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Tool Box Talks: TBT 11 ROOT CAUSE ANALYSIS PRESENTERS’ NOTES

AIMS: The aims of this Tool Box Talk are to (1) raise the participants’ awareness of the need for Root Cause Analysis and appropriate Corrective / Preventative Actions when dealing with accidents / incidents / near misses / process failures etc by (2) explaining how to carry out effective investigations; and (3) how to deal with the outcome(s) of investigations through the development and implementation of appropriate controls and corrective and preventative actions.

OBJECTIVES: at the end of this presentation the participants will (1) know and understand the how to carry out investigations including Root Cause Analysis to identify problems / potential problems; (2) know and understand how to develop corrective / preventative actions and (3) be able implement and review corrective / preventative actions to reduce / prevent root cause(s) of hazards / problems.

AFTER EACH SLIDE / PAGE ASK FOR QUESTIONS / QUERIES / COMMENTS.IF APPROPRIATE, FEED THESE BACK TO ENVIRONMENTAL MANAGER / H&S

MANAGER

NOTE: Obviously in the aftermath of a serious “adverse event”, dealing with casualties or environmental problems must take priority over investigation of the “adverse event” – refer to Hills’ Emergency Procedures. This tool box talk deals with the investigation that follows such an event.

PRESENTER NB: You must also be familiar with Hills’ procedures for dealing with emergency situations and the documentation and software used for

reporting and investigation accidents, incidents, RIDDOR requirements, “near-misses” (“near-hits”), environmental accidents/incidents, reporting to the EA

etc (see References at the end of this TBT11 guide).

1. INTRODUCTION: ROOT CAUSE ANALYSIS FOR PROBLEM SOLVING

“ADVERSE EVENTS” are the various problems / hazards may arise from an accident or incident; nonconforming output or product; process problems; environmental problems; customer complaint; failure to achieve targets or goals.

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In all of these situations the problems / hazards may be actual, potential or generated perhaps by mechanical failure / human error / possibly even sabotage. Typically, work-related problems are likely to be one or a mixture of the following:

A. Accident / Incident / Near-miss (Near-hit)B. NonconformityC. Process ProblemsD. Environmental ProblemsE. Complaints F. Missed Targets/Goals

In Root Cause Analysis we are looking for fundamental problems / hazards that in some way interfere with a smooth, productive operations and processes. Typically these root causes will be health and safety related or environmental in nature or a process problem or human error – or a combination of these! In production processes these may be “log jams” / “bottlenecks” or “pinch points” that interfere with the process.

PRESENTER: for each of the problems, have the group suggest examples.

A. ACCIDENT / INCIDENT / NEAR-MISS / NEAR-HIT

These are perhaps the most commonly encountered problems. They are responsible for enormous costs to individuals and to industry. The aim of carrying out risk assessments and imposing controls is, of course, to minimise these impacts.

B. NONCONFORMITY

For example: excessive contamination of an input or output of a process.

C. PROCESS PROBLEMS

For example: jams on belts on production lines.

D. ENVIRONMENTAL PROBLEMS



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These will include nuisance risks and potentially licence / permit non-conformance. Commonly: noise, dust, mud, odours, vermin, flies.



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E. COMPLAINTS / SUGGESTIONS

Although complaints are most likely to arise from the public, the work force must also be listened to and they should be encouraged to make suggestions to improve processes / procedures.

F. MISSED TARGETS / GOALS

These are of particular importance when they affect compliance with contracts and our ability to fulfil contract specifications and requirements.

In all cases, the aim must be to scientifically analyse the causes of the problems / hazards with a view to identifying their origin or origins. Data / information on causes must be gathered and confirmed then possible solutions developed and tested.

2. HOW TO CARRY OUT INVESTIGATIONS

The HSE document “Investigating Accidents and Incidents” (HSG245) sets out in considerable detail how to go about getting to the root cause of problems and how to develop control measures. The full document can be downloaded from the internet (see references).

