so that root causes are addressed rather than hidden... 

Warnings went unheeded - Findings indicated that most incidents were often preceded by a series of smaller accidents, near misses, or accident precursors. Operations and maintenance procedures must include analysis, root cause investigation, and corrective action. 

Traditionally the only reasons for accident investigations were to appropriate blame and find a guilty party. This will never solve the problem or determine the root causes of downgrading events, and will not fix the real cause of the problem. This is termed prescription without diagnosis. Finding one cause of an accident is totally insufficient, as there are always a number of reasons for an action or incident. 

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