Incident investigation and Root Cause Analysis

Introduction to Incident Introduction to Incident Investigation & Root Cause Investigation & Root Cause

Analysis: Learning From Analysis: Learning From Experience Experience

Introduction

• Incident Investigation & NS Safety Legislation• Incident Investigation Steps• Individual and Group Activities• Action Plan • Root Cause Analysis

Prevention Through Investigation

• Preventing another incident is a key reason for investigations.

• Finding root causes of an

event means being able to

control the hazards in those

root causes • Effective incident and injury investigation means fact-

finding not fault-finding. Fix the problem not the blame! • Importance of ‘near miss’ investigation

• What do you investigate now?

• How?

• For every incident, do you know who was involved, what happened, how and why it happened?

• Are there any repeat incidents or near misses?

• Are all members of your workforce familiar with past incidents so that they might recognize and avoid the same situations?

In Your Environment

Investigating Incident/Injury• Time sensitive• Objective and clear• Analyzes potential for harm, even where actual

harm was less• Investigates near-misses, asks “What if?”• Fact-finding, not fault-finding• Makes recommendations and plans for change• Implement and Evaluate• Communicates!

Under what circumstances, when and how must you notify the OHS Division of an incident in your workplace?

,

NS OH&S Act• Nova Scotia Labour and Workforce Development

24 hour notice:– workplace incident resulting in death – explosion involving injuries or not.

• 7 days written notice:– a fire resulting in injury– an incident resulting in serious injury – Examples: unconsciousness; loss of substantial blood;

fractures; amputation; major burns; loss of sight; any life threatening injury).

NS OHS Act• S. 28 Program Requirements

• S. 63 ‘Notice of Accidents at the Workplace’- Serious bodily injury- Accidental explosion- Fatality

• S. 64 ‘Disturbance of Accident Scene’• S. 65 ‘Duty to Disclose Accident Information’

No person shall disturb the scene of an incident that results in serious injury or death except to:

• attend to persons injured or killed;

• prevent further injuries; or

• protect property that is endangered as a result of the incident.

Except as directed by an officer

N.S. OH&S Act

The Bad Thing happens. What’s next?

• Report the event to a designated person (usually supervisor first).

• Provide first aid and medical care to injured person(s); prevent further injuries or damage.

• Investigate to identify the causes. • Report the findings. • Develop a plan for corrective action. • Implement plan and then evaluate the

effectiveness of the plan.

Investigation Steps

• The investigation steps are simple: gather information, analyze it, draw conclusions, make recommendations, evaluate planning and implementation of recommendations.

• An open objective mind is necessary.

• Preconceived notions can lead us down the wrong path, leaving significant observations and facts uncovered.

Collect Data

There are two main types of evidence:

• physical evidence such as ….

• documentary such as….

• Physical evidence should be gathered as witnesses are being interviewed.

• Be thorough and inquisitive when collecting evidence but do not contaminate it.

Collect Data

• Need to interview client and/or worker sooner rather than later. Why?

• Interview as soon as possible after.

Interview

Do... put the worker at ease; emphasize reason for the investigation (what

happened and why); let the worker talk, listen carefully; confirm understanding of statements; make short notes only during the interview.

Data Collection Interviewing:

•“Tell me what you were doing at the time.” •“Tell me what you saw, and/or what you heard.” •“Describe the conditions (weather, housekeeping, light, noise, etc.) at the time.”

Interviewing: Ask open-ended questions...

• Most incidents are multi-causal even when they seem straight forward! • Was the worker trained? If not, why not?• Was the worker distracted? If yes, why was the

worker distracted? • Was a safe work procedure being followed? If not,

why not? • Were safety devices in order? If not, why not?

Need to reveal conditions that are open to correction rather than attempts to prevent "carelessness".

Analyzing Facts

• Look for supporting facts in:• People • Equipment• Materials• Environment

Analyzing contributing factors

Before During After

PeopleStaff arriving for work 30 minutes early

7:30am Slipped on ice, breaking wrist

Additional staff attended to injured party, called ambulance

EquipmentSalt spreading equipment available

not used Salt spread

Materials Salt available not used Salt effective in controlling hazard

EnvironmentIce on parking lot,Cold weather;Lighting poor (before sunrise)

same as before

Temperature higher, salt effective, sunrise brightened area

Processes Maintenance not on until 8:00am

Called in early to control situation

Shift changed to have one member of crew arrive ½ hour early to salt and one to stay ½ hour later

BrokenWrist Fall

IcySurface

Incident Investigation

No Salt

Worker’s Statement

BrokenWrist Fall

IcySurface


No Salt

Worker’s Statement

BrokenWrist Fall

IcySurface

ImproperWinter

Footwear

Rushing

No Salt

Victim Statement

Observation

Observation

Observation

Witness Statement

Victim StatementObservation


BrokenWrist Fall

IcySurface

ImproperWinter

Footwear

Rushing LateFor work

FashionChoice

No Salt

FearOf

Penalty

PersonnelOff

TempDroppedVictim

StatementObservation

VictimStatement

Observation

VictimStatement

Interview


Final Analysis• Each conclusion should be checked to

see if: • it is supported by evidence • the evidence is direct (physical or documentary) • based on eyewitness accounts• Not based on assumptions!

