Republic of the Philippines

BATANGAS STATE UNIVERSITY

Pablo Borbon Main II, Alangilan Batangas City
College of Engineering, Architecture & Fine Arts
Chemical and Food Engineering Department
www.batstate-u.edu.ph Tel. No. (043) 425-0139 loc. 118

ChE 422
Safety Management and Applications in
Process Industries

Accident/Incident Investigation

Members:
Balitaan, Jeamnard D.
Clerigo, Aikovin O.
Dalisay, Arvin Dave P.
Olivar, Kiara Lainne J.

Rhoda G. Pangan
Instructor

April 02, 2019

INTRODUCTION

Occupational Safety and Health Administration (OSHA) strongly encourages employers

to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called
"near misses"), in which a worker might have been hurt if the circumstances had been slightly
different.

In the past, the term "accident" was often used when referring to an unplanned, unwanted
event. To many, "accident" suggests an event that was random, and could not have been
prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA
suggests using the term "incident" investigation.

Important Definitions

 Incident
o A work‐related event in which an injury or ill‐health (regardless of severity) or
fatality occurred, or could have occurred.
 Root Causes
o The underlying reasons why unsafe conditions exist or if a procedure or safety rule
was not followed in a workplace. Root causes generally reflect management,
design, planning, organizational or operational failings (e.g., a damaged guard had
not been repaired; failure to use the guard was routinely overlooked by supervisors
to ensure the speed of production)
 Close Call
o An incident that could have caused serious injury or illness but did not; also called
a “near miss.”

Incident investigations

 focus on identifying and correcting root causes, not on finding fault or blame
 improve workplace morale and increase productivity by demonstrating an employer’s
commitment to a safe and healthful workplace
 often conducted by a supervisor, but to be most effective, these investigations should
include managers and employees working together, since each bring different knowledge,
understanding and perspectives to the investigation

Benefits of Incident Investigations

 Prevent future incidents (leading to accidents).

 Identify and eliminate hazards.
 Expose deficiencies in process and/or equipment.
 Reduce injury and worker compensation costs.
 Maintain worker morale.
Steps to Follow in Incident Investigation

1. Fact Finding
• Gather evidence from many sources during an investigation
• Get information from witnesses and reports as well as by observation
• Don’t try to analyze data as evidence is gathered
2. Gather Evidence
• Examine the accident scene
• Diagram the scene
• Take photographs
 • Supplement with Video
3. Gather Data
• Data includes:
– Persons involved
– Date, time, location
– Activities at time of accident
– Equipment involved
– List of witnesses
4. Review Records
• Check training records
• Check equipment maintenance records
• Check accident records
5. Documents
• Collect All Related Documents

Isolate Fact From Fiction

• Use NORMS-based analysis of information
– Not an interpretation
– Observable
– Reliable
– Measurable
– Specific
• If an item meets all five of above, it is a fact

ROOT CAUSE ANALYSIS

 allows an employer to discover the underlying or systemic, rather than the generalized
or immediate, causes of an incident
 correcting only an immediate cause may eliminate a symptom of a problem, but not the
problem itself

The Occupational Safety and Health Administration (OSHA) and the Environmental
Protection Agency (EPA) urge employers (owners and operators) to conduct a root cause analysis
following an incident or near miss at a facility. By conducting a root cause analysis and addressing
root causes, an employer may be able to substantially or completely prevent the same or a similar
incident from recurring.

How to Conduct a Root Cause Analysis

A successful root cause analysis identifies all root causes—there are often more than one.
Consider the following case:

A worker slips on a puddle of oil on the plant floor and falls.

 A traditional investigation may find the cause to be “oil spilled on the floor” with the
remedy limited to cleaning up the spill and instructing the worker to be more careful.
 A root cause analysis would reveal that the oil on the floor was merely a symptom of a
more basic, or fundamental problem in the workplace.
 An employer conducting a root cause analysis to determine whether there are systemic
reasons for an incident should ask:
– Why was the oil on the floor in the first place?
– Were there changes in conditions, processes, or the environment?
 – What is the source of the oil?
– What tasks were underway when the oil was spilled?
– Why did the oil remain on the floor?
– Why was it not cleaned up?
– How long had it been there?
– Was the spill reported?
 It is important to consider all possible “what,” “why,” and “how” questions to discover
the root cause(s) of an incident. In this case, a root cause analysis may have revealed that
the root cause of the spill was a failure to have an effective mechanical integrity program—
that includes inspection and repair— that would prevent or detect oil leaks.
 In contrast, an analysis that focused only on the immediate cause (failure to clean up the
spill) would not have prevented future incidents because there was no system to prevent,
identify, and correct leaks.

