Environmental

INCIDENT INVESTIGATION: SECTION 6.2 OF 210

In Chapter 3, "Innovations in Serious Injury and Fatality Prevention," comments were made about analyses of over 1800 incident investigation reports to assess their quality, with an emphasis on contributing and causal factors. It was also said that the gap between established procedures on incident investigation and what actually takes place can be enormous. Even in the best safety management systems, the quality of incident investigation can be substantially less than adequate. For example, in a very large organization, it was agreed-that if the safety staff promoted adoption of a system as uncomplicated as the Five Why Technique to improve incident investigation and the organization achieved a B + grade in two years, a huge step forward would have· been taken.

Safety professionals are encouraged to make internal evaluations of the quality of incident investigation to establish a database from which improvements can be proposed. But they should be aware that such evaluations often indicate that culture problems exist. They may find that it.had become accepted practice for supervisors, ~anagement personnel above the .supervisor level, and. safety ·professionals to sign-off on shallow investigation reports, indicating that they, were acceptable. • . In my studies I observed that safety professionals would better serve their clients' lllterests if they:

• Viewed incident inve~tigation as. a pote~tial source f~r 1

selepting the improve- ~~Ilts .that should be made in ,safety management systems. Because-if incident inve&tigation is done well, the reality of , the technical and organizational

!ec0nd Editionty ;1<:nagement: Focusing on ZJO and Serious Injury Prevention, 2014 John W'l red A. Manuele.

1 ey & Sons, Inc. Published 2014 by John Wiley & .Sons, Inc.

441

442 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

methods of operation and cultural causal factors for incidents and expos that result in serious injuries and illnesses will be revealed. Ures

• Sought to have incident investigation given a much higher place within all of th elements of a safety managemen_t system .. Because-~e ~u~ity of inciden~ investigation is a principal marker m evaluating an orgamzation s safety culture.

To provide an information base for safety professionals who choose to promote improvement in the incident investigation process, in this chapter we:

• Discuss the incident investigation provisions in ZlO • Comment on the cultural difficulties facing safety professionals who try to have

incident investigations improved if an organization has condoned a low quality of incident investigation

• Promote having compassion for supervisors • Explain why supervisors who complete incident investigations may be reluctant

to record the reality of contributing and causal factors • Discuss why supervisors may not be adequately qualified to make thorough

incident investigations • Suggest studies of needs and opportunities and courses of action for improvement . . • Comment on incident investigation forms • Promote use of the Five Why System . , • Make observations on selected resources

INCIDENT INVESTIGATION PROVISIONS IN Z10

The requirements for incident investigation are set forth concisely in Section 6.2 of ZlO. They are contained in one paragraph with no subsections. To fulfill the standard's requirements:

Organizations shall establish processes to report, investigate and analyze inci- dents in order to address occupational health and safety management system non-conformances and other .factors that. may •be causing. or contributing to · the occurrence of incidents. The investigations shall be performed in a timely manner.

That is the whole of it-one brief paragraph on incident investigation sets forth the requirements for this very important subject. It might seem that this safetY management process is dealt with too briefly. On the other hand, within an AN!~ management system standard, all that needs to be said is said. Advisory comments incident investigation are more extensive. They say that:

• Incidents should be viewed as possible symptoms of problems in the occupational health and safety management system.

THE POSITION IN WH ICH SUPERVISORS ARE PLACED 443

. to identify and correct hazards and system deficiencies before goal 1s , 'fhe • . ts oecur. . . . .

jnc1den bows that incident mvestlgahons should be begun as soon as • f;1'perience s

practical: tigations should be used for root-cause anaiysis to identify system ·dent inves 1 · d · 1 · · · • Jnc1 deficiencies for deve opmg an imp ementmg corrective action plans.

or otber 1 arned from investigations are to be fed back into the planning and 1 .,55ons e , i.,v • action processes.

Orrecuve C I

LE EXPLANATIONS FOR INCIDENT INVESTIGATIONS pOSSGISooNE POORLY SEIN ,

studies of incident investigation reports, oq a sc~le of 10, with 10 being best, In IDY ·es were given scores ranging from 2 to 8, with an average of 5.7, and that comparucould be a stretch. These relatively poor scores were troubling and prompted ~ve~ge into situations that exist in the investigation process that might be barriers to :~;'th determinl\tions of contributing factors and why this important safety

anagement function is ofte_n done ~uperficially. m Typically, first-line supervisors are given the responsibility to initiate an incident investigation report. It is presumed. that they are clos~st to the work and they know more of the details regarding what has occurred.

