Guide for Identifying Causal Factors and for Providing Corrective Actions

Transcription

1 Guide for Identifying and for Providing s This guide has been designed to assist Incident Investigators on completing the root causes section of the Safety and Loss Control Incident Investigation Report form. Behaviors (Select all that apply) 1. Was employee authorized to operate equipment? 2. Was awareness of surroundings a cause of the 3. Was employee wearing clothing adequate for the job? 4. Were driver actions the cause of the Actions Review employee training records on specific equipment. Ensure procedures identify training requirements for all employees operating equipment. Review employee training records and retrain employee on job/task. Identify if the use of clothing or the lack of was a contributing factor and update the procedures to address this issue. Review VUP and employee training records and retrain (when at fault). 5. Was the use of drugs or alcohol involved in the Was employee provided a copy of the policy? 6. Was correct equipment, tool(s) or materials used for the job? 7. Did employee(s) know where to obtain equipment/tool(s)/material used in place of correct one? 8. Were substitute equipment/tool(s)/material used in place of correct one? 9. Was failure to secure a contributing factor for Were employee(s) trained on specific task and the hazards associated with it? 10. Did grip or hold fail? Were employee(s) trained on specific task and the hazards associated with it? 11. Was horseplay or fighting one of the causes of the Were employees trained on safety codes specifically on Horseplay or Workplace Violence Prevention? 12. Was incident caused by intentional act/sabotage. Are employees trained on type of act or sabotage? Review County s Drug and Alcohol Use Policy. Review employee training records Specify correct equipment, tool(s) or material in job procedures. Review procedures for storage, access, delivery, or distribution, Review job procedures for obtaining equipment, tool(s), or materials. Provide correct equipment, tool(s), or materials. Warn against use of substitutes in job procedures and in job instruction. Review JSA and SOP for the task. Write a JSA if none available and train employees on securing procedures. Review JSA and training on specific task. Check for step on securing grip or hold and the hazards associated when these fail. Check for audits on equipment for possible corrections. Review Safety Codes to ensure that horseplay or fighting is included. Define horseplay in safety codes. Review security measures and policies that apply to type of act/sabotage. Update policy/procedures if necessary. Review training records of affected employees. Page 1 of 11

2 Guide for Identifying and for Providing s 13. Was lifting, pushing or pulling one of the causes leading to the incident. specific 14. Was unsafe loading or stacking the cause of the specific 15. Was failure to Lockout / Tag Out a contributing factor? Is there a written Lockout / Tag Out procedure? Are employee trained on Lockout / Tag Out procedures? 16. Was mixing or combining of substances one of the causes of the Does department have a written Hazard Communication Your Right to Know Policy in place? on specific 17. Was the use of mobile Radio/cell phone use a contributing factor? on specific 18. Was the need for assistance a contributing factor that lead to this Possible s Review SOPs for lifting, pushing or pulling. Write or update JSA to including hazards associated with the task/job and recommendations on how to prevent a similar incident. Train employees on revised SOP and JSA for task. Review procedures for loading or stacking. Write or update JSA to including hazards associated with the task/job and recommendations on how to prevent a similar incident. Train employees on task. Review Lockout / Tag Out procedures and policy. Update policy as needed. Review employee training on lock out tag out, JSA and SOP for task/job. Train employees on updated procedures and associated hazards. Review Hazard Communication, Your Right to Know Policy. Update if necessary. Update/write a new policy. Update/write a new JSA on specific task. Train all employees on updates and JSA. Review JSA, Safety Codes and the Cell Phone use Policy. Review radio training procedures. Update policies and procedures as needed. Review/write SOP and JSA. Include language indicating the need to get assistance for the task. Train all affected employees on new or updated SOP and JSA. on specific Page 2 of 11

