Root Cause Analysis Systems Safety Technique used to identify the “Root Causes” of accidents A root cause is the most basic cause for a accident that can.

Slides:



Advertisements
Similar presentations
Accident and Incident Investigation
Advertisements

Accidents: Review & Investigation Basics. It is important that you check with your Comprehensive Loss Control Coordinator, Human Resources, and Supervisor.
Root Cause Analysis Workshop Pima Medical Institute, Albuquerque, New Mexico Friday; May 18, 2007; 8:30 am.
Incident Reporting and Investigation College of Engineering Team 2: Joseph Duffy, Andrew Sullentrop and Zlatko Sokolikj March 29, 2013 Revised April 2,
Integration of Quality Into Accident Investigation Processes ASQ Columbia Basin Section 614 John Cornelison January 2008.
Introduction to effective Incident/Accident Analysis
Accident Investigation: The “3W” Process Gary D. Braman, CSP Sikorsky Aircraft Corporation A Presentation to the Tennessee Valley Chapter American Society.
Accident Investigation State of Florida Loss Prevention Program.
Modern Techniques of Accident Investigation C.Jayasuriya, S.V.Karthikeyan and S.E.Kannan IGCARKalpakkam.
Incident Investigation. An incident is any unplanned event that results in personal injury or in property damage The failure of people, equipment, supplies,
ACCIDENT INVESTIGATION
SIM5102 Software Evaluation
Bureau of Workers’ Comp PA Training for Health & Safety (PATHS)
ACCIDENT INVESTIGATION
Root Cause Analysis: Why? Why? Why?
Accident Investigation.
ACCIDENT AND INCIDENT INVESTIGATION
How to Implement, Process and Administer the Preventive Action Process
Research Studies Involving Witness Reliability How reliable are eye witness accounts of an activity? – Investigators often rely on information provided.
Data Management Grade 7. What’s the Story? Secondary data is information that was collected by someone else. Referring to information that was published.
CS499 Use Cases References From Alistair Cockburn Writing Effective Use Cases (Book) - Use Case.
Accident InvestigationSlide 1 The Basics of Accident Investigation.
Presented by Joe Angyus, CSP October 7, 2009 Easy Incident & Accident Investigations.
Guidance Notes on the Investigation of Marine Incidents
Procedures for Assessing Risks Chapter 13 – Event and Causal Factor Charting.
Worker Focused Safety Program Violence in the Workplace Worker Training Module 5.
FAULT TREE ANALYSIS (FTA). QUANTITATIVE RISK ANALYSIS Some of the commonly used quantitative risk assessment methods are; 1.Fault tree analysis (FTA)
Chapter 10 Analyzing Content: Historical, Secondary, and Content Analysis, and Crime Mapping.
11th International Symposium Loss Prevention 2004 Prague Ľudovít JELEMENSKÝ Department of Chemical and Biochemical Engineering, STU BRATISLAVA, SLOVAKIA.
A Use Case Primer 1. The Benefits of Use Cases  Compared to traditional methods, use cases are easy to write and to read.  Use cases force the developers.
CBM Optimization – Complex items An item is a group of components that is convenient to monitor and analyze together Equipment units, as defined in the.
Investigating Investigation Methodologies By Ludwig Benner Jr © 2003 by Starline Software Ltd.
sharif university of technology industrial engineering Safety at work (Accident Investigation) Razieh shoeleh Roya mohamad ali poor fall2006.
Experimental Design and Implementation Honors Biology.
Scientific Investigation. Terms Problem – The question Materials – A list of everything you need Hypothesis – Your guess at the answer to the problem.
Scientific Method. What is the scientific method? It is a process that is used to find answers to questions about the world around us.
SERIOUS ACCIDENT INVESTIGATION TEAM INTRO BRIEFING.
Types of Research: General categories. The general types: 1. Analytical –Historical –Philosophical –Research synthesis (meta-analysis) 2. Descriptive.
WHAT IF ANALYSIS USED TO IDENTIFY HAZARDS HAZARDOUS EVENTS
Why Similar Accidents Keep Duplicating Themselves Prevent Recurrence of The Goal: Prevent Recurrence of Similar Accidents and Injuries.
EFFECTIVE INVESTIGATIONS  DESCRIBE WHAT HAPPENED  IDENTIFY CAUSE OF INCIDENT  IDENTIFY CONTROLS  DEFINE TRENDS  DEMONSTRATE CONCERNS.
REL103; Slide 1 Introduction to FMECA n What is a FMECA? –An Analysis technique which facilitates the identification of potential design problems.
SCIENTIFIC METHOD SNC 1D MRS. ROOT. WHAT IS THE SCIENTIFIC METHOD? It is a process that is used to find answers to questions about the world around us.
Work Place Committees and Health and Safety Representatives Training Module 4 - HAZARDOUS OCCURRENCE INVESTIGATION AND REPORTING.
EFFECTIVE ACCIDENT/INCIDENT INVESTIGATION 15 FEBRUARY 2013 PHILIPPINE ASSOCIATION OF SAFETY ENGINEERS -QATAR- -QATAR- COMMITTEE ON SAFETY EDUCATION 2013.
© BLR ® —Business & Legal Resources 1501 Accident Investigation.
Accident analysis One-hour training.
Version 1.0, May 2015 BASIC PROFESSIONAL TRAINING COURSE Module XX Regulatory control Case Study This material was prepared by the IAEA and co-funded by.
ACCIDENT INVESTIGATION PRESENTATION
Accident Analysis 1.
Root Cause Analysis Roger Brauninger
People and Culture Office Safety, Health and Wellbeing
Motor Vehicle incident Investigation
Causal Analysis & Resolution (CAR) Support Category
Multilinear Events Sequencing
ROOT CAUSE ANALYSIS RCA
Circle Map Objective Question: Bio: How did a virus get to Riverton?
PENYEBAB INSIDEN RCA2.
Practicum: Root Cause Analysis
ACCIDENT INVESTIGATION PRESENTATION
Director, Quality and Accreditation
People and Culture Office Safety, Health and Wellbeing
Root Cause Analysis: Why? Why? Why?
Introduction to FMECA What is a FMECA?
What is History? It’s an investigation. It can include whole cultures, countries or just an individual.
What is History? It’s an investigation. It can include whole cultures, countries or just an individual.
Accident Investigation
BASIC PROFESSIONAL TRAINING COURSE Module XX Regulatory control Case Study Version 1.0, May 2015 This material was prepared by the IAEA and.
Accident Investigation.
What is History? It’s an investigation. It can include whole cultures, countries or just an individual.
Presentation transcript:

