The most common analysis methods are:
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Transcript The most common analysis methods are:
Objectives
Students will be able
to:
Differentiate between
Surface and Root
Causes
Define Change
Analysis, Barrier
Analysis, MORT,
Kepner-Tregoe
Problem Solving and
Decision Making.
Identifying Causes of
Accidents
Surface vs. Root Causes
Surface causes are:
the hazardous conditions or unsafe work practices
that directly or indirectly contributed to the accident.
Root causes are:
the safety or loss control system weaknesses that
allow the existence of hazardous conditions and
unsafe work practices.
Most accident investigations only identify the surface
causes of accidents.
Major Concept tonight
Investigation
Methodical
Analytical
Systematic process
Events and Causal Factor
Analysis
Events and Causal Factor Analysis identifies
the time sequence of a series of tasks and/or
actions and the surrounding conditions
leading to an occurrence.
The results are displayed in an Events and
Causal Factor chart that gives a picture of the
relationships of the events and causal factors.
Example charts
http://www.docstoc.com/docs/43977209/Even
t-and-Causal-Factor-Chart
Participation opportunity
Name some “Surface Causes.”
Name some “Root Causes”
Change Analysis
(DOE SSDC-4 1983)
Change Analysis is used when the problem is
obscure.
It is a systematic process that is generally
used for a single occurrence and focuses on
elements that have changed.
Example: worker comes in early and starts
work therefore didn’t get a safety briefing
Barrier Analysis
(DOE SSD-4 1983)
systematic process that can be used to
identify physical, administrative, and
procedural barriers or controls that should
have prevented the occurrence.
Barrier Defined: A construct between a
hazard and a target, intended to prevent
undesired effects to the target
http://www.bill-wilson.net/b52.html
Management Oversight and Risk
Tree (MORT) Analysis
MORT and Mini-MORT are used to identify
inadequacies in barriers/controls, specific
barrier and support functions, and
management functions.
It identifies specific factors relating to an
occurrence and identifies the management
factors that permitted these factors to exist.
(Vincoli, p.190)
Human Performance Evaluation
Human Performance Evaluation identifies
those factors that influence task
performance.
The focus of this analysis method is on
operability, work environment, and
management factors.
Man-machine interface studies to improve
performance take precedence over
disciplinary measures.
Kepner-Tregoe Problem
Solving and Decision Making
management consulting firm
systematic framework for gathering, organizing,
and evaluating information and applies to all
phases of the occurrence investigation process.
Phases:
Situation appraisal: Identify concerns
Problem analysis: Define the problem (Similar to Change
Analysis)
Decision Analysis: Evaluate alternatives, assess risks
Potential Problem Analysis: What new problems may be
introduced by the alternatives?
http://www.kepner-tregoe.com/AboutKT/AboutKT.cfm
Accident Investigation
Process
The accident investigation process involves the
following steps:
Report the accident occurrence to a designated person
within the organization
Provide first aid and medical care to injured person(s) and
prevent further injuries or damage
Investigate the accident
Identify the causes
Report the findings
Develop a plan for corrective action
Implement the plan
Evaluate the effectiveness of the corrective action
Make changes for continuous improvement
Participation Opportunity
How do you evaluate
the effectiveness of
any of your programs?
Retrospective Investigations
Retrospective investigations are accident
investigations that look back in time at a
situation. Most investigations conducted in
the workplace can be classified as a
retrospective investigation.
Statistical Investigations
Statistical investigations utilize data collected
over a period of time to determine causes and
develop prevention measures.
Statistical investigations utilize mathematical
techniques that identify the causes for
accidents in terms of statistical probabilities.
Give some examples
from your organization
of statistical
investigations (post
accident)
Large Loss Investigations
in-depth investigations directed at an accident
that resulted in a larger than usual loss of life,
money, or property damage.
Examples of large loss investigations include
large industrial fires, plant explosions, and
airplane crashes
Chemical Safety Board
http://www.youtube.com/watch?v=ob7OM3v5zXo&list=UUXIkr0SRTnZO4_QpZozvC
CA&index=1&feature=plcp
Systems Investigations
Systems investigations utilize a systems
approach to the identification of causal
factors.
There are a variety of systems investigation
techniques available including root cause
analysis, Fault Tree Analysis (FTA), and Failure
Modes and Effects analysis (FMEA).
Conclusions
Differentiate between Surface and Root
Causes
Define Change Analysis, Barrier Analysis,
MORT, Kepner-Tregoe Problem Solving and
Decision Making
Questions?
Sources
http://www.hss.energy.gov/sesa/analysis/orps/taskgroup/HPI_
Investigation_Slides_for_EFCOG.pdf
Los Alamos Human Performance Investigations
training (informative)
http://www.kepner-tregoe.com/NewsArtPub/InTheMedia.cfm
Additional reading
http://fmea-fmeca.com/how-is-fmea-done.html
How to conduct FMEA