The guide explains all steps in detail and provides case studies, proformas and worked examples to assist investigators. It suggests a 4-step approach (the steps are summarised in this Tool Box Talk).

A. Gathering the informationB. Analysing the informationC. Identifying risk control measuresD. The action plan and its implementation

These 4-stages are further broken down into 24 activities – the 24 point HSE numbering system is used in their forms. This Tool Box Talk looks at the various stages required to carry out a successful investigation of an “adverse event”.

All 24 activities are listed at the end of this document.



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3. GATHERING INFORMATION/THE INVESTIGATION

The aims must be to determine (1) Immediate Causes (agent / tool / equipment / substance); (2) Underlying Causes (unsafe acts / unsafe conditions); (3) Root Causes (the underlying reason (or reasons) for the problem / adverse event).

Obviously it is important to begin gathering information as soon as possible after the adverse event so that witnesses’ memories are as fresh as possible. However, priority must be given controlling the adverse effects of the event (for example, tending to casualties and minimising environmental pollution).

It is important to realise that in the event of a serious accident or environmental incident the “Adverse Event” may become the subject of an investigation by the Health and Safety Executive and/or the Environmental Agency.

In very serious cases criminal prosecution may be brought by these governmental bodies against the company directors and personnel.

In cases of personal injury or damage to property, the company may be pursued for damages and that may involve civil prosecution of the company directors and personnel. It is therefore crucial that you make sure that that investigations are

carried out and documented correctly.

A. The investigation teamB. What happened?C. Where and when did it happen?D. Why did it happen?E. Who was involved?

A. THE INVESTIGATION TEAM

For relatively simple Adverse Events only a small team (or perhaps just one person) is required to carry out the investigation. However, in a large organisation it is common to find experienced specialists who will carry out the investigation with the assistance of departmental supervisors or managers. In smaller organisations the investigation is likely to be carried out by departmental supervisors or managers. In Hills the Health and Safety Manager and the Environmental Manager are central in these roles.



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(PRESENTER: ask the group what qualities they think are important in an investigator).

The make-up of the team has a profound effect on the likelihood of the true facts being found and the fundamental Root Cause being established. Required qualities in team members include: their objectivity; their observational, analytical and investigation skills; their experiences; their personalities; their honesty; their fairness; and the trust of both management and employees.

Depending on the organisation, employee representatives and/or union representatives are very likely to be involved.

B. WHAT HAPPENED?

If serious adverse events happen that involve injury, ill health or environmental pollution and these must be clearly described by the investigators as it is quite possible that later legal proceedings may occur.

The early stages of the investigation must concentrate on information gathering and the investigators must keep an open mind. The investigators should try to avoid becoming prejudiced in this early step in the investigation process. When questioning witnesses or victims it is extremely important to avoid bias and to allow witnesses and victims to explain what happened in their own words.

Listening skills are very important in this and it must be remembered that the people giving information are more likely to give accurate information if they do not feel under pressure or that they are being judged. Remember, at this stage of the investigation the emphasis must be on information gathering rather than on formal interrogation or on apportioning blame (if this is necessary, it happens at the Analysis stage that occurs later).

The investigators must make notes and, if possible, write down statements word for word and/or use audio recording. You can ask witnesses to sign and date every page of their statements.

Photographic evidence is, of course, extremely valuable.



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C. WERE AND WHEN DID IT HAPPEN?

Try to establish a timeline leading up to the adverse event and also what followed afterwards. Again, this must be written down at the time.

Photographic evidence is extremely useful to record the scene.

D. WHY & HOW DID IT HAPPEN?

At the information gathering stage these questions are asked to find out if there has been, for example, plant or equipment failure, infrastructure problems, actions taken or not taken by employees.

In simple adverse events it may be possible to say immediately why the event occurred. However, in more serious events the question “why” should be postponed until Analysis of the event is carried out.

E. WHO WAS INVOLVED?

A list of everybody who was directly affected by the adverse event and all the witnesses of the adverse event is needed.