3 Guide for Identifying and for Providing s 19. Was operating speed the cause of this Possible s Review the SOP for equipment /VUP with employee. the operation of the equipment or vehicle? For auto: Has employee been trained on Defensive Driving? Provide training on proper speed. Review employee training records and retrain. 20. Was employee wearing proper Personal Protective Equipment (PPE)? Was appropriate PPE specified for the task or job? Was the PPE adequate for the Was appropriate PPE available? Did employee(s) know that wearing specific PPE was required? Did employee(s) know how to use and maintain the PPE? Review methods to specify PPE requirements. Review PPE requirements, check standards, specification and certification of the PPE. Write a JSA which includes PPE requirements. Provide appropriate PPE. Review purchasing and distributing procedures. Review training procedures. Include JSA as a tool to train employees. Train affected employees on new/updated SOP and JSA. Was the PPE used Properly when the injury occurred? 21. Placement or storage: Was/were employee(s) or equipment in correct location? on specific 22. Was/were employee(s) positioning for Task the correct one? Review housekeeping audits. Revise to address the identification of placement and storage hazards. Write new SOP and JSA if none available. Train all affected employees on new/updated SOP and JSA. Review SOP/JSA for job/task. Update SOP/JSA addressing the hazards with recommendations on how to prevent injury. Write new SOP and JSA if none available. on specific 23. Did employee follow safe work practices or rules? Does the department have written safety codes posted, available to all employees? on specific Train all affected employees on new/updated SOP and JSA. Review location safety codes, JSA and SOP. Review employee training records. Update safety code, JSA and/or SOP or write new if none available. Train employee on all of the above. Page 3 of 11

4 Guide for Identifying and for Providing s 24. Was the lack/failure of safety devices one of the leading causes of the Possible s Review audit/ inspections of equipment/location. Include equipment/location audit/inspection as part of a planned maintenance (PM). 25. Was servicing equipment in operation one of the causes that lead to the on specific Train employee on all of the above. Review employee training records, SOP and JSA for task. Review equipment Safety Operating Manual. Update all documents as necessary or write new SOP and JSA for task. Train or retrain employee(s) on safety hazards and how to prevent injury. 26. Was the improper use of equipment or tools the cause of the Review employee training records, SOP and JSA for task. Review equipment or tool Safety Operating Manual. on specific Update all documents as necessary and train or retrain employee(s) on all updates specifically on safety hazards and how to prevent injury 27. Was the lack of warning or instruction the cause of the incident/ Were warning signs posted? on specific List other causal factors attributed to behavior(s). Conditions (Select all that apply) 28. Were environmental conditions a contributing factor? (gases, dusts, smoke or fumes) 29. Defect in equipment, tools, or materials? on how to identify defects in tools or materials? 30. Did the design of the equipment/tool(s)/material create operator stress or encourage operator error? Review employee training records on specific task/equipment/tool/machine. Check for posted warning signs. Update all documents as necessary or write new SOP and JSA for task. Train or retrain employee(s) on safety hazards and how to prevent injury. Monitor or periodically check environmental conditions as required. Check results against acceptable levels. Initiate action for those found unacceptable. Review control procedures for inspecting, reporting, maintaining, repairing, replacing, or recalling defective equipment, tools, or materials. Review training documents for affected employee(s) Review human factors engineering principles. Alter equipment, tool(s) to make it more compatible with human capability and limitations. Review procurement procedures and specification. Check out new equipment and job procedures involving new equipment before putting into service. Encourage employees to report potential hazardous conditions created by equipment design. Page 4 of 11

5 Guide for Identifying and for Providing s 31. Did the general design or quality of the equipment/tool(s) contribute to hazardous condition? Possible s Review criteria in codes, standards, specifications, and regulations. Establish new criteria as required. 32. Was the exposure to cold temperatures the cause of the Was employee wearing adequate clothing for the Review SOP/JSA for job/task. Update SOP/JSA addressing the hazards with recommendations on how to prevent injury. Write new SOP and JSA if none available. Train all affected employees on new/updated SOP and JSA. specific 33. Was the exposure to hot temperatures the cause of the Does department have a written Heat Illness Prevention Plan? Was water available to employee? Was shelter provided to employee? Review Heat Illness Prevention Plan and SOP/JSA for job/task. Update the plan and SOP/JSA to address the hazards with recommendations on how to prevent injury. Write new Heat Illness Prevention Plan, SOP and JSA if none available. Train all affected employees on new/updated plan, SOP and JSA. Was employee provided breaks? plan and specific 34. Was Fire / Explosion the cause of the Investigate what caused the fire/explosion. Does the department have a written Fire Prevention Plan in place? Does the department have a written Emergency Evacuation Plan that includes fires. 35. Was the lack of guards or barriers the cause of the Were the barriers or guards removed? Were the barriers or guards broken? Were the barriers or guards not installed by the manufacturer? Review the Fire Prevention Plan and update as needed. Review and update the Emergency Evacuation Plan as needed. Retrain all affected employees on new or updated plans. Review and update SOP/JSA procedures for task to address the hazards and recommendations on how to prevent similar incident. Write new SOP and JSA if none available. Review audit/ inspections of equipment/location. Include equipment/location audit/inspection as part of a planned maintenance (PM). Train employee on all of the above. Page 5 of 11

