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
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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