Root Cause Analysis of
Accident or Customer Critical Criteria Incident
Investigation and Corrective Actions
1. Who should Investigate Incidents and/or Accidents?
Only people with the appropriate skills and experience should investigate incidents or accidents.
If an incident or accident occurs and has resulted in serious harm, or includes the potential for it, and there is a likelihood of a recurrence, a formal group approach Root Cause Analysis investigation is justified and required.
A formal Root Cause Analysis investigation will bring a range of skills, tools and perspectives to bear in ;
Defining,
Measuring,
Analyzing,
Improving and
Controlling the recurrence of the incident or accident.
2. Gather all the facts
Describe what happened?
Interview witnesses and describe events in detail, using any photos, diagrams or other exhibits that may be appropriate.
Has the prescribed accident or incident report been completed and OSHA, or any other agencies been informed?
Be sure team understands the sequence of events fully before any analysis takes place.
3. Identify all the hazards or Customer Critical Criteria Problems involved.
Identify all the hazards or CCC problems involved. Consider:
Equipment, materials, etc.
Work practices and procedures
Work environment
Health issues
Are any hazards or Customer Critical Criteria problems significant, or are they likely to cause serious harm or damage to individuals or reputations?
4. Assess the hazard or Customer Critical Criteria controls in place?
What controls were in place, and why did not they work?
What is needed?
Is there a need to train or inform employees?
5. Decide on future action.
Describe fully what needs to be done to prevent further accidents or incidents.
Who should do what, and by when?
6. Inform all those affected.
Inform everyone who needs to know; not only those directly involved.
This is likely to involve circulating your report, or a summary of its findings.
7. Follow up.
There must be checks to ensure that recommended changes have been made and results achieved.
This relies on measures being in place to ensure people are accountable for their actions, or lack of actions.
Root Cause Analysis Investigation Procedure
Introduction
Accidents or incidents occur when hazards/problems escape detection during preventive measures, such as a job or process or safety analysis, when hazards or problems are not obvious, or as the result of combinations of circumstances that were difficult to foresee.
A thorough RCA investigation may identify previously overlooked physical, environmental, or process hazards/problems, the need for new or more extensive safety training, or other work practices exists.
The primary focus of any RCA investigation should be the determination of the facts surrounding the incident, Customer Critical Criteria problems and the lessons that can be learned to prevent future similar occurrences.
Scope and Application
All accidents or Customer Critical Criteria problems should be investigated.
The depth and complexity of the investigation will vary with the circumstances and seriousness of the accident, or Customer Critical Criteria incident.
The Supervisor or other individual responsible for operations involved in an accident or Customer Critical Criteria incident should ensure that an RCA investigation is conducted and corrective actions are taken.
Program Description
The first priority whenever an accident or Customer Critical Criteria incident occurs is to deal with the emergency and ensure either receives prompt attention.
The RCA investigation should begin immediately thereafter. This ensures that details of what occurred will be fresh in people’s minds and that witnesses do not influence one another by talking about the accident or Customer Critical Criteria incident. It also minimizes the likelihood that important evidence is not moved, lost, taken, destroyed, or thrown away before the scene has been thoroughly inspected.
Accidents and Customer Critical Criteria incidents fall into two categories, serious and non-serious.
Non-serious accidents do not cause lost workdays even though the worst that could happen did happen.
Examples of these include paper cuts, minor scratches or abrasions, or system failures that have minor consequences, such as a low-pressure hose that ruptures and sprays cool water.
Serious accidents include both those, which did involve lost workdays, and those, which might have.
This second type of serious accident is called a "near miss." Examples of near misses with serious injury potential include:
A worker twists an ankle in a fall from a low scaffold (this could easily have been a broken leg or worse);
A worker tips back in a chair and topples backward (backward falls are always serious because head injury might result);
A worker turns on a machine and gets a slight shock (shock from voltage potential greater than 75 volts DC or 40 volts AC is considered serious).
After an accident, near miss, or Customer Critical Criteria incident occurs supervisors should determine what level of investigation is needed.
All serious accidents and Customer Critical Criteria incidents, those involving lost workdays or near misses, are investigated with the same thoroughness.
Who Should Investigate
Supervisors should make their own initial investigation of all accidents or Customer Critical Criteria incidents.
When circumstances warrant (e.g. complex technical issues, chemical exposures, serious injury) a more comprehensive investigation involving other departmental staff, the Environmental Health and Safety (EHS), or other organizational offices (Public Safety, Legal Council, Risk Management, Six Sigma Team, etc.) may be conducted.
