Root Cause Analysis in Construction

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Dave Murphy

Safety Director

Pepper Construction Company of Indiana

317-557-6648

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What we Build

• Health Care

IU Health Various Projects

Community Hospital East

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What we Build

• Higher Education

Purdue University Flex Lab

Facility

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What we Build

• Retail

Apple Stores

Meijer Stores – New and

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What we Build

• Industrial & Manufacturing

Ambrose // CAT - Carrier Corp. - Jones // Fedex

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Goals

• GOAL #1

– To

SAFELY

build high

QUALITY

projects

PRODUCTIVELY

.

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Goals

• Keep in mind what

sets safety apart from

everything else is –

Safety is about

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• Focus over time has progressed

Our Path to RCA

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• Focus over time has progressed

Our Path to RCA

Accident

Reports – Field

• Description

Accident

Investigations –

Field

• Easy Answers

Accident

Investigations -

Safety

Professionals

• “Fact Finding”

RCA - Safety

Professionals

w/ Field

• Identify - Causal

Factors, Root Cause,

Corrective Actions

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• Late 90’s introduced to RCA

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• Software

Our Path to RCA

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Why?

Answer

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• Root Cause Analysis (RCA)

is a method of problem

solving used for identifying the root causes of undesirable

events.

• Causal Factor

is one that affects an event's outcome but it

does not prevent its recurrence with certainty. However,

removing a causal factor can benefit an outcome.

• Root Cause

is a factor whose removal from the

problem-fault-sequence prevents the final undesirable event from

recurring.

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Undesired

Result

Investigation

Root

Cause

Analysis

Application of

Lessons Learned

Process or

Activity

RCA Process

Near Certain

Desired

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• Root Cause Analysis will drive change

– Can be perceived as a threat

– Can be met with resistance

– Management support required to achieve maximum benefit

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• Our process:

– Not about blame

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• Our process:

– Not about easy answers

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• Our process:

– Cannot be in a hurry!

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• Key Concept:

– “The most basic cause (or causes) that can reasonably

identified that management has control to fix and, when

fixed, will prevent (or significantly reduce the likelihood of)

the problem’s recurrence.”

– Mark Paradies

– “A Root Cause is the absence of a best practice or the

failure to apply knowledge that would have prevented the

problem.”

– Mark Paradies

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• There maybe more than one Root Cause!

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• Step 1 – Complete the event timeline

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INCIDENT:

EVENT:

CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR:

EVENT:

ROOT CAUSE ANALYSIS

WORKSHEET

DATE:

PROJECT:

ANALYSIS BY:

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• Step 2 – Run each

Causal Factor

thru the Root

Cause Analysis

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HUMAN ENGINEERING Workplace Layout •Controls NI •Labels NI •Displays NI •Excessive lifting •Tools NI Intolerant system

•Errors not detectable •Errors not recoverable

Work Environment •Housekeeping NI •PPE NI •Lighting NI •Noise levels NI •Ambient Conditions NI •Work positioning NI •Excessive environmental stresses Workload

•Excessive control action req. •Unrealistic monitoring req. •Knowledge based decision req. •Excessive calculation or data manipulation required IMMEDIATE SUPERVISION Preparation •No preparation •Job plan NI •Pre-job walk NI •Instructions to tradesmen NI •Scheduling NI Worker Selection •Not qualified •Not trained •Fatigued •Attitude/ attention NI •Mental state •Team selection NI

Supervision during Work

•No supervision •Not enough supervision •Supervision NI •Crew teamwork NI •Improper performance not corrected

PROCEDURES

Not Used/ Not Followed

•No procedure •Procedure unavailable •Procedure inconvenient to use

•Procedure difficult to use •Procedure use not required •Existing procedure not used

Wrong/Incomplete

•Typo or sequence wrong •Facts Wrong •Wrong revision •Inconsistent requirements •Situation not Covered

Misleading/ Confusing

•Details NI •> 1 action per step •No Checklist or inadequate •Confusing instructions TRAINING No Training •No THA •No Certification •Not required Training Records NI •Records incorrect •Records not available •Records not current

Training NI •THA NI •Content NI •Instruction NI •Practice NI •No Testing or NI COMMUNICATIONS

No Comm. or Not Timely

•Method unavailable or NI •Late communication •Comm. between contractors NI

•Comm. between tradesmen NI

•Comm. w/ owner NI •Comm. btwn tradesmen and foremen/ superintendents NI

Misunderstood Comm.