Where exactly everybody was at the time of the event is also of importance.

4. ANALYSING THE INFORMATION

A. Systematic analysis of causes and consequencesB. What information is missing?C. Immediate causesD. Root causes

A. SYSTEMATICS ANALYSIS CAUSES AND CONSEQUENCES

Analysing the event involves the team working through information gathered at the time of the adverse event and reconciling witness statements and other data. The earlier questions are applied to the information gathered: what happened; where and when did it happen; why and how did it happen; who was involved.



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The question “why?” is asked over and over again (and answers noted) in the team meeting until the immediate causes and underlying or root causes are determined.

B. WHAT INFORMATION IS MISSING?

It may be found at evidence and information is not sufficient, there may be gaps that need to be filled. In this case it may be necessary to go back to personnel affected by the adverse event and any witnesses to question them further - remembering the importance of listening as opposed to interrogation that may make people defensive and less likely to give comprehensive information.

C. IMMEDIATE CAUSES

The immediate causes may be as obvious as equipment failure or human failure. However, the question “why?” must be asked until it is discovered why the failure occurred.

D. ROOT CAUSES

The root causes are those that underlie the immediate causes, for example, why did the equipment fail; what caused that human failure.

PRESENTER: see what examples the participants have (some are included in the HSE document),

5. LIKELY RESULTS OF THE ANALYSIS

The outcome of the analysis to discover contributory factors is likely to reveal one or more of the following:-

A. Job factorsB. Human factorsC. Human failingsD. Organisational factorsE. Plant and equipment factors



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A. JOB FACTORS

These may include the level of attention needed to do the job; distractions; poorly defined procedures; lack of time.

B. HUMAN FACTORS

Human factors may include(i) the individual’s physical abilities (size and strength, possible illness, pregnancy); (ii) their competence to do the job (their knowledge, skills and experience); (iii) fatigue; (iv) stress; (v) morale; (vi) alcohol or drugs.

C. HUMAN FAILINGS

“Human failings” (errors and violations) may include:(i) skill-based errors/slip or lapse of memory(ii) mistakes or errors of judgement – perhaps they apply the wrong rule or have insufficient knowledge to deal with an unfamiliar situation(iii) violations – breaking rules, perhaps to save time(iv) malicious damage or sabotage

D. ORGANISATIONAL FACTORS

Organisational factors may include:(i) the pressure of work, working long hours;(ii) having the right resources;(iii) having the correct supervision(iv) the organisation’s health and safety culture

E. PLANT AND EQUIPMENT FACTORS

Plant and equipment factors may include:(i) difficult or poorly labelled controls;(ii) is it well designed to prevent errors;(iii) is the



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6. IDENTIFYING RISK CONTROL MEASURES

The reasons for the immediate causes and the root causes form the basis of the risk control measures and will result in an action plan by which the control measures will be implemented – the action plan will also specify who will implement the control measures.

A. Draw up a list of possible control measuresB. Evaluate each of the possible control measuresC. Prioritise the possible control measuresD. Have similar adverse events happen beforeE. Can the control measures be applied elsewhere

A. DRAW UP A LIST OF POSSIBLE CONTROL MEASURES

The analysis should have identified failures that occurred in existing control measures. New, alternative control measures must now be listed.

B. EVALUATED EACH OF THE POSSIBLE CONTROL MEASURES

The possible control measures should be evaluated to determine which are likely to be the most effective in preventing re-occurrence of the adverse event. Also the ease of implementation can be determined. Time and cost considerations may also be taken into account.

C. PRIORITISE THE POSSIBLE CONTROL MEASURES

Prioritise the possible control measures in the following order:(ii) elimination of the risk (e.g. new system / different procedure)(ii) combating the risk (e.g. guards)(iii) minimising the risk (training, PPE)

D. HAVE SIMILAR ADVERSE EVENTS HAPPEN BEFORE?

If a similar adverse event has happened before then why have control measures failed again? This is particularly relevant when investigating near-miss / near-hit.



