Accident Investigation
Root Cause Analysis
Root Cause Analysis
Objectives
• Identify three consistent and
systematic approaches to
investigating workplace
accidents.
• Understand how to apply
these approaches to a
workplace accident
investigation.
Root Cause Analysis
Overview
Data Collection
Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Data Collection
•Interviews
•Photographs
•Equipment Specs.
Data
Collection
•Equipment Manuals
Event Charting
•Safety Rules Change Causal Factor Barrier
Analysis Analysis Analysis
•Training Records Root Cause ID
Recommendations
Root Cause Analysis
Event Charting
•Organizes collected data
for analysis
•Sequence diagram
Data
Collection
•May uncover needs for
Event Charting
additional data collection
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Event Charting
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen
Mary uses Mary Fire Mary
FE throws
fire ext. fails spreads calls
water on 911
fire Data
Collection
Kitchen Event Charting
Fire FD puts out destroyed
department fire Change Causal Factor Barrier
arrives Smoke damage Analysis Analysis Analysis
throughout
restaurant Root Cause ID
Recommendations
Root Cause Analysis
Event Charting
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen
Mary sees FE not Grease
fire charged fire
Mary uses Mary Fire Mary Data
FE throws
fire ext. spreads calls Collection
fails water on 911
fire Event Charting
Kitchen Change Causal Factor Barrier
destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
Root Cause Analysis
Causal Factor Analysis
Casual Factors:
1. Direct Cause: Immediate
event/ condition that caused
accident)
2. Contributing Cause: Data
Event/condition that increased Collection
probability or severity of the Event Charting
accident
Change Causal Factor Barrier
3. Root Cause: Event/condition Analysis Analysis Analysis
that, if corrected, will prevent Root Cause ID
recurrence
Recommendations
Root Cause Analysis
Causal Factor Analysis
Potential Causal Factors:
• Lack of awareness
• Lack of safe work practices
• Lack of adherence/enforcement Data
to safe work practices Collection
• Improper/inadequate Event Charting
equipment/materials Change Causal Factor Barrier
• Improper/inadequate design Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Causal Factor Analysis
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen
Mary sees FE not Grease
fire charged fire
Mary Data
Mary uses FE Fire Mary
throws Collection
fire ext. fails spreads calls
water on
911
fire Event Charting
Kitchen Change Causal Factor Barrier
destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
Root Cause Analysis
Change Analysis
Used to identify deviations from
the norm
• “What happened” vs. “What
should have happened”
Data
• Used mostly when operations Collection
and standardized Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Change Analysis
Common Changes and Differences:
• Personnel
• Plant
• Hardware Data
• Procedures Collection
• Managerial Controls Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Change Analysis
Phone
rings in Grease AL pan Arcing Electric
front of ignites on melts heats pan burner
restaurant burner shorts out
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen
Mary sees FE
FE not
not Grease
fire charged
charged fire
Mary Data
Mary uses FE Fire Mary
throws Collection
fire ext. fails spreads calls
water on
911
fire Event Charting
Kitchen Change Causal Factor Barrier
destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
Root Cause Analysis
Barrier Analysis
Basic premise is that there is a
flow of energy associated with
all accidents
– Kinetic
– Potential
– Electric Data
Collection
– Thermal
Event Charting
– Steam
– Pressure Change Causal Factor Barrier
Analysis Analysis Analysis
Barriers are placed to reduce the
Root Cause ID
energy from people, property,
environment. Recommendations
Root Cause Analysis
Barrier Analysis
Barrier Categories:
