ACCIDENT INVESTIGATION (ROOT CAUSE ANALYSIS)

ACCIDENT INVESTIGATION (ROOT CAUSE ANALYSIS) Salina Tukimin DOSH Selangor Department of Occupational Safety and Health (DOSH) 1

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 2

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 3

Definition Definition of Incident Is an unplanned event, which could or does result in harm. Harm occurs to people, property, processes or the environment and it means that someone or something getting injured, damaged or hurt. An incident could have two possible outcomes : one results in unintended harm and the other results in no harm. This recognizes that there can be two type of incident : Accident and Near-misses. An incident, which results in harm is called an Accident. 4

Example of accident Meaning of Accident An electrician was working on a machine energised by highvoltage without is being locked-out. The screwdriver he was using connected two terminals and caused an explosion and resulting in third degree burn to the electrician A general worker was repairing damaged roof, while going down after finished his work, he has stepped on the transparent roof. He fell and die Example of near miss An electric forklift was being parked in its storage bay, but the brake were not responsive as they should have been. The forklift travelled slightly further and bumped the battery charger station. No visible damage to the station or the forklift occurred An operator was preparing to connect a door panel to the door car, it slipped out of his hands and fell to the floor. The operator found that the panel was not damaged and he proceed the his work without any interruption to the line. 5

Are incidents always unplanned? We like to think that incidents are unexpected or unplanned events, but sometimes, that is not necessarily so. In the workplaces there are unsafe act / unsafe conditions that have been ignored or tolerated for weeks, months or even years In such cases, it s not a question of IF the incident is going to happen. It s only a matter of WHEN 6

But unfortunately, the decision is made to take the risk A competent person can examine workplace conditions, to predict closely what kind of incidents will occur. Control features for unacceptable risk are deficient or fail. Control features are not incorporated because risks are not identified or are improperly understood Changes introduce unintended risks or defective control features Technically, we can t say an incident is always unplanned. Therefore a Safety Management System is designed perfectly to produce what is intends 7

Ratio Study Frank E.Bird, 1969 One of the most accepted studies involved an analysis of 1,753,498 incident reported by 297 companies representing 21 industrial groups and 1,750,000 employees. This study revealed that for every major injury and illness (e.g. death, disability, lost time or medical treatment), there were 9.8 minor injuries and illnesses. The study also indicated that there were approx 30 property damage incidents and 600 near misses occurring for every major illness and injury The 1-10-30-600 ratio indicates a tremendous opportunity to prevent serious and major events by investigating and correcting all potential loss producing events. 8

HSE Study, 1993 In 1993, the Health and Safety Executive (HSE) group of the British government published the results of their studies. The study was conducted by team of professionals, who visited five different locations representing different industry types. The relationship of major injury incidents to minor incidents to no injury incidents was 1-7-189 (near-miss type were not addresses in this study. Other finding: One org. lost up to 37% of its annual profit due to incident costs One org. lost the equivalent of 5% of its operating budge One org. lost the equivalent 8.5% of its product s total annual revenue 9

The cost of incidents Considering these studies: 10

The cost of incidents It will be noticed by reviewing the iceberg that for every 1 unit of cost, there are 6 to 53 times that amount of loss due to property, process, material and mis. costs 11

Point of interest Considering these studies: There is fundamental relationship between major incident, minor incidents and near-misses. The exact numbers are not important, the study tell us that our best results can be achieved by focusing on all event. Even near-misses and minor incidents should be investigated because they provide valuable information on the cause which lead to major events. They are in effect free lessons and, as such, should be take full advantage 12

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 13

The importance of incident investigation Key goals for incident investigations IDENTIFICATION, NOT ASSUMPTION of all causes, events, people, equipment, materials, environmental factors etc EVALUATION, NOT RESIGNATION of common causes, trends, potential losses, likelihood of recurrence etc LONG-TERM THINKING, NOT SHORT-TERM FIXING in developing controls, problem-solving etc SHOWING CONCERN, NOT CONDEMNATION for employees health and safety, environment, production, quality etc BEING PROACTIVE, NOT REACTIVE acting on information collected to prevent future incident, taking corrective action etc Features of poor investigation Focus only on personnel Foster distortion of facts Stipulate blame and / or liability Tend to make employees protect themselves Do not present all fact Do not eliminate system causes 14

