Transcript The most common analysis methods are:

IDENTIFYING CAUSES OF ACCIDENTS
Surface vs. Root Causes
 Surface causes are:
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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.
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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.
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CHANGE ANALYSIS
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.
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BARRIER ANALYSIS
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Barrier Analysis is a systematic process that can
be used to identify physical, administrative, and
procedural barriers or controls that should have
prevented the occurrence.
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.
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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.
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KEPNER-TREGOE PROBLEM SOLVING AND
DECISION MAKING
Kepner-Tregoe is a management consulting firm
 Kepner-Tregoe provides a systematic framework
for gathering, organizing, and evaluating
information and applies to all phases of the
occurrence investigation process.
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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?
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ACCIDENT INVESTIGATION PROCESS
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The accident investigation process involves the
following steps:
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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
RETROSPECTIVE INVESTIGATIONS
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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.
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LARGE LOSS INVESTIGATIONS
Large loss investigations are considered 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
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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).
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HUMAN ERROR AND ACCIDENT
MANAGEMENT
Human Error and Accident Management offers
means and ways to recognize and prevent these
behaviors.
 Provides for a means to control and recover from
these behaviors when they do occur and to
contain and escape from their adverse.
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ACCIDENTS AND HUMAN ERRORS
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Human error is the cause of accidents
To explain a failure, you look for a failure
 You must find people's inaccurate assessments,
wrong decisions, and bad judgments
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Human error is a symptom of trouble deeper
inside a system
To explain failure, do not try to find where people
went wrong
 Instead, find how people's assessments and actions
made sense at the time, given the circumstances that
surrounded them
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TYPES OF HUMAN ERRORS
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Random versus Systemic Errors
What’s the difference?
 Is one type easier to control than the other?
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ACTIVE ERRORS
Active errors become very visible in the evolution
of an event.
 The active errors are also the most obvious
occurrences and the most rapidly identified
human contributors in an accident.
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LATENT ERRORS
The higher in the organization these latent errors
are made, the more serious the consequences at
the front line operation.
 Latent errors of strategic nature, such as
defining company policies affect safety attitudes
and the safety culture in the organization.
 The most serious and dangerous errors to be
tackled.
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ACCIDENT INVESTIGATION PROCESS
What are some ways you as an investigator can
identify human errors as they contribute to the
accident sequence?
 Are human errors the root causes for accidents?
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Why or why not?
HUMAN ERROR AND ACCIDENT
INVESTIGATIONS
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As an accident investigator, what role does your
knowledge about human error play in your
investigation process?
QUESTIONS FOR PROBING THE REASONS FOR
EVENTS THAT APPEAR TO BE CAUSED BY
HUMAN ERROR
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WAS THE POSSIBILITY OF THE ERROR KNOWN? *
WERE THE POTENTIAL CONSEQUENCES OF THE ERROR KNOWN? *
WHAT ABOUT THE ACTIVITY MADE IT PRONE TO THE OCCURRENCE OF
THE ERROR?
WHAT ABOUT THE SITUATION CONTRIBUTED TO THE CREATION OF THE
ERROR?
WAS THERE AN OPPORTUNITY TO PREVENT THE ERROR PRIOR TO IT'S
OCCURRENCE? *
ONCE THE ERROR WAS COMMITTED, WAS THERE ANY WAY TO RECOVER
FROM IT? *
WHAT ABOUT THE SYSTEM SUSTAINED THE ERROR INSTEAD OF
TERMINATING IT?
WHAT FED THE ERROR, AND DROVE IT TO BECOME A BIGGER PROBLEM?
WHAT MADE THE CONSEQUENCES AS BAD AS THEY WERE?
WHAT (IF ANYTHING) KEPT THE CONSEQUENCES FROM BEING WORSE?
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* IF YES, WHY DID THE EVENT PROCEED BEYOND THIS POINT? IF NO, WHY
NOT?