1. OSHE 421 Measurement of Safety Performance and Accident Investigation/Analysis Spring Semester, 2016
Instructor: Mr. Chris Kuiper, CSP

2. 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

3. 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

4. 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

5. 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

6. 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

7. The Five M’s

8. 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

9. 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

10. 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 

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

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

20. 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

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