6 Guide for Identifying and for Providing s 36. Was housekeeping the cause of Does the department perform monthly housekeeping audits as part of a monthly PM? Possible s Review Housekeeping inspection procedures. Include methods to identify hazards and recommendations on how to prevent similar incident. Initiate monthly housekeeping inspections. Have employees received training on hazards involving Include equipment/location audit/inspection as part of a planned maintenance (PM). 37. Was illumination one of the causes that lead to the Train affected employee(s) on all of the above. Analyze lighting of location. Add more lighting as needed. 38. Was the lack of or improper labeling one of the causes that lead to the Chemical: Was the chemical transferred to a different container? Does the department have a written Hazardous Communication Your right to know Plan in place? Chemical: Affix proper label on container. Review / update or write a new Hazardous Communication plan. Train employees on the department s Hazardous Communication Plan and all the MSDSs for the chemicals they work with. Equipment: Check equipment for missing labels and install new ones. Is employee trained on the department s Hazardous Communication plan and the MSDSs for the chemicals he/she was handling? Equipment: Does the equipment have the proper labels per the Standard Operating Manual? Write inspection checklist for employees to use prior to using the equipment. Train employees on conducting daily inspections. Do employees perform safety checks using a written checklist? Are new employees trained on Safe Operating procedures and how to perform daily inspections using the written checklist prior to initiating work and are annual refresher trainings provided to employees? 39. Was new or modified equipment one of the causes that lead to the Review and update or write, if none on available, JSA and SOP. Address the need to follow Management of Change MOC) process. Is there a written JSA and SOP for the use of new or modified equipment? Train employees on all new equipment or modifications. Page 6 of 11

7 Guide for Identifying and for Providing s Did JSA and SOP identify the hazards associated with the use of the new or modified equipment? Was/were employee(s) trained on the new or modified equipment s JSA and SOP? 40. Was a new or Modified procedure the cause of the Is there a written JSA and SOP for the procedure? Did JSA and SOP identify the hazards associated with the procedure? Possible s Review and update or write a new, if none available, JSA and SOP. Address the need to follow Management of Change MOC) process anytime change occurs. Train employees on all procedural modifications. Was/were employee(s) trained on new or modified procedure s JSA and SOP? 41. Was noise a cause of the Review Hearing Loss Prevention Program. Update as needed. Has equipment or operation been tested for noise levels? Was PPE available? Was employee wearing PPE? Review noise level audits. Review the need to wear appropriate or additional PPE. Review/update JSA for task as needed. donning and maintaining the PPE? 42. Was the lack of, defective or inadequate Protective Equipment the cause of the Is there a written JSA and SOP for the task/job? Assess the need for PPE. Assess procurement for PPE. Write a JSA addressing the need for PPE and ways to prevent injury. Have employees 43. Was exposure to radiation the cause of the 44. Was the lack of Tools/equipment availability the cause of the 45. Was the lack of ventilation the cause of the 46. Was vibration the cause of the Review/update procedures for preventing exposure to radiation. Train all affected employees on procedures for preventing exposure to radiation to include the use and donning of personal protective equipment. Check with procurement to see when last order was placed. Check PM schedule for the HVAC system. Make a plan B for addressing heat issues when HVAC system is down. Check PM schedule of the equipment. Train employees to report unusual vibrations. Page 7 of 11

8 Guide for Identifying and for Providing s 47. Was the lack of visibility the cause of the 48. Was the walking or working surface the cause of the 49. Was the lack of or inadequate warning systems a factor that led to the Possible s Provide a description of the issues relating to visibility. Provide methods to prevent future similar incident. Take pictures, provide a description of the walking/working surface and, if known, explain what caused the incident. If the incident was a slip, trip or fall, provide pictures of the shoes injured person was wearing at the time of incident. Were signs in place warning others of hazard? Take pictures of location and any signs or warning signs in the vicinity. Add new signs as needed. 50. Was weather conditions a factor that led to the 51. Was the workspace conditions (congested or restricted access/egress) the cause of the 52. Was the hazardous condition(s) recognized? (if yes, answer a and b if no proceed to next question. a. Was/were the hazardous condition/s reported? b. Was/were employee/s informed of the hazardous condition/s and the job procedures for dealing with it? List other causal factors attributed to the environment. Basic or Root Cause 53. Was the cause of the incident due to abuse or misuse of equipment? Was the employee trained on proper use of equipment? 54. Was employee knowledge adequate? Train all employees on ways to identify the need to include warning systems to prevent incidents. Provide a description of the weather conditions that were a factor that lead to the incident. Review audit reports for area/location where incident occurred. Make recommendations to clear area. Perform job safety analysis (JSA). a. Train employees in reporting procedures. Stress employees responsibility for safety. b. Remove hazard. Review job procedures for hazard avoidance. Train employees on JSA. Review equipment s Safety Operating Manual. Review training records. Retrain employee on proper use of equipment. Review training records on specific job/task. 55. Was employee s skill adequate for the job/ 56. Was the engineering or design of location / equipment adequate for the job/ Retrain as needed. Review training/experience on job specific tasks. Review Safety Operating Manual. Check to see if guards were removed. Check to see if equipment was manufactured without guards. Check for emergency stop buttons and their location. Page 8 of 11