Root Cause Analysis Systems Safety Technique used to identify the “Root Causes” of accidents A root cause is the most basic cause for a accident that can be identified. Effective recommendations can be made to fix the problem.

Root Cause Analysis Process Determine what happened in a particular accident Determine how it happened Determine why it happened

Steps in the process Accident occurs Collect evidence Analyze information Identify root causes Develop recommendations

Data to collect People Physical evidence Position (location of people and physical evidence) Paper

Causal Factor Charting Determine: Loss events: what prompted the need for the investigation Primary events: Actions leading up to the loss event Secondary event: Actions or happenings that led to the primary events Conditions: Circumstances pertinent to the loss event

Causal Factor Charting Develop building blocks Identify actions or conditions One actor and one verb Time of the events or conditions Location

Identifying Causal Factors With the events charted out, identify the causal factors Causal factors are those contributors (both human actions and component failures) that if eliminated, would have prevented the occurrence or reduced its severity.

Root Cause Levels Root Cause Map used to identify the root causes

Levels of the Root Cause Map Primary Difficulty Source Equipment, People, or Other Problem Categories Equipment Reliability Root Cause Category Admin, Procedures, Training, etc. Near Root Cause Circle items Root Causes Bottom level

Using the Root Cause Map Map is read from the top down May be used multiple times with one accident Depends upon the number of root causes Shape next to descriptor represents the map level Numbers in the shapes represent the page number in the book.

Using the Root Cause Map Start with the causal factor Determine the Primary Difficulty Source Determine the problem category Determine Root Cause Category Any root cause category may be analyzed under each Problem Category (Except Equipment Design) Determine Root Causes

Developing Recommendations For each node (Root cause box), typical recommendations are provided to offset that particular root cause.

Summarizing Findings of Root Cause Analysis Set up a table with 3 columns Column #1: Description of the causal factor Column #2: Paths through the Root Cause map Column #3: Recommendations