1. Beyond the Root Cause Brian Price CH2M HILL – Trigon February 6, 2009

2. Beyond the Root Cause  Description of the Incident  Incident Analysis Process Results  Digging Deeper – Why?  Areas of Concern  Target Zero  Conclusion

3. Description of the Incident  December 18 th – Snow, cold  Shutdown job – Crews had left and the project team was getting ready to go  Inspector left the trailer and fell down the steps  Circumstances  Factors in incident

4. Incident Analysis Process Results  Conducted the Analysis using a top down flow chart  Participation, good discussion, and obtained a root cause  Poor Judgment  Information gathering to look closer as to the why

5. Digging Deeper – Why?  Why the poor judgment?  What about the others in the room?  What caused the actions that generated the incident?  Look into our safety culture for answers of what went wrong  Once identified what are we going to do about it?

6. Areas of Concern  We came up with four keys to the why 1.Individual Commitment to eliminating injuries, incidents, environmental impacts and errors/omissions. This commitment involves every employee Taking Responsibility for their Own Behavior and for every employee around them. 2.Everyone, Everywhere, Always: every employee and subcontractors — at home, at play, in offices, on project sites, and the world we live in. 3.Instill a mind set where People Believe any level, frequency or severity of injury, negative environmental impact or work error is preventable. 4.Seek Continual Improvement by evaluating the causes, implementing corrective actions, learning from our mistakes

7. Safety Philosophy - Target Zero Target Zero is a goal to work towards every day. Target Zero culture is based on Individual Commitment to eliminating injuries, incidents, environmental impacts and errors/omissions. This commitment involves every employee Taking Responsibility for their Own Behavior and for every employee around them. It applies to Everyone Everywhere Always : everyone in the firm, at home, offices, project sites and the world we live in. When an incident does occur we seek Continual Improvement by evaluating the causes, implementing corrective actions, learning from our mistakes and re-aiming on Target Zero. Every day Target Zero is achieved is another day towards achieving World-class Performance.

8. Safety Philosophy - Target Zero Defined by beliefs, values and behaviors Consistent among all employees. A Value, not a priority. A Commitment, not a goal. A mind set where People Believe any level, frequency or severity of injury, negative environmental impact or work error is preventable. A philosophy focused on people having Intrinsic Worth for who they are as much as for what they do. ∙About Relationships, not just statistics. A person behaving in at at-risk manner is not a confrontation to avoid, rather an Opportunity to Share concern, learn, coach and build relationships.

9. Conclusion  We as safety professionals must find the ways to improve our company’s safety performance  Looking beyond the root cause can help to make those improvements  The culture of a company can influence the incident rates and other incidents  Target Zero is our philosophy – yours is probably similar – use your company beliefs to question the why – Even before an incident occurs