9 Guide for Identifying and for Providing s 57. Does department conduct scheduled inspections that would identify hazards in that area. 58. Was the lack of maintenance a factor that led to the 59. Management systems Is there a written Safety Operating Procedure that includes training. Does the job/task have a JSA to help identify the hazards and ways to prevent injury at every step of the job? Possible s Review inspection records for location where incident occurred. Review PM (planned maintenance) schedule to ensure that maintenance is performed regularly. Review JSA s, Standard Operating Procedures, Safety Operating Manual(if available. Audit reports, disciplinary actions taken (if any). Require that all audit systems be Implemented for location/equipment. Make additional recommendations for improvement, as needed. Does the job/task/location include an audit system to ensure that all areas of safety are covered: Housekeeping Machine guarding Audits Training Disciplinary Action Retraining 60. Was mental stress or fatigue a factor that led to the 61. Was mental or psychological capability a factor that lead to the 62. Was the lack of motivational factor that lead to the incident 63. Was the lack of physical capability a cause that led to the 64. Was physical Stress or fatigue a factor that led to the Request that employee, supervisor and any known witness provide a narrative with sequence of events (in chronological order) that caused the mental stress or fatigue. Request that employee, supervisor and any known witness provide a narrative with sequence of events (in chronological order) that caused the mental stress or fatigue. Describe if lack of motivation was the cause of the incident Does the department require employees to go through job placement fitness test prior to hiring? Was employee working overtime at the time of 65. Was Procurement / purchasing a contributing factor that led to the 66. Had a Risk Assessment been previously performed by writing an SOP and JSA? Review current SOP and JSAs. Update documents or write new ones if none available. Page 9 of 11

10 Guide for Identifying and for Providing s 67. Was the lack of supervision or leadership a contributing factor that led to the Was injured employee trained? Possible s Review training records for employee and supervisor. Interview injured employee and supervisor and request that they provide a sequence of events of the incident. Review audit and PM records. 68. Was the injured employee asked to work under unsafe conditions? Were audits and PM checks performed on equipment? How often? 69. Tools, equipment or material Check tool, equipment or material employee was using. Was injured employee using the right tool, equipment or material for the job. Was the right tool, equipment, material for the job available? Check on procurement records to check order status. Check employee and supervisor training records. Was the tool, equipment, or material in safe working order safe use of tool, equipment or material? 70. Training the job/task he/she was performing? 71. Wear and tear Review training records. Interview employee to assess his/her knowledge of the job/task he/she was performing. Check equipment, space, material for wear and tear. Was equipment, tool or material s wear and tear the cause of the incident/ Is the tool, equipment or material required to be audited, inspection prior to each use? Review JSA or Standard Operating procedures for information regarding the tool, equipment, material s wear and tear signs and what to do to prevent injury. Review inspection records. Review procurement records. Are there written guidelines on when to purchase/order new tool, equipment or material? Review PM records. Is the tool, equipment or material on a PM schedule? Page 10 of 11

11 Guide for Identifying and for Providing s 72. Was there a written procedure for this job? Possible s Perform job safety analysis and develop safe job procedures If answer a), b) and c). If no, proceed to next question. a) Did job procedures anticipate the factors that contributed to the accident? b) Did employee(s) receive training on job procedures? c) Did employee(s) deviate from the known job procedures 73. Are there written procedures for conducting inspections/audits on equipment? 74. Is existing equipment inspection/audit adequate? a) Perform job safety analysis and change job procedures. b) Improve job instruction. Train employees in correct job procedures. c) Determine why. Encourage all employees to report problems with an established procedure to supervision. Review expectations of employees and the consequences for their actions. Counsel or discipline employee(s). Review procedures, if none available recommend for department to write procedures for conducting inspections/audits for the different locations. Review current procedures; change frequency or comprehensiveness. Provide test equipment as required. Train employee in detecting defects and hazardous conditions. Change job procedures as required. Page 11 of 11