•Standard terminology not used

•Verification/ repeat back not used •Long message Wrong Instructions Job Turnover NI •Comm. Between Contractors and Superintendent NI MANAGEMENT SYSTEMS SPAC NI •No SPAC •Not strict enough •Confusing or Incomplete •No Safety Plan •Drawings/plans NI •Technical error •Responsibility for

SPAC Not Used

•Comm. of SPAC NI •Recently changed •Enforcement NI •Accountability NI Oversight/Employee Relations •Infrequent Problem Identification/Control •Problem reporting NI •Problem Analysis NI •Audits NI •Corrective Actions NI •Corrective actions not yet implemented Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Fatigue, impairment, personal issues, inattentiveness? Procedure not used or

used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor

body positioning, Vibration, lifting? Communications Training Communications Immediate Supervision Communications Coordination between team members? Lack of agreement on

who/ what/ where/ when of task? Communication between

contractors or owner required? Task performed in a hurry or short cut used?

Recurring error or potential for failure known before

occurrence? Standards, Procedures

Admin Controls, or policies to prevent/ mitigate error not used

missing or in need of improvement? Independent check should have caught the

problem? Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1) INDIVIDUAL PERFORMANCE 2) TEAM PERFORMANCE 3) MANAGEMENT SYSTEMS CAUSAL FACTOR =

ROOT CAUSE – ACTION ITEMS =

HUMAN FACTORS ANALYSIS

BASIC CAUSE CATAGORIES

Root Causes

1. Review each causal factor one at a time, by

answering the Human Factors Analysis

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• Step 3 – Identify

Corrective Actions

– Assign responsibilities and follow up date

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• An earth retention contractor was engaged as a third tier

sub to install an earth retention system on a portion of

the project where sloping was not a viable protective

solution option. The earth retention system is installed

by vibrating h-piles into the soil then wood lagging is

fastened as the soil is removed. During the installation of

the sixth earth retention pile, the steel pile damaged an

underground water main line, causing the water main to

rupture. The owner was immediately notified and within

one hour the damaged water line was shut off.

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INCIDENT: Steel H

beam damaged 10”

water line causing

uncontrolled flow

of water

EVENT: Crew did not see

water line locate marks in

proximity of next pile

CONDITION OR CAUSAL FACTOR: Paint marks stopped at the valve and did not continue thru work area

CONDITION OR CAUSAL FACTOR: Line was not identified by locator or marks were erased by equipment and

EVENT: 5/5/16 – Risk

Assessment completed

with earth retention

contractor

EVENT: 5/13/16 – Earth

retention contractor

began staging on site

EVENT: 5/16/16 - Crew

began work installing H

piles

CONDITION OR CAUSAL FACTOR: Pepper Superintendent not on site due to other project commitments

EVENT: 5 H piles were

installed per drawing

CONDITION OR CAUSAL FACTOR: Project team did not identify water line in close proximity (12”) to buried water line CONDITION OR CAUSAL FACTOR: Drawing was difficult to read because of contour lines and amount of information

EVENT: Excavator with

vibratory attachment

was positioned to drive

next pile

EVENT: Steel H beam

was vibrated to bury it

to required depth

EVENT: Steel H beam

contacted water line at

6’ to 7’ depth

EVENT: Utility turned

water off at valve to

isolate

ROOT CAUSE ANALYSIS

WORKSHEET

DATE:

5/16/16

PROJECT:

Xxxxxxxxxxxx

ANALYSIS BY:

Dave Murphy

INCIDENT DESCRIPTION: During the installation of the sixth earth retention pile that was being installed along the North side of the property, the steel pile damaged an underground water main line,

causing the water main to rupture. The water department was immediately notified and within one hour the area of the damage water line was shut off.