Regardless of the type of investigation, the process supervisor should be involved for the following reasons:
Supervisors have a responsibility to provide their workers with a safe and healthful workplace;
Supervisors know the workers, their work styles, and work processes better than anyone else and are in the best position to gather the facts and find a practical solution to the problem;
The supervisor’s accident or Customer Critical Criteria incident investigation can help promote better relations with workers by demonstrating concern for their safety, attention to accident or Customer Critical Criteria incident prevention.
How to Investigate
As with most other tasks, skill in conducting effective accident or Customer Critical Criteria incident investigations improves with experience.
A good basic approach is to find out what caused the accident or Customer Critical Criteria incident and what can be done to prevent or minimize the chances of a similar accident or incident occurring. Some suggestions that may help supervisors or RCA team get the facts and reach a conclusion include:
Maintain objectivity throughout the investigation.
Its purpose is to find the cause of the accident or Customer Critical Criteria incident, not to assign blame for its occurrence.
Check the accident site or Customer Critical Criteria incident circumstances thoroughly before anything is changed.
Discuss the accident with the injured person, but only after first aid or medical treatment has been given.
Discuss the Customer Critical Criteria incident with the end user, but only after through briefing from senior management.
Also talk with anyone who witnessed the accident or Customer Critical Criteria incident and those familiar with conditions immediately before and after it occurred.
Be thorough. Small details may point to the root cause.
Reconstruct the events that resulted in the accident or CCC incident, considering all possible causes.
Determine unsafe conditions or actions that separately or in combination were contributing factors.
If help is needed in determining the cause, ask for it.
EHS can provide assistance with accident investigations; Six Sigma Black/Green Belts can provide assistance with Customer Critical Criteria incidents.
What to Do with Results
Supervisors or RCA teams should act to control or eliminate the conditions that caused the accident or Customer Critical Criteria incident once these have been conclusively identified.
EHS and/or Six Sigma Root Cause Analysis Investigation team can provide assistance in determining the level of action that may be necessary, such as the following:
When equipment changes or safeguards are necessary, supervisors should discuss specific recommendations with Department management;
When an operation can be changed to eliminate the hazard, supervisors should make the change if it is within their authority, or seek the necessary approval from Department or Executive management.
If unsafe acts by workers are involved, ensure that the worker is properly trained and that training is followed. All others involved in similar operations should be trained as well.
Roles and Responsibilities
Department
Ensure accidents or Customer Critical Criteria incidents involving their operations or workers are investigated.
Ensure corrective actions are thoroughly completed.
Supervisors
Investigate accidents or Customer Critical Criteria incidents promptly and thoroughly.
Call Environmental, Health and Safety or Six Sigma Management Champions for assistance when needed.
Complete and document all corrective actions.
EHS or Six Sigma Black/Green Belts
Assist supervisors with investigations when requested.
Provide training in RCA investigation methods and techniques when requested.
Individual
Cooperate with supervisors and others during investigations.
Accident or Customer Critical Criteria Incident Investigation
Supervisors, Department Safety Coordinators, and safety committee members or Six Sigma team members:
Do you know how to conduct a thorough investigation after an accident or Customer Critical Criteria incident occurs in your department?
Are you aware that serious injuries or Customer Critical Criteria incidents require the immediate notification of Environment, Health & Safety (EH&S) or Six Sigma Teams?
Investigating accidents is not only required by law, it can also help prevent future accidents or Customer Critical Criteria incidents.
Following the steps outlined below will help you and your department complies with the law and provides a good way to improve procedures and condition to create a safer and quality work environment.
After Customer Critical Criteria Incident or Accident Occurs, there are basic steps to take following any accident which include the following:
Provide medical attention and secure the scene.
Notify all appropriate parties.
Gather information (including interviewing witnesses).
Analyze the information, identifying causes.
Prepare a report, assigning corrective actions.
Ensure all corrective actions are implemented.
Provide Immediate Attention (Medical if needed) and secure the Scene
Attending to an injured worker's medical needs is always the first priority after an accident.
Always be sure that it is safe for you to approach the victim by checking for environmental causes or other still-present dangers that may have caused the illness or injury.
After treatment of the injury has begun, secure the scene of the accident to ensure that conditions are not altered before investigators can examine them. This may mean keeping the room closed or using barricade tape or rope to keep others out of the immediate area.
Retain broken or defective equipment so it can be examined.
Take note of anyone who may have either witnessed the incident or been in the area immediately before or after the incident.
Call the Police if the accident may involve vandalism or other crimes. Police can also provide assistance in securing the area around serious accidents.
Notify All Appropriate Parties
The appropriate supervisor must be notified immediately following any accident or Customer Critical Criteria incident.
The supervisor is responsible for investigating the cause of the accident since he/she is most familiar with the hazards and precautions of the task, as well as the training and capabilities of the worker.
