System safety root cause analysis

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

The proposed integration of management tools and systems in the areas of Health, Safety, Environment and Reliability was widely applauded, specifically as to their reporting and root-cause analysis. 

The US Department of Veterans Affairs National Center for Patient Safety (NCPS) of the US Department of Veterans Affairs, which developed a new root cause analysis model to be used in the healthcare system consisting of assigning a safety assessment code to prioritise... 

Lagging indicators by themselves do not provide much explicit guidance to management as to what needs to be done to keep improving safety. The events themselves have to be analyzed using some type of root cause analysis. Also, lagging indicators tend to react quite slowly to system changes. 

There are several applications for root cause analysis. It has use in safety and failures, in quality control when studying reasons for nonconformance with quality practices, in processes, and in systems. 

Techniques used in systems safety frequently have specific goals and areas that they can address. For example, some techniques are used to analyze the hardware and equipment aspects of the system while other techniques are used to assess the human aspect. From a safety metrics standpoint, systems safety techniques can be used to identify areas for improvement in the organization. While there are hundreds of system safety techniques available, some of the more commonly used are Fault Tree Analysis (FTA), Procedure Analysis, Failure Modes and Effects Analysis, and Root Cause Analysis. 

For a safety program to be effective, the safety climate needs to be supportive of the program. The safety climate includes management, workers, the physical equipment in the workplace, and the interfaces between the people and the environment. Perception surveys can be used to assess the status of the safety climate in the workplace. Key areas that perception surveys can assess include management support for safety and employees attitudes and beliefs about safety. Environmental conditions and interfaces between equipment and workers can be assessed using various system safety techniques. Examples of system safety techniques include root cause analysis and failure modes and effects analysis. 

Nertney, R.J., J. D. Comelison, and W. A. Trost. Root Cause Analysis of Performance Indicators, (WP-21). System Safety Development Center, Idaho Falls, ID EG G Idaho, Inc., 1989. 

This chapter provides a brief summary of the root cause analysis process and will help you understand and conduct successful incident investigations. Incident investigation is an important element in an effective safety management system. The basic reason for investigating and reporting the causes of occurrences is to identify action plans to prevent recurrence of incidents. 

MORT User s Manual. DE-76-45/4. SSDC-4. Systems Safety Development Center. EG G. Idaho. INPO Good Practice OE-907. Root cause analysis. 

Root cause analysis is a technique to determine the root causes of failures in systems (Stapelberg, 2009). It can be used in multiple contexts like manufacturing improvements, safety projects, clinical accident, and crime reports (Reid and Smyth-Renshaw, 2012). 

Buys, J.R. and J.L.Clark. Events and Causal Factors Charting, System Safety Development Center. (SSDC-14). Idaho Falls EG G Idaho, Inc., August 1978. United States Department of Energy. Office ofNuclear Energy. Root Cause Analysis Guidance Document. Washington February 1992. 

Confirmation bias is the tendency to seek and highlight data that fit your preconceptions or confirm your views, expectations, fears, or desires. In patient safety, this bias most often shows itself in how we filter data to support our opinions about the need for systems change, how we conduct risk assessments, and how we approach root cause analysis. For example, selective percep-... 

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