Benefits of Root Cause Analysis for Employers

 prevent similar events from happening again

 will reduce the risk of death and/or injury to workers or community
 will reduce environmental damage
 avoid unnecessary costs resulting from business interruption, emergency response and
clean-up, increased regulation, audits, inspections, and fines
 earn public trust
 attract and retain high performing staff
 more effective control of hazards
 improved process reliability
 increased revenues
 decreased production costs
 lower maintenance costs
 lower insurance premiums

Root Cause Analysis Tools

Below is a list of tools that may be used by employers to conduct a root cause analysis. The
tools are not meant to be used exclusively. Ideally, a combination of tools will be used.

• Brainstorming
• Checklists
• Logic/Event Trees
• Timelines
• Sequence Diagrams
• Causal Factor

Regardless of the combination of tools chosen, employers should use these tools to answer
four important questions:

• What happened
• How did it happen
• Why it happened
• What needs to be corrected

Interviews and review of documents, such as maintenance logs, can be used to help answer
these questions. Involving employees in the root cause investigative process, and sharing the
results of those investigations, will also go a long way toward preventing future similar incidents.
OSHA and EPA encourage employers to consult the resources below for more information about
how to use these tools.

FISHBONE DIAGRAM

 It is also called Cause-and-Effect Diagram or Ishikawa Diagram.

 Invented by Dr. Kaoru Ishikawa
 It is a root cause analysis tool that allows quick and effective root causes to be
understood, in the pursuit of corrective actions.
 It identifies many possible causes for an effect or problem.
 In this, various causes are grouped into categories and the causes cascade from the main
categories, flowing towards the effect, forming what resembles a fishbone appearance.
 Its main goal is to illustrate in a graphical way the relationship between a given outcome
and all the factors that influence this outcome.

Main Objectives of Fishbone Diagram

1. Determining the root causes of a problem.

2. Focusing on a specific issue without resorting to complaints and irrelevant discussion.
3. Identifying areas where there is a lack of data.

The prime remit is to brainstorm all the possibilities that could cause the problem and then drill
down to the factor(s) that are causing this issue. Once found, eliminate them. It enables the team
to focus on why the problem occurs, and not on the history or symptoms of the problem, or other
topics that digress from the intent of the session. It also displays a real-time ‘snap-shot’ of the
collective inputs of the team as it is updated.

When To Use A Fishbone Diagram

 When identifying possible causes for a problem.
 When a team’s thinking tends to fall into ruts.

Fishbone Diagram Procedures

1. Agree on a problem statement (effect). Draw a box around it and draw a horizontal arrow
running to it.
2. Brainstorm the major categories of causes of the problem. If this is difficult use generic
headings:
a. Methods
b. Machines (equipment)
c. People (manpower)
d. Materials
e. Measurement
f. Environment
3. Write the categories of causes as branches from the main arrow.
4. Brainstorm all the possible causes of the problem. Ask “Why does this happen?” As
each idea is given, the facilitator writes it as a branch from the appropriate category.
Causes can be written in several places if they relate to several categories.
5. Again ask “Why does this happen?” about each cause. Write sub-causes branching off the
causes. Continue to ask “Why?” and generate deeper levels of causes. Layers of branches
indicate causal relationships.
 6. When the group runs out of ideas, focus attention to places on the chart where ideas are
few.

Fishbone Diagram Example

A production line goes down for three shifts due to a failed machine. A root cause
analysis determines that the machine had multiple design issues. Such problems weren't detected
or mitigated by maintenance processes. When the machine needed to be replaced, several issues
complicated the process making the outage longer.

REFERENCES

 Safety and Health Topics | Incident Investigation | Occupational Safety and Health
Administration. (n.d.). Retrieved April 1, 2019, from
https://www.osha.gov/dcsp/products/topics/incidentinvestigation/index.html
 Determine Root Causes 4 Implement Corrective Actions United States Department of
Labor Occupational Safety and Health Administration. (n.d.). Retrieved from
https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf
 The Importance of Root Cause Analysis During Incident Investigation. (n.d.). Retrieved
from http://energy.
 What is a Fishbone Diagram? Ishikawa Cause & Effect Diagram | ASQ. (n.d.).
Retrieved April 1, 2019, from https://asq.org/quality-resources/fishbone
 4 Examples of a Fishbone Diagram - Simplicable. (n.d.). Retrieved April 1, 2019, from
https://simplicable.com/new/fishbone-diagram