Root cause analysis, accidents

However, in the case of a root cause analysis system, a much more comprehensive evaluation of the structure of the accident is required. This is necessary to unravel the often complex chain of events and contributing causes that led to the accident occurring. A number of techniques are available to describe complex accidents. Some of these, such as STEP (Sequential Timed Event Plotting) involve the use of charting methods to track the ways in which process and human events combine to give rise to accidents. CCPS (1992d) describes many of these techniques. A case study involving a hydrocarbon leak is used to illustrate the STEP technique in Chapter 7 of this book. The STEP method and related techniques will be described in Section 6.8.3. 

In the following sections, a number of methodologies for accident analysis will be presented. These focus primarily on the sequence and structure of an accident and the external causal factors involved. These methods provide valuable information for the interpretation process and the development of remedial measures. Because most of these techniques include a procedure for delineating the structure of an incident, and are therefore likely to be time consuming, they will usually be applied in the root cause analysis of incidents with severe consequences. 

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. 

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. 

Root cause analysis begins at the time of the occrurence and works backward in time investigating all inputs. Any variation is recorded. In the case of an accident this involves investigating ... 

Root cause - the action or activity that resulted in contact with the immediate cause. Root-cause analysis involves checking on the sequence of events and decisions that led to the accident and identifying the often remote action that triggered that sequence of events. 

In addition, the valne of root canse analysis has been demonstrated beyond medical accidents. Root canse analysis has proved useful for some organizations outside clinical areas and can serve as the beginning for decision support tools. For example, one hospital, when it implemented its program of root cause analysis, established significant defection of key personnel as one of the criteria for a sentinel event. This criterion was shown to be an effective indicator when the vice president for hnman resoirrces contacted the vice president for performance improvement and alerted her that seven pharmacists had resigned within one week. The discovery allowed a significant management problem to be rapidly resolved. 

Conduct a fact finding of the accident, using accepted structured tools, which may include root cause analysis... 

Safety, patient safety, sentinel event, medical accident, near miss, good catch, Office of Patient Safety, JCAHO, focused event analysis, disclosure, peer review, confidentiality, maltreatment of minors, root cause analysis, patient safety report, accident, documentation... 

The principal role of the U.S. Chemical Safety Board is investigating accidents to identify the conditions and circumstances that led to the events. It also investigates hazardous conditions that could lead to accidents. The agency uses root cause analysis and other methods to identify causes to prevent events. It makes recommendations to government agencies, companies, trade associations, labor unions, and other groups. It publishes reports and offers DVDs about cases it investigates. 

A root cause analysis is not a search for the obvious but an in-depth look at the basic or underlying canses of occnpational accidents or incidents. The following should be considered when performing analyses ... 

A root cause analysis is only the beginning and a fraction of the analysis process and should not be considered the sole approach to an analysis of an accident. 

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. 

The principle of multiple causes indicates that accidents and near miss incidents are usually the result of multiple causes. Investigations should not cease until all the contributing causes have been identified. Once all the obvious causes are found, a root cause analysis should be conducted to delve into the root causes of the problem. Only by identifying and rectifying the root causes wiU the problem be solved. 

One of the best ways to think about root cause analysis is to consider the question, To when would I have to travel back in a time machine to prevent this accident happening In complex accident sequences (such as the Whatcom Park accident described in Chapter 12) there may be more than one answer to this question. 

Accident and incident investigation and root cause analysis. 

Suddenly, all the holes in the slices of Swiss cheese had become exactly aligned. Root cause analysis was described in Chapter 10, and the time machine question was introduced. To when would 1 have to travel back in a time machine to prevent this accident happening By this rule, all of the above six points count as root causes. 

When there is an incident or accident, engineers do a root cause analysis (Chapter 10). Ultimately, a root cause analysis is trying to answer the question, If you had a time machine, how far back in time would you have had to go to stop this event from happening ... 

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