Effective Investigation Find out what really happened the full and unbiased story Find the underlying or root causes Provide data for effective trend analysis Improve employee morale by showing company commitment to prevention of future incidents Help the company assure regulatory requirements are met Identify any key learning s for organizational distribution Increase of production time and reduction of operating cost by control of accidental losses FACT FINDING, NOT FAULT FINDING 15

The importance of reporting In order to be evaluated and investigated, incidents must first be reported. Encourage reporting Allow employees to report Overcome people s fear of reprisal resulting from reporting Educate everyone in the org about the importance of reporting all types of incidents Demonstrate the importance of reporting incidents when they are reported Streamline the reporting process to make it as short and simple as possible Reporting to DOSH Occupational Safety and Health (Notification of Accident, Dangerous Occurrence, Occupational Poisoning and Occupational Disease) Regulations 2004 16

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 17

Incident investigation STEPS IN CONDUCTING INVESTIGATION Incident Investigation To prevent recurrence Learn about What happen To determine immediate and root cause Understand the risk To develop preventive measures

Incident investigation process STEPS IN CONDUCTING INVESTIGATION Report the incident PROPER INITIAL RESPONSE GATHER INFORMATION ANALYZE CAUSES TAKE REMEDIAL ACTIONS REPORT MANAGEMENT REVIEW AND FOLLOW-UP

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 20

Cause analysis Technique Fault Tree Analysis (FTA) Event Tree Analysis (ETA) Systematic Cause Analysis Technique (SCAT) Loss Causation Model HAZOP Hazard and Operability Study FMEA Failure Mode and Effects Analysis 21

Cause Analysis Process Accident Are goals and objectives met? Is conclusion valid YES Complete Report and Action Plan NO SPECIFY ANALYSIS Goals Objective Working Hypothesis COLLECT EVIDENT ANALYZE EVIDENCE CONCLUSIONS OF ROOT CAUSATION 22

Loss Causation Model TECHNIQUE : CAUSATION MODEL LACK OF CONTROL Inadequate System Standards Compliance BASIC CAUSES Personal Factors Job/System Factors IMMEDIATE CAUSES Substandard Acts/Practices Substandard Condition Classifying information into five stages : Losses Incidents or contacts Immediate causes Basic causes Lack of control INCIDENT Event T H R E S H O L D L I M I T LOSS Unintended Harm or Damage

CAUSATION MODEL LOSS CAUSATION MODEL The Causation Model - not only helps us understand why this is so, but also points the way to what must be done to control these causes. LOSS : Unintended Harm or Damage result of an accident the most obvious losses are harm to people and property damage important related losses are performance interruption and profit reduction

LOSS CAUSATION MODEL INCIDENT : An Event the event that precedes the loss. the contact that could or does cause the harm or damage to anything in the working or external environment. possible contact with a source of energy above the threshold limit of the body or structure exists.

LOSS CAUSATION MODEL TYPES OF ENERGY TRANSFERS AND SUBSTANCE CONTACTS : Struck against (running or bumping into) Struck by (hit by moving object) Fall the lower level (either the body falls or the object falls and hits the body) Fall on same level (slip and fall, tip over) Caught in (pinch and nip points) Caught between (crushed or amputated) Contact with (any harmful energy or substance, includes ignition, explosions, emissions, etc)

LOSS CAUSATION MODEL IMMEDIATE CAUSES : Substandard Acts / Practices and Conditions Immediate causes of accidents are the circumstances that immediately precede the contact Unsafe acts/practices behaviours which could permit the occurrence of an accident. Unsafe conditions circumstances which could permit the occurrence of an accident.