Many models• ISO 9001 Corrective Action• Six Sigma DMAIC• PLAN-Do-Check-Act(PDCA)

• DO IT2 problem solving model (10 step model)– Focus on getting the problem statement right– This model fits the PDCA-more in-depth on the plan

• Steps 1-7 PLAN• Step 8 DO• Step 9 CHECK• Step 10 ACT

DO IT2…Root Cause Analysis( the core of problem solving and corrective actions) Duke Okes 2009

Root Cause Analysis

Find it(cause of the problem)Diagnostic phase1. Define the problem2. Understand the process3. Identify possible causes4. Collect the data5. Analyze the data

Fix it(cause of problem)Solution phase6. Identify possible solution7. Select solution(s)8. Implement the solution(s)9. Evaluate the effect(s)10. Institutionalize the change

DO IT2

Problem statement

Find it(cause of the problem)Diagnostic phase1. Define the problem2. Understand the process3. Identify possible causes4. Collect the data5. Analyze the data

Fix it(cause of problem)Solution phase6. Identify possible solution7. Select solution(s)8. Implement the solution(s)9. Evaluate the effect(s)10. Institutionalize the change

DO IT2

10

“ A problem well stated is a problem half solved” Former GM executive Charles Kettering

THE PROBLEM STATEMENTWHAT: a description of what happened

WHERE: where specifically the problem was found

WHO: If the problem directly affected an individual or a group of people , “who’’ often becomes an expansion of or replaces for , “where”

WHEN: when the problem was first found or began

HOW MUCH: the frequency and/or magnitude of the problem


Step 1: Define the Problem

Understanding the process is all about stepping back and taking a broad view of the problem before jumping to possible causes.

SETTING PROCESS BOUNDARIES• Keep it internal to your organization• What’s logical from a relative timing perspective?

FLOWCHARTING THE PROCESS• Flowcharting can be constructed to understand steps between them

WHY IS PROCESS SO IMPORTANT• There is a prescribed or natural time order in which things get done, where something is

transferred from one step to another . When the out put of the process isn’t satisfactory(objective not met),something probably went wrong within the process.


Step 2: Understanding the Process

Here are some reasons processes fail:

• If there are no defined standards for how the process is to be carried out , people will do what they perceive as necessary or sufficient .

• The process definition is incorrect.

• Sometimes the process definition is not followed.


Step 2: Understanding the Process

Understanding the process(Step2)provides problem solvers with a broad view of the system that has failed.

Step 3 is then about identifying what factors are more or less likely to have caused the problem.

3 APPROACHES FOR IDENTIFING POSSIBLE CAUSES:• Treat each step of the flowchart as a possible cause• Use a logic tree (why-why)to identify possible causes• Brainstorm a list of possible causes


Step 3: Identify Possible Causes

Use a logic tree (why-why)to identify possible causes


Step 3: Identify Possible Causes

The basic steps for data collection involve the following:1. Knowing what theories are to be tested, that is, what cause and affect

relationship are to be evaluated? This is the purpose of Step 3.

2. Knowing what variable are involved and where they can be or should be measured

3. Knowing what form the data will be in and deciding when and how they should be gathered

4. Predicting what form the data will be in and deciding when and how they should be gathered

5. Preparing for and carrying the data collection process.


Step 4: Collect Data

The basic steps for data analysis include the following:

1.Being clear about the theory to be tested and the data acquired(step 4) to test it

2.Predicting what the data would look like if the theory were true

3.Analyzing and interpreting the data to see whether they support or deny the theory being tested

4.Considering other conclusions the data might support, other ways to slice the same data, and other data that might confirm or deny the same conclusion


Step 5:Analyze the Data

In Step 5 we have identified what has failed now we identify possible solutions

Techniques• Scale up or scale down• Mind maps• What would X Do?• No limits( brainstorming)• Mistake proofing• Benchmarking


Step 6: Identify possible Solution

Now that you have your list of possible solutions.

Two major issues to be considered relative to the decision-making process:

1) Who should make the decision?

2) What criteria should be used to make it?


Step 7: Identify and Select Solution

There is no one correct method, but it will instead depend on the particular situation;

1) Who should make the decision?a) Autonomous-makes the decision on the basis of what he or she knows and/or believes to be

bestb) Consultative-makes the decision, but only after first getting inputs from other who may have

knowledge about the situationc) Consensus-shares the decision-making process equally with knowledge of or responsibility for

the change.

2) Issues that impact which approach is best includes the following:a) How much knowledge does the individual have relative to others who might be involved?b) How much time is available for making the decision? That is how critical is it to take action

quicklyc) How much will lack of input impact willingness of others to support the change?



1) What criteria should be used to make it?

Typical criteria include the following:•Potential technical gains to be achieved, such as reduction in errors, improvement of throughput, and so forth

•Financial return such as benefit/cost ratio or payback period

•How long will it take

•How well will it fit in to the organizational system and culture



Finding a good solution is one thing, but effectively implementing it is another

Implementation calls for management of three knowledge areas:• Technology• Project management• Organizational change management

-How well will it fit in to the organizational system and culture


Step 8: Implement the solution(s)

Taking action without checking to see whether the process improvement worked is like shooting in the dark.

During the follow-up you need to check two things:• To see whether performance of the process is back to what is

normal or expected

• Check to ensure that the changes have been properly implemented


Step 9: Evaluative the effects

Some ways of doing this are as follows:• Make it impossible to do it the old way• Include adoption of change as a component of personnel evaluation• Revise the reward system to include consideration of flexibility• Have personnel who work in changed process assess the degree of

success and then report on the successes, difficulties and perceived barriers

• Shape organizational culture and norms to support the change


Step 10: Institutionalize the change

The key reasons people resist change:• People are familiar and often comfortable with the way things are• They fear change they believe might negative impact them• The process of change is poorly managed by organization

• Everett Rodgers(1995) classified people into 5 groups• 1)innovators• 2) early adopters• 3)early majority• 4) late majority• 5)laggards


Resistance to change

Questions

Incident investigation and Root Cause Analysis

Healthcare

logic tree

basic steps

diagnostic

investigation

broad view

corrective

select solution

worker distracted