In addition, EH&S must be notified immediately if any of the following occurs:
Worker fatality
Inpatient hospitalization
Loss of any body part
Possible permanent disfigurement
In these cases EH&S is required to notify OSHA, who will send an inspector to the accident scene.
OSHA will expect that an investigation has begun before its representatives arrive. (Any agency inspection is independent of the business organization's inspection.)
When OSHA does arrive on the scene, be sure to contact EH&S again so that a health and safety specialist is present during the agency's investigation.
Of course, EH&S should also be notified whenever an accident investigation requires technical expertise beyond that available in the department.
In all cases, the Department Safety Coordinator and the safety committee should be notified so that they can help track the implementation of appropriate corrective actions.
EH&S can help identify and contact management, committees, or organizations that may also have an interest in the incident.
Gather Information
Familiarize yourself with the accident scene and the conditions leading up to the accident or Customer Critical Criteria incident.
Take thorough notes and make sketches or take photos or videos if appropriate.
In addition, examine documentation relevant to the people or materials involved, such as applicable instruction manuals, material safety data sheets (MSDS), and safety training records.
Interview anyone who witnessed the accident or the events before or after. Interview witnesses separately and as soon after the accident as possible.
Conduct interviews in a "neutral" setting rather than in the supervisor's office.
Maintain an impartial tone when asking questions and avoid assigning blame.
Ask open-ended questions intended to elicit detailed information rather than simple yes or no answers.
Analyze the Information
Next, analyze the information you have gathered to determine:
What was the immediate cause of the accident or Customer Critical Criteria incident?
What other (contributing) causes may have played some part in setting up the accident or Customer Critical Criteria incident?
What employee actions or workplace conditions may have led to those causes?
Were safe work procedures established, and were they adequate?
Was adequate training provided on the procedures?
Were the procedures regularly implemented and enforced?
Prepare a Report, Assigning Corrective Actions
As the next step, prepare a written Customer Critical Criteria incident or accident investigation report that details the information gathered, identifies all contributing causes, and assigns corrective actions to responsible parties for each contributing factor.
The report should not unduly assess blame but rather spell out the specific corrective measures needed to prevent similar accidents from happening.
A copy of the RCA investigation report should be shared with the Department Safety Coordinator and the safety committee, Six Sigma teams so they can track and help ensure the implementation of corrective actions.
The supervisor of an injured employee must help complete a Workers' Compensation Form, "Employer's Report of Injury."
In particular, the supervisor's input is needed to identify appropriate actions to prevent a similar injury.
An Employee Claim Form must be given to an injured employee within 24 hours.
Copies of both forms must be submitted to the NRG Energy’s Workers' Compensation Office.
Ensure All Corrective Actions Are Implemented
Finally, the supervisor or other responsible party must ensure that the corrective actions called for in the report are implemented in a timely fashion.
Department Safety Coordinators, safety committees and Six Sigma teams should periodically review recent accidents or Customer Critical Criteria incidents to verify that each has been investigated and that all corrective actions have been completed.
For assistance investigating an accident, call EH&S.
For assistance investigating a Customer Critical Criteria incident, call your Six Sigma Management Champion.
To report a serious injury call EH&S during weekdays or after hours.
Safety and Customer Critical Criteria is everyone’s business.
Safety and Customer Critical Criteria are a part of our organizations Strategic Plans. Improving safety and Customer Critical Criteria involves the efforts, costs, time, other resources, and as well the development of people, systems and procedures.
Safety and Customer Critical Criteria improvements create a safe, productive and profitable working environment for all stakeholders to enjoy the rewards of your organization's successes.
Improving safety and Customer Critical Criteria performances, training, processes, and people will assist in creating a business advantage for your organization's stakeholders.
Improving safety and Customer Critical Criteria, as a business advantage, will lend to the desired business results of your organization towards increased profitability and improved performances towards world class.
In recognition of your personal dedication to safety and our Customers Critical Criteria, your contributions, to all our Programs and Processes, (insert the name of your business here) Executive Management Teams say “Thank You”.
About the Author
Charles E. Wilson, Ph. D. is President/CEO of Lakota Training & Development. As well he owns and operates LTD Publishing and Six Sigma Doctor. Wilson is the author of several books, including "Six Sigma Deployment". He serves on TreQna Board of Directors, the Board of Directors for Brazoria County Dream Center, and has responsibility for knowledge development for TreQna University.
Dr. Wilson holds multiple degrees in Psychology. He is a motivational speaker, training facilitator, training developer, management coach, business improvement consultant, and author. Charlie has 36 years of experience in the business and coaching worlds.
Please visit http://treqnauniversity.org/default.aspx to learn more about effective and unique “blended learning” and “be able to do” skills approach for Six Sigma training.
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