• Equipment
• Design
• Administration (procedures Data
processes) Collection
• Supervisory/Management Event Charting
• Warning Devices Change Causal Factor Barrier
Analysis Analysis Analysis
• Knowledge and Skills
Root Cause ID
Recommendations
Root Cause Analysis
Barrier Analysis
Phone
rings in Grease
Greaseon AL pan Arcing Electric
front of ignites
burneron melts heats pan burner
restaurant ignites
burner shorts out
Mary Mary Fire Smoke Mary
starts leaves alarm enters
starts
cooking kitchen sounds kitchen
Mary sees FE not Grease
fire charged fire
Mary Mary Data
Mary uses FE Fire
fire ext. throws spreads calls Collection
fails water on 911
fire Event Charting
Kitchen Change Causal Factor Barrier
destroyed Analysis Analysis Analysis
Fire FD puts out
department fire
arrives Smoke damage Root Cause ID
throughout
restaurant Recommendations
Root Cause Analysis
Root Cause Identification
Root causes
– Derived from the facts
and analysis conducted
– Should answer two Data
Collection
questions: Event Charting
1. What happened? Change Causal Factor Barrier
Analysis Analysis Analysis
2. Why it happened?
Root Cause ID
Recommendations
Root Cause Analysis
Root Cause Identification
• Root causes should identify
reasons for each casual factor
identified by the analysis.
• Root causes which can not be
Data
completely supported by fact Collection
should identified in the report.
Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Root Cause Identification
• Unattended stove
– Facility design less than adequate
– Lack of operational policy
• Heating element failure Data
Collection
– Lack of preventative maintenance Event Charting
program
Change Causal Factor Barrier
– Facility design less than adequate Analysis Analysis Analysis
(auto-suppression system) Root Cause ID
Recommendations
Root Cause Analysis
Root Cause Identification
• Fire Extinguisher failure
– Inadequate inspection program
• Water on grease fire
Data
– Inadequate training (abnormal events) Collection
Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Recommendations
Identify the corrective actions for each
cause.
Ensure the corrective action is viable by
answering:
• Will the corrective action prevent Data
recurrence? Collection
• Is the corrective action feasible? Event Charting
• Does the corrective action introduce Change Causal Factor Barrier
Analysis Analysis Analysis
new hazards/risks?
Root Cause ID
Recommendations
Root Cause Analysis
Recommendations
• What are the consequences of
not implementing the
recommendations?
• What time frame is adequate to
Data
implement the Collection
recommendations?
Event Charting
• Is the implementation of the
Change Causal Factor Barrier
recommendations measurable? Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Recommendations - Direct/Contributing Cause #1
• Unattended stove
RC #1: Facility design less than
adequate
RC #2: Lack of operation policy
• Install phone in kitchen Data
Collection
• Implement policy that hot oil is never
left unattended (any other Event Charting
operations?)
• Modify procedure development Change Causal Factor Barrier
Analysis Analysis Analysis
process to identify and address
potential emergencies and hazards
(JSA). Root Cause ID
Recommendations
Root Cause Analysis
Recommendations - Direct/Contributing Cause #2
• Heating element failure
RC #3: Lack of preventative maintenance
program
• Develop preventative maintenance strategy
to periodically replace burner elements. Data
RC #4: Facility design less than adequate Collection
(auto-suppression system)
Event Charting
• Consider alternative preparation methods
(baking) or alternative equipment (gas Change Causal Factor Barrier
stove). Consider additional hazards these Analysis Analysis Analysis
my introduce.
• Install commercial kitchen fire suppression Root Cause ID
system per building code.
Recommendations
Root Cause Analysis
Recommendations - Direct/Contributing Cause #3
• Fire Extinguisher failure
RC #5: Inadequate inspection program
• Refill/replace extinguisher.
• Inspect all extinguishers
Data
monthly/annually. Collection
• Report incidences using extinguishers to
owner to trigger refilling (training). Event Charting
Change Causal Factor Barrier
Analysis Analysis Analysis
Root Cause ID
Recommendations
Root Cause Analysis
Recommendations - Direct/Contributing Cause #4
• Water on grease fire
RC #7: Inadequate training
• Review training program for
adequacy (contingency plan in case
of extinguisher failure). Data
Collection
• Provide hands-on training on fire
extinguishers. Event Charting
• Review other skill-based activities Change Causal Factor Barrier
to ensure level of hands-on training Analysis Analysis Analysis
is adequate.
Root Cause ID
Recommendations
Root Cause Analysis
Objectives
• Identify three consistent and
systematic approaches to
investigating workplace
accidents.
• Understand how to apply
these approaches to a
workplace accident
investigation.