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E. CAN THE CONTROL MEASURES BE APPLIED ELSEWHERE?

It may be possible to recognise that the control measures could apply elsewhere in the organisation. In which case effective reporting and communication is the key to helping others.

7. THE ACTION PLAN AND ITS IMPLEMENTATION

Senior management must ensure that the action plan is implemented and hold to account those who are responsible for its implementation. It is usual for the action plan to have SMART objectives (Simple, Measurable, Agreed, Realistic, Timescales). In considering the SMART objectives the following three questions must be answered

(i) What is essential to securing the health and safety of the workforce today?(ii) What cannot be left until another day?(iii) How high is the risk to employees if this risk control measure is not

implemented immediately?

A. Who is involved?B. SMART objectivesC. Risk assessments updateD. Safe working procedures updateE. Full recording and analysisF. Further investigations

A. WHO IS INVOLVED?

A senior manager or director should bear overall responsibility for monitoring the actions of the implementation team. The team should be led by a senior manager who has authority for decision-making involved in the implementation. The implementation team is also likely to include company safety professionals, departmental managers and/or supervisors, employees and their representatives (perhaps union representatives).

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The action plan should have SMART objectives (Specific, Measurable, Agreed, Realistic, Timescales).

C. RISK ASSESSMENTS UPDATE

The action plan is likely to include a review of the relevant risk assessments to ensure that they are suitable and sufficient. This applies to both health and safety risk assessments and environmental risk assessments.

D. SAFE WORKING PROCEDURES UPDATE

The action plan is likely to include a review of the relevant safe working procedures to ensure that they are suitable and sufficient.

E. FULL RECORDING AND ANALYSIS

In addition to RIDDOR requirements or Environmental Agency notifications it is important to make sure that they adverse event analysis and action plans are properly documented and recorded.

F. FURTHER INVESTIGATIONS

The investigation may identify trends common causes of adverse events. In this case the action plan may highlight the need the further investigations

8. COMMON PROBLEMS IN RCA INVESTIGATIONS

PRESENTER: ask the participants what they think are the main problems in carrying out successful investigations (Root Cause Analysis).

In a “learning culture”, investigations and the outcomes should result in ongoing improvements. In contrast, in a “blame culture” it is likely that it will be harder get to the root cause. So, because the root cause is not defined (or therefore controlled), the same problems will repeatedly occur.

A. Inexperienced investigatorsB. Defensive/forgetful employeesC. Failure to find the immediate cause(s)



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D. Failure to find the root cause(s)E. Unable to find / devise a solution

A. INEXPERIENCED INVESTIGATORS

Obviously experience can only be gained by undertaking adverse event investigations – learning by undertaking training and by carrying out investigations alongside a mentor are the obvious ways to develop the necessary skills.

Investigators must have the correct skill-set including analytical skills, objectivity, honesty, trustworthiness, reliability,

B. DEFENSIVE EMPLOYEES

In a “blame culture” it is likely that those affected by the adverse event and witnesses of it will tend to be defensive or evasive. They may well edit or lie over their version of events in an attempt to reduce any blame to them or their colleagues.

In a “learning culture” the emphasis is on finding out the root causes of the adverse event and preventing its repetition.

Or, it may simply be that the individual is confused and may have “false memories” or perhaps, they simply cannot remember what happened.

C. FAILURE TO FIND THE IMMEDIATE CAUSE(S)

If it is difficult to obtain information about the adverse event and it may not be possible to determine immediate cause(s). If this happens then the root cause will not be found. However, experienced investigators may be able to guess “in all probability” what happened.

D. FAILURE TO FIND THE ROOT CAUSE

It is not always possible to find the root cause an adverse event. This may be due to inexperienced investigators or defensive employees or the loss or destruction of evidence – or other factors. In this event it may be possible to agree a probable root cause and to devise plans to prevent re-occurrence.



