OSHE 421 Measurement of Safety Performance and Accident Investigation/Analysis Spring Semester, 2016 Instructor: Mr. Chris Kuiper, CSP Email: august.kuiper@selu.edu 985-549-3751

Incident Investigation Techniques Investigation aimed at prevention, not fault finding Various analytical techniques available, e.g., 5 Why MORT TOR Tap Root Root Cause Analysis Hartford Process Fish Bone or Ishikawa Diagram TOP-SET

Which Technique to Use? Easy to use in the field by non-experts Consistently good root cause identification Well documented Supported by effective user training Credible with the workforce – no finger pointing Helpful presenting results to management Designed to allow collection, comparison and measurement of root cause trends

Definitions Investigation – detailed, systematic study to discover who, what, where, when, why and how Analysis – method to arrange facts Inference – probable facts based on actual facts

Definitions Judgment – formal opinion – just remember, everything you say can and will be used … Recommendation – corrective actions believed applicable to correct the root cause(s) CSR’s – Codes, Standards and Regulations Error – deviation from a required or expected standard of performance

Sequence of Events Domino theory Multiple causation theory Ancestry/social environment Fault or person Unsafe act Unsafe condition Injury Multiple causation theory Things have to come together at the right time and place to result in an incident

The Five M’s

Inferential Conclusions Consider information that may not be fully documented and “infer” conclusions Positive and negative evidence and conclusions Conclusion reached through reasoning Inductive process Everyone at the location wears safety glasses; so the injured person was wearing safety glasses

Hartford Procedure Equipment Material People Select Select Select Arrange Place Place Use Handle Train Maintain Process Lead Ask why, what, where, when, who and how of each item under the headings Develop corrective actions

5 Why Technique Used to screen level of detail investigation requires Five is general guideline to reach the root cause level Key is to find and fix recurring problems by addressing true causes - not symptoms 

Categories Select Categories to Study: People Policies Procedures Processes Machinery Materials Environment (facilities, weather, noise, lighting, etc.) Technology

5 Why Start asking questions about the incident following each category Ask “why” as many times as required to get to the root cause as agreed by the investigation team

Management Oversight and Risk Tree (MORT) Uses diagrams and charts Premise - damage to property or injury to persons must have a hazard, a target, and some barrier that usually separates the hazard and the target Results of technical incident analysis using MORT analysis identified average of 38 factors per mishap

Management Oversight and Risk Tree (MORT) Mishap – unwanted transfer of energy that produces injury, damage, process degradation and unwanted losses Based on the concept losses arise from: Job oversights and omissions Management system factors Assumed risk – properly evaluated – is not accidental

MORT Diagrams Logic tree starting with the mishap Uses and/or “gates” Less than adequate – LTA Intense process – best used as analytical tool with facts from the incident site

MORT Diagrams Experienced analyst can complete less serious cases in 20-30 minutes Highly complicated processes at least 4 hours “Mini-MORT” Deductive or inductive process?

Fishbone–Cause and Effect Diagram First list the problem/issue in the “head” of the fish Label each fish bone with major categories Repeat procedure with each factor to produce sub-factors Ask “Why is this happening” and put additional segments under each sub-factor

Taproot If the investigator becomes a witness at trial – work product privilege waived and the investigator may be deposed and subpoenaed Expert witness can pay well but must be qualified by education, experience or both Credible in presentation Correct is answers Clear in content Concise – answer the question, don’t pontificate Candid – natural, sincere and honest

Agency Reporting Consumer Product Safety Act Medical Devices Act Fails to comply with applicable product safety rule Defect creates substantial product hazard to public Immediately notify CPSC Medical Devices Act Failure of medical device requires investigation and written record submitted

Agency Reporting Occupational Safety and Health Act Recordkeeping and reporting as discussed in Lecture 1 slides