LOSS CAUSATION MODEL IMMEDIATE CAUSES : Substandard Acts / Practices and Conditions Why??? Symptom What to look for / What people do wrong Why did that substandard practice occur? Why did that substandard condition occur? Why did the loss control system permit that practice or condition?

BASIC CAUSES : Personal and Job/System Factors Basic causes are the diseases or real cause behind the symptoms - the reasons why the substandard acts and conditions occurred. Explain why people perform substandard practices / acts. LOSS CAUSATION MODEL Explain why substandard conditions exist.

LOSS CAUSATION MODEL LACK OF CONTROL 3 reasons for lack of control inadequate program inadequate program standards inadequate compliance with standards

1) inadequate program LOSS CAUSATION MODEL too few or improper system activities. lack of element for safety/loss control management system. 2) inadequate program standards standards that are not specific, not clear and high enough 3) inadequate compliance with standards the single greatest reason for failure to control accident loss

To recommend active to bring back to the correct manner / standard Symptom What to look for / What people do wrong BASIC CAUSE To recommend the preventive measure eliminate the root cause Why people do wrong ROOT CAUSE INCIDENT What goes wrong Cause Analysis to find the root cause to find deficiencies / gap of the system to identify system failures, to prevent future incidents

Case Study 1 The worker was installing the staircase and platform at the 200 feets height of tower structure. While going down, he fell and landed on the metal piece on the ground.

PPE been used by the victim Safety belt, safety shoe dan safety helmet that has been used for working at tower structure

Cause Analysis Loss Causation Model Installation of component tower structure INADEQUATE RISK ASSESSMENT LACK OF CONTROL ROOT CAUSE IMMEDIATE CAUSES INCIDENT LOSS Risk Assessment has not been done (HIRARC) Inadequate System Procument OSH elements not been incorporated and empersized Training and Compentency (Ariel Rigger) Selection of PPE Indentify and analyze high risk activity Control of contractor Human Factors Poor judgement) Indentification of unsafe act inadequate Workplace Factors No safe working procedure Installation of tower component is based on experience, no proper method statement given No trainning working at heigh Substandard Act Using only safety belt for working at height Substandard Conditions No temporary crossing bar equipped with life line for worker performing working at height Falling from height 200 feets Competency experience worker die Project cost and duration Installation activity stopped due to investigation Legal compliance Hoisting approval Reputation- Prosecution No supervision

Case Study 2 KES KEMALANGAN DI TAPAK PEMBINAAN Summary of case: 3 worker death while doing plastering at 19 th floor of building under construction. TEMPORARY WORKING PLATFORM COLLAPSED

GALANG BESI YANG DIGUNAKAN JENIS BERONGGA (HOLLOW STEEL BAR 50mmW x 100mmH x 3200mmL)- DIDAPATI BENGKOK PADA BAHAGIAN TENGAH POSISI GALANG BESI MENJADI FAKTOR IA TIDAK DAPAT MENAMPUNG BEBAN Distortion at the middle of primary truss i. POSISI MENDATAR i. POSISI MENEGAK POSISI GALANG BESI PADA KEDUDUKAN MENDATAR (KES INI) TIDAK DAPAT MENAMPUNG BEBAN PELANTAR BERBANDING POSISI MENEGAK

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 39

Legal Requirement Reporting to DOSH Occupational Safety and Health (Notification of Accident, Dangerous Occurrence, Occupational Poisoning and Occupational Disease) Regulations 2004 - NADOOPOD Guidelines NADOOPOD Incident Investigation and analysis Occupational Safety and Health (Safety and Health Committee) Regulations 1994 Reg 11 (a) carry out studies on the trends of accident, near-miss etc Reg 13 investigation into any accident, etc Reg 14 action to be taken, corrective action Reg 16 Communication system 40

Contents Overview The importance of incident investigations and getting them reported Incident investigation process Root cause analysis Legal requirements on investigation Conclusion 41

Conclusion Incident investigation only take place, when incident been reported Incidents should be viewed as opportunities to improve management system rather than as opportunities to assign blame Near-misses and minor incidents should be investigated because they provide valuable information on the cause which lead to major events 42

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