ACCIDENT INVESTIGATION (ROOT CAUSE ANALYSIS)

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ACCIDENT INVESTIGATION

(ROOT CAUSE ANALYSIS)

Department of Occupational Safety

Salina Tukimin

DOSH Selangor

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Contents

•

Overview

•

The importance of incident investigations

and getting them reported

•

Incident investigation process

•

Root cause analysis

•

Legal requirements on investigation

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Contents

•

Overview

•

and getting them reported

•

Root cause analysis

•

Conclusion

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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

.

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Meaning of Accident

An electrician was working on a machine energised by high-voltage 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

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

Example

of

accident

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.

Example

of near

miss

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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

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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

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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.

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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

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The cost of incidents

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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

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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

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Contents

•

Overview

•

Root cause analysis

•

Conclusion

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The importance of incident investigation

• 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

Key goals for incident investigations

• 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

Features of poor investigation

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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

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The importance of reporting

In order to be evaluated and investigated,

incidents must first be reported.

• 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

Encourage

reporting

• Occupational Safety and Health (Notification of Accident, Dangerous Occurrence, Occupational

Poisoning and Occupational Disease) Regulations 2004

Reporting

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Contents

•

Overview

•

Root cause analysis

•

Legal requirements on investigation

•

Conclusion

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STEPS IN CONDUCTING INVESTIGATION

Incident

Investigation

Incident investigation

To prevent recurrence

Learn about



What happen



To determine immediate and

root cause



Understand the risk



To develop preventive

measures

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STEPS IN CONDUCTING INVESTIGATION

PROPER INITIAL RESPONSE

ANALYZE CAUSES

TAKE REMEDIAL ACTIONS

MANAGEMENT REVIEW AND REPORT

GATHER INFORMATION

Report the incident

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Loss Causation Model

•

HAZOP – Hazard and Operability Study

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Cause Analysis Process

Accident

Are goals and objectives met?

Is conclusion valid

Complete Report and Action Plan SPECIFY ANALYSIS Goals Objective Working Hypothesis COLLECT EVIDENT ANALYZE EVIDENCE CONCLUSIONS OF ROOT CAUSATION NO YES

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TECHNIQUE

: CAUSATION MODEL

LACK OF CONTROL Inadequate •System •Standards •Compliance BASIC CAUSES Personal Factors Job/System Factors IMMEDIATE CAUSES INCIDENT Substandard Acts/Practices Substandard Condition Event Unintended Harm or Damage LOSS T H R E S H O L D L I M I T

Classifying information into five stages :

• Losses

• Incidents or contacts

• Immediate causes

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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

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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.

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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)

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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.

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IMMEDIATE CAUSES : Substandard Acts /

Practices and Conditions

Why ???

Why did that substandard practice occur ?

Why did that substandard condition occur ?

Why did the loss control system permit that practice

or condition ?

LOSS CAUSATION MODEL

Symptom – What to look for / What people do wrong

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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.

Explain why substandard conditions exist.

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LACK OF CONTROL

3 reasons for lack of control



inadequate program



inadequate program standards



inadequate compliance with standards

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1) inadequate program

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

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ROOT CAUSE INCIDENT BASIC CAUSE To recommend the preventive measure – eliminate the root cause Why people do wrong

To recommend active – to bring back to the correct manner / standard

Symptom – What to look for / What people do wrong

What goes wrong

Cause Analysis – to find the root cause

– to find deficiencies / gap of the system – to identify system failures, to prevent

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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.

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Safety belt, safety shoe dan safety helmet that has been used for working at tower

structure

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Falling from height 200 feets

Risk Assessment has not been done (HIRARC) INADEQUATE RISK ASSESSMENT LACK OF CONTROL IMMEDIATE CAUSES ROOT CAUSE INCIDENT LOSS Competency – experience worker die

Project cost and duration – Installation activity stopped due to investigation Legal compliance Hoisting approval Reputation-Prosecution 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

No supervision

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

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

Installation of component tower structure

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KES KEMALANGAN DI TAPAK PEMBINAAN

Summary of case:

• 3 worker death while doing plastering at 19th _{floor of building under}

construction.

•TEMPORARY WORKING PLATFORM COLLAPSED

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•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

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Reporting to

DOSH

• 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

Incident

Investigation

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Contents

•

Overview

•

Root cause analysis

•

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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

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