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would be beneficial
But we already
know what
happened
Do you really ???
5
??
The Process
The Team
Individual(s) involved in the incident
Witnesses
Supervisor of the area
Someone who can facilitate the root
cause process
Consider individuals with safety,
maintenance, operating backgrounds
to assist
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Information ...
List all facts whether they were
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INFORMATION GATHERING
Should occur as soon as possible after the incident
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The
The
The
The
The
He
She
He
Now What ?
OK,
weve assembled our team
weve collected available information
weve listed the facts
NOW WHAT ???
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Causal Factors
Behaviors
Conditions
Management Control
Why?
Why?
Why?
Why?
Why?
but WHY?
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20
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Chronic
Challenges
Chronic Challenges
Distinguishing Between Symptoms and Root Causes
Dos
Find out the whys
Show flaws in the overall
management system
IDENTIFY MANAGEMENT
SYSTEM BREAKDOWN
Correct identification of root
causes will lead to
prevention of recurrence if
appropriate corrective
actions are implemented
Get to the underlying
reasons behind the human
factors
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Donts
Do not stop at operator
Individual Factors
Change in staff
Time
Performance
Management of change
Changes to instrumentation
or equipment
Personal influences
Lack of Knowledge
(Insufficient training or
understanding of the job)
Lack of Skill
Distractions
Limitations
Some facts may be left over as they did not fit into the
sequence of events thats OK THEY SHOULD BE LISTED
OFF TO THE SIDE AS THEY MAY STILL REQUIRE AN ACTION
ITEM
Facts identified during the process that did not directly impact the incident,
but that require some corrective action may be put those on a separate list
and/or captured in your action tracking database
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The floor
was wet
Ben was
using a
utility knife
Ben stated
he did not
know about
forearm
guards
Ben stated
he was
cutting
toward
himself
3 long cut
to left
forearm
Any
others?
RULES TO REMEMBER
1.
2.
3.
DO NOT INTERPRET
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YOUR TURN
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A listing of facts
that did not
contribute to
the incident
do they need a
corrective
action?
Ben stated he
did not know
about forearm
guards
Ben stated
he cut
toward
himself
The floor
was wet
Ben was
working
alone
The knife
blade was
exposed
Ben was
using a
utility knife
30
3 long cut
to left
forearm
Ben stated he
did not know
about forearm
guards
Ben stated
he cut
toward
himself
The floor
was wet
Ben was
working
alone
The knife
blade was
exposed
Ben was
using a
utility knife
31
3 long cut
to left
forearm
TARGET
ORGANIZATION
Ben did not
know about
forearm guards
CORRECTIVE ACTIONS
BY
DATE
VLM
x/x/xx
PKL
x/x/xx
CKS x/x/xx
HUMAN
Ben cut
toward himself
MATERIAL
Ben was using
utility knife
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Look at your corrective actions and ask -If these had been in place, could the incident have
occurred?
If so, you have not identified all root causes and/or appropriate corrective
actions
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Dont Forget
Enter your investigation report into the incident
database
Enter corrective actions into your action tracking
database
Go back and see if the corrective actions have really
accomplished what they were supposed to
Communicate with your site and other Rhodia sites
so learnings can be shared
Trend your incidents and near misses they will
help identify missed opportunities with your root
cause analysis process
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