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E. UNABLE TO FIND/DEVISE AND SOLUTION

It may be that the investigators, having found the root cause of an adverse event, cannot agree an appropriate solution to prevent its re-occurrence. Such problems may arise because investigators are locked into one thought process for example, “but there shouldn’t be a problem, we’ve always done it this way”, or, they may simply be looking for a scapegoat and don’t investigate deeply enough.

In the circumstances “lateral thinking” or “thinking outside the box” or “brainstorming” can be used. Ultimately, it may be necessary to bring in other personnel/specialist consultants or investigators.

9. REVISION:

NOTE TO PRESENTER: YOU MUST FEED BACK FINDINGS / PROBLEMS IDENTIFIED / PARTICIPANTS’ PARTICULAR CONCERNS ETC ON SPILLS MANAGEMENT TO THE ENVIRONMENTAL MANAGER

1. Root cause analysis for problem solving2. How to carry out investigations3. Gathering information/the investigations4. Analysing the information5. Likely results of the analysis6. Identifying risk control measures7. The action plan and its implementation8. Common problems in RCA investigations

REFERENCES:

HILLS’ PHILOSOPHY: IMPROVEMENT; ENGAGEMENT; PREVENTION; ACCOUNTABILITY; PROGRESSIVE; FRONT FOOT; ROLES AND

RESPONSIBILITIES

HSE Investigating Accidents and Incidents: http://books.hse.gov.uk/hse/public/saleproduct.jsf?catalogueCode=9780717628278

HSE Latest workplace health and safety statistics: www.hse.gov.uk/statistics/index.htm



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HSE RIDDOR 2103: http://www.hse.gov.uk/riddor/what-must-i-report.htm

HSE Management of Health and Safety at Work Regulations 1999: http://www.hse.gov.uk/pubns/books/l21.htm

ALSO SEE HILLS’ PROCEDURES:

Quality of management core procedure 7 – control of non-conforming product

Environmental management core procedure 11 – EMS 4.5.3 non-conformance, corrective and preventative action.

Hills Emergency Procedure

THE FOLLOWING ARE THE HSE’s 24 ACTIONS (+ 3 ADMINISTRATION ACTIONS) FOR CARRYING OUT INVESTIGATIONS OF AN “ADVERSE EVENT”

STEP 1: INFORMATION GATHERING

1. Where and when did the adverse events happen?2. Who was injured/suffered ill health or was otherwise involved with the adverse

event?3. How did the adverse events happen? (Note any equipment involved).4. What activities were being carried out at the time?5. Was there anything unusual or different about the working conditions?6. Whether adequate safe working procedures and where they being followed?7. What injuries or ill health effects, if any, were cause?8. If there was an injury, how did it occur and what caused it?9. Was the risk known? If so, why wasn’t it controlled? If not, why not?10.Did the organisation and arrangement of the work influence the adverse

event?11.Was maintenance and cleaning sufficient? If not, explain why not.12.Where the people involved competence unsuitable?13.To the workplace layout influence the adverse event?14.To the nature or shape of the materials influence the adverse event?15.Did difficulties using the Plant and equipment to influence the adverse event?16.Was the safety equipment sufficient?



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17.Did the other conditions influence the adverse event?

STEP 2: ANALYSING THE INFORMATION

18.What were the immediate, underlying and root causes?



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STEP 3: IDENTIFYING SUITABLE RISK CONTROL MEASURES

19.What risk control measures are needed/recommended?20.Do similar risks exist elsewhere? If so, what and where?21.Have similar adverse events happen before? Give details.

4. THE RISK CONTROL ACTION PLAN AND ITS IMPLEMENTATION

22.Which risk control measures should be implemented in the long and short term?

23.Which risk assessments in safe working procedures need to be reviewed and updated?

24.Have the details of the adverse event and the investigation findings been recorded and analysed? Are there any trends or common causes which suggest the need for further investigation? What do the adverse event cost?

25.Signed on behalf of the investigation team.26.Members of the investigation team.27.The findings of this investigation need to be communicated to the following

managers, union and employee safety representatives.



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