2. Rev-up Your Incident Investigations John Rupp Jr

3. Analyzing Incidents Sequencing Events Cause & Effect Active Triggers Cause and Effect Charting Context & Consequence What happened whenLatent Conditions STEP Sequentially Timed Event Plotting STEP Sequentially Timed Event Plotting Effective Corrective Action

4. Session Objectives  Identify latent conditions and active triggers  Practice skills by analyzing and charting incidents  Given an incident scenario; –develop a sequence of events chart –create a cause and effect chart –identify latent conditions and active triggers  Develop an action plan to rev-up your investigations

5. A QUICK REVIEW

6.  People –Communicating –Observing  Things –Observing –Analyzing –Reading –Listening There are only two sources of information during an accident investigation

7. Mental Movie Concept

8. The first law of accident investigation states that everyone and everything is always someplace doing something during the accident.

9. INCIDENT SCENARIO

10. Fatal Incident Classification: Electrician, Journeyman Seniority Date: 3-25-93 Age: 42 years At approximately 3:16 a.m. a journeyman electrician suffered a fatal crushing injury to his head from an unguarded shear hazard. The victim was standing on the upper maintenance platform for test stand #4, looking for cracks in the structural support plate for the main hydraulic cylinder of the Lowerator system when the injury occurred.

11. Fatal Incident As he leaned in slightly to inspect the plate on the hydraulic cylinder; a relief operator assigned to continue running the test stand through lunch, cycled the machine. The relief operator was completely unaware of the victim’s presence on the upper maintenance platform. It is probable that the victim, a maintenance worker, was not aware the test stand operation would run through lunch.

12. Fatal Incident A decision made earlier in the shift by production management to run the test stands through lunch because of production problems, may not have been communicated fully to the maintenance group. Earlier in the shift, the victim had discovered a broken plate while troubleshooting a problem on test stand #5. Witness reports indicate he believed the cracked support plates posed an imminent danger to operators in the area. He had reported the condition to a maintenance supervisor but felt the response to his report was inadequate.

13. Sequencing Events What happened when STEP Sequentially Timed Event Plotting STEP Sequentially Timed Event Plotting

14. Transferring the Mental Movie

15. Sequencing Events Time 8:00 AM8:15 AM8:30 AM8:45 AM Victim Co-worker Supervisor Machine Vehicle Valve People And Things

17. 6:00 – 7:157:15 – 8:008:00 – 8:458:45 - 9:00 9:00 – 9:15 Operator 1 Operating block line.Assisted another operator fixing a gun drill. Operated the line. Went on break Found operator 2 Operator 2 (back side) (Victim) Inspecting blocks on bench, west side of line, last time seen by operator 1 between 7:00 and 7:15. Working back side job. Supervisor observed him on east side of line at 7:50. Observed by skilled trades person at 8:35 on east side of line walking near station #11959. Caught in machine during this period. Lying on floor on east side of machine Block Line Machine running normal.Machine not running. Machine operating. Machine not running.

18. INCIDENT SCENARIO Sequence of events

23. SEQUENCE EVENTS EXERCISE

26. Your Turn

28. Cause & Effect Cause and Effect Charting Effective Corrective Action

29. Step slippery Seal leaked Slipped on bottom step Hydraulic oil leaked onto step Ankle landed in awkward position Fell off machine step Wrong hydraulic fluid Employee’s sprained ankle Sort the cards into effects and causes.

30. EffectsCauses Employee’s sprained ankle CausedBy Ankle landed in awkward position CausedBy Fell off machine step CausedBy Slipped on bottom step CausedBy Step slippery CausedBy Hydraulic oil leaked onto step CausedBy Seal leaked CausedBy Wrong hydraulic fluid “When we ask why of a cause it becomes an effect.” Apollo

31. Additional Facts Carrying a tool with right hand. There were three steps. Hand rail on the right side as he was going down the steps. Steps were worn and not constructed of slip resistant material. Create a cause and effect chart using the cards provided and create additional cards as needed. You can make up facts. Examples; you can make up the type of tool, the purpose of the tool, why the tool was needed, the construction of the step.

32. Exercise 1.Sort the cards by effects and causes. 2.Arrange the cards into a cause and effect chart – from past to present. 32 If you get stuck Think “caused by”, “because”, “why”

33. Card Exercise Scenario Past to Present Sprained Ankle/Landed awkwardly, Fell off step No guard rail on left side Seal leaked Wrong Hydraulic Fluid Holding tooling in right hand Leak above steps Hints Take “baby” steps Ask “why” or say “caused by” To check causes ask “does it happen every time?” Steps worn Original Machine Design Not holding guard rail Hydraulic oil leaked onto step Not slip resistant material Step slippery Slipped on bottom step

34. INCIDENT SCENARIO Cause & Effect Chart

36. Context & Consequence Active TriggersLatent Conditions

37. Sharp End Blunt End Workers Managers Supervisors DepartmentHeads Executives Conklin & Howe Highest Influence Over System Highest Potential Risk for Failure

38. How We See Events Old View  Human error is a cause of accidents  To explain failure, investigations must seek failures of parts of systems  These investigations must find inaccurate assessments and bad decisions New View  Human error is a symptom of trouble deeper inside a system  To explain failure, do not try to find out where people went wrong  Instead, find out how peoples’ actions and assessments made sense at the time given the circumstances that surrounded them.

39. Incident Overview—B2 Op 71 Robot Automation Conveyor Automation Photo Eye Mechanical Work Stop At approximately 5:05 am an electrician responded to the andon call and discussed fault with operator. The fault indicated that the unload automation was blocked. The employee began trouble shooting the Op 71 conveyor. It was determined that the faulted switch was within the Op 71 Robot Cell. The electrician obtained entry into the robot cell, opened the gate and reached across automation conveyor filled with blocks to wipe suspect photo eye. The wiping of the photo eye triggered Op 70 to transfer blocks causing blocks to crash together and smashing employees forearm between two blocks. The picture below illustrates location of incident.

40. Why did he believe it was safe to do this task?

41. Condition Types  Active Trigger: Change in equipment, system, or process that triggers immediate undesired consequences. In other words, an active error has immediate harm and you know who did it.  Latent Condition: Result in undetected organization- related weakness or equipment flaws that lie dormant in the system.

42. INCIDENT SCENARIO Context & Consequences

43. Time Information Event What You Ask For Is What You Get The Pressure To Know.. Outweighs The Pressure To Learn.. Conklin NotifyLearn Fix

44. Its pretty simple… You can Blame & Punish Or Learn & Improve. Conklin