CONDITION OR CAUSAL FACTOR: No morning huddle with Pepper and Earth Retention contractor to review locates and procedures

EVENT: Locators marked

buried utility lines

CONDITION OR CAUSAL FACTOR: Earth retention foreman spoke with locator but did not review drawings together

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PROCEDURES

•Procedure difficult to use •Procedure use not required

•Existing procedure not used

•Verification/ repeat back not used •Long message Wrong Instructions Job Turnover NI •Comm. Between Contractors and Superintendent NI MANAGEMENT SYSTEMS SPAC NI •No SPAC •Not strict enough •Confusing or Incomplete •No Safety Plan •Drawings/plans NI •Technical error •Responsibility for activity/item definition NI •Planning, scheduling or tracking NI

SPAC Not Used

•Comm. of SPAC NI •Recently changed •Enforcement NI •Accountability NI Oversight/Employee Relations •Infrequent audit/evaluations •Audit/evaluations NI •Employee comm. NI Problem Identification/Control •Problem reporting NI •Problem Analysis NI •Audits NI •Corrective Actions NI •Corrective actions not yet implemented Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Fatigue, impairment, personal issues, inattentiveness?

Procedure not used or used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor

occurrence? Standards, Procedures

Admin Controls, or policies to prevent/ mitigate error not used

problem? Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1) INDIVIDUAL PERFORMANCE 2) TEAM PERFORMANCE 3) MANAGEMENT SYSTEMS

CAUSAL FACTOR =

Earth retention foreman spoke with locator but did not review

drawings together including the excavation contractor input.

ROOT CAUSE – ACTION ITEMS =

Procedure not used or used incorrectly? Procedures - Existing

Procedure

not

used

– Reportedly, University locator refreshed

markings on the morning of the incident. The earth retention

contractor foreman did discuss the locates but they did not review

the site drawings as required by the project specific safety plan.

Knowledge of task or equipment missing?

Preparation - Job plan NI

Training NI - Instruction NI

Action Items: follow the PSSP Underground Utility Locating Plan -

Procedures for private and public locate personnel. The

subcontractor shall:

• Review Master Utility Location Drawing with the utility locating

service representative.

• Observe locating of line(s).

• Insure that markings are painted and staked, if possible.

HUMAN FACTORS ANALYSIS

BASIC CAUSE CATAGORIES

Root Causes

ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS

1. Review each causal factor one at a time, by

answering the Human Factors Analysis

questions.

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PROCEDURES

•Procedure difficult to use •Procedure use not required •Existing procedure not used

•Verification/ repeat back not used •Long message Wrong Instructions Job Turnover NI •Comm. Between Contractors and Superintendent NI MANAGEMENT SYSTEMS SPAC NI •No SPAC •Not strict enough •Confusing or Incomplete •No Safety Plan •Drawings/plans NI •Technical error •Responsibility for

SPAC Not Used

•Comm. of SPAC NI •Recently changed •Enforcement NI •Accountability NI Oversight/Employee Relations •Infrequent Problem Identification/Control •Problem reporting NI •Problem Analysis NI •Audits NI •Corrective Actions NI

•Corrective actions not yet implemented Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Fatigue, impairment, personal issues, inattentiveness? Procedure not used or

used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor

occurrence?

Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used

problem? Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1) INDIVIDUAL PERFORMANCE 2) TEAM PERFORMANCE 3) MANAGEMENT SYSTEMS

CAUSAL FACTOR =

Pepper Superintendent not on site due to other project

commitments

ROOT CAUSE – ACTION ITEMS =

Recurring error or potential for failure known before occurrence?

Management Systems - Planning, scheduling or tracking NI –

Scheduling of Supervision was compromised by conflicting job

assignments and responsibilities.

Problem Identification/Control - Corrective Actions NI –

This is a

recurring problem for Pepper where projects are started without

sufficient time allotted for Superintendent pre-planning. Projects

also begin without adequate supervision on site to manage the risks

of the work scope.

Action Items: Suggest that management draft and implement a

policy for project coverage to ensure that experienced, qualified

supervision is in place on all projects for risks associated with the

work scope.

HUMAN FACTORS ANALYSIS

BASIC CAUSE CATAGORIES

Root Causes

1. Review each causal factor one at a time, by

answering the Human Factors Analysis

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CAUSAL FACTOR =

No morning huddle with Pepper and Earth Retention contractor to review locates and procedures. No Excavation Permit form was completed.

ROOT CAUSE – ACTION ITEMS =

Procedure not used or used incorrectly? Procedures Not Used/ Not Followed - Existing procedure not used

Communication between contractors or owner required? Communications - Comm. between contractors NI

Recurring error or potential for failure known before occurrence? Management Systems SPAC Not Used - Comm. of SPAC NI

Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? Immediate

Supervision - Supervision during Work - No supervision

The Daily Coordination Meeting is required by the PSSP based on past lessons learned from utility hits.

Action Items: follow the PSSP Underground Utility Locating Plan -

Daily Coordination Meeting – The Pepper Superintendent and the subcontractor(s) will meet before work starts at the beginning of each shift.

The meeting agenda shall contain the following items:

• Completion of Excavation Permit form. Subcontractor to return form to Pepper Superintendent at the end of the shift.

• Prior to issuing permits ensure that:

• A qualified PCCI employee reviewed the layout of underground installations to identify possible conflicts with existing utilities.

• Discussion and documentation of previous days (shift) trenching and excavating activities the on the Master Utility Location Drawing.

• Discussion of the scope and location of work for the days (shift) work.

• Verification of known underground utility locations and applicable private and public locates using the Master Utility Location Drawing and

Project Utility Locate Calendar.

• Review of the pot-hole/daylight/hand excavation procedures for all located utility crossing points.

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CAUSAL FACTOR =

Project team did not identify water line in close proximity (12”) to buried water line

ROOT CAUSE – ACTION ITEMS =

Displays/indicators to recognize/analyze task unavailable or unclear? Displays NI –

Drawing of underground utilities and piles was very

difficult to read (EX 6).

Knowledge of task or equipment missing? Immediate Supervision - Preparation - Job plan NI

Pre-job walk NI –

Earth retention contractor Superintendent was not part of the PSSP/Risk Assessment meeting.

Supervision during Work - No supervision - Not enough supervision –

Pepper Superintendent was not on site to review plans and utility

locates with excavation and earth retention contractors.

Communication between contractors or owner required?

Communications - Comm. between contractors NI –

Superintendents for excavation

and earth retention contractors did not review pile locations and utility location for this pile to determine work should not be completed until

the line had been day lighted with the hydro-vac.

Recurring error or potential for failure known before occurrence? Management Systems -Comm. between contractors NI –

This error has

happened before and plan was amended to help prevent future recurrence. Will continue to recur without improved communication

between contractors.

Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? SPAC NI - SPAC NI

- Drawings/plans NI

Procedures - Existing procedure not used –

Pepper did not have site drawing posted with utility and plie overlays for review before days work

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CAUSAL FACTOR =

Project team did not identify water line in close proximity (12”) to buried water line

ROOT CAUSE – ACTION ITEMS =

Action Items: follow the PSSP Underground Utility Locating Plan -

• Contract private locating service to locate and grid the project for all utilities – public and private; and overlay all utility locations on one Master Utility Location

Drawing.

• Private locating service will be contracted to daylight all utilities before work begins.

• Verify locates against drawings.

• Daily Coordination Meeting – The Pepper Superintendent and the subcontractor(s) will meet before work starts at the beginning of each shift. The meeting agenda

shall contain the following items:

• Completion of Excavation Permit form. Subcontractor to return form to Pepper Superintendent at the end of the shift.

• Prior to issuing permits ensure that:

• A qualified PCCI employee reviewed the layout of underground installations to identify possible conflicts with existing utilities.

• No dig zones are identified with white paint.

• Discussion and documentation of previous days (shift) trenching and excavating activities the on the Master Utility Location Drawing.

• Discussion of the scope and location of work for the days (shift) work.

• Verification of known underground utility locations and applicable private and public locates using the Master Utility Location Drawing and Project Utility

Locate Calendar.

• Discussion of private and public locates needed for upcoming trenching and excavating activities.

• Review of the excavation protective system i.e. sloping, benching, trench box prior to be utilized during the shift.

• Review of the pot-hole/daylight/hand excavation procedures for all located utility crossing points.

Follow 6.2 and 6.3 of the Subcontractor Safety Handbook Requirements -

6. SAFETY PLANNING & PROGRAMS

6.2. Safety Plan Review Meeting – all SUBCONTRACTORS are required to attend a Safety Plan Review Meeting that must take place before any work starts. The PEPPER

CONSTRUCTION Superintendent will schedule the meeting. Required attendees include the SUBCONTRACTOR full time Site Superintendent/Foreman and the PEPPER