1 ran a Five Why exercise to examine the incident investigation process to try to determine why there was such a huge gap betw.een. procedures adopted regarding incident investigation and what actually takes place. As the Five Why exercise proceeded, it became apparent that our model is flawed on several counts.

THE POSITION IN WHICH SUPERVISORS ARE PLACED

When supervisors complete incident investigations, they are being asked to write performance reviews on themselves and on the people to whom they report-all the way up to the board of directors. · - · · h It is understandable that supervisors would tend to avoid expounding on their own

8 oncomings. The supervisor probably would not write:

accident occurred in my area of supervision and I take full responsibility ;r

1 kt. 1 overlooked .. ~. I should have done .... My boss did not forward the

or order ~0 · , . . , . _1 ' r repairs I sent him two months ago .... It is not su · · · , ·

in the rpnsmg that supervisors would be reluctant 'to write about shortcomings , manageme t .

s1bJe, If s . n systems for which the people to whom they report are respon- relationsh~Pervisors do write ·about such systems· shortcomings, adverse personnel

ips could 'result. 1 , •

444 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

(fi t-line employees) and incident causation, Jame With respect to operators rs s Reason wrote in Human Error that: '

. th · 1· nstigator of an accident, operators tend to be the Rather than bemg e mam • • • . . f d 1:ects created by poor design, mcorrect mstallation mhentors o system ei, · . . . . • •

. d bad management dec1s10ns. Therr part 1s usually that of faul~y mthamfit_enalance h to a lethal brew whose ingredients have already been adding e n garms long in the cooking." (p. 173)

Supervisors are one step above line empl?yees. They_ als~ work in a "l~thal brew whose ingredient~ have .. alrea~y been long m the coo~ng. They have httle or no influence on the original design of operations and work systems and are hampered in being able to have major changes made in them. ·

In some organizations, the procedure is to have a team of t~o or three investigate certain accidents, such as all OSHA recordables. Then, if the team consists of fellow supervisors, the team is expected to write a performance appraisal on the supervisor for the area' in which the accident occurred, and that supervisor's boss, and her boss-all the way up to the board of directors.

It is not difficult to understand that supervisors would· be averse to criticizing another supervisor and management personnel above the supervisor's level. At every level of management above the line supervisor, it would a:lso be normal to try to avoid being factually critical of themselves. Self-preservation dominates at all levels.

CULTURAL IMPLICATIONS THAT ENCOURAGE GOOD INCIDENT INVESTIGATIONS

In some organizations, senior management insists on being informed of the factors contributing to an accident and that reports be factual. An example follows.

In a company where management is fact -based and sincere when they say that tbey want t? ~ow_ about the contributing factors for accidents regardless of where the respons1b11ity bes a special · ti" · · · ' · · ·

. . • mves gation procedure 1s m place for serious mJunes and fatalities. , . · Management recognized th t ·t d"ffi ·

1:actual · ti" • a 1

was 1 icult for leaders at all levels to complet~ 1 ' mves gation reports that b · · facilitator serv~s as the investi · ~ay e C~tical ~f themselves. Thus, an independent edgeable people serve on th/:tlon and discussion team leader. At least five. knowl- report is expected. earn. All members of the team know that a factual

It is known that the CEO reads th complete, and sees that the eo le e reports, ask~ questions to a~&ure th~t they are conclusion all of the recorn .... p dp : who repprt · to him. or her resolve to a proper h . uuuen ations mad Th , . . et ~tions that the organizati , e. us, the CEO demonstrates by his or

improvem~n.t.. on 8

-cu1t4re requires fact determination and continual In some compan · · . · · ·

• ies, .Incident inv t" · . will not tolerate other than . . ,y~ igatic;:>n, is <Jone Well because the safety culture

superior perform . . al " ance. In the studies made of the qu ity

cuLTURAL IMPLICATIONS THAT MAY IMPEDE GOOD INCIDENT INVESTIGATIONS 445

. ns some companies scored 8 out of a possible 1 o (M th tigauo • f be' h d • ore an one f jnves accused me o mg a ar marker.) . o director . . ~s:

1 afetY ..-.panies, the positive sw.ety cu ture is driven by the senior ti' s those co 1 .u b d f di execu ves,

111 ·nstances, by the oar o rectors. At those levels incident e . . 0111e 1 • xpenence .~d 111 s ed d personnel are held accountable for results . .., .. w an f . .

is rev1e le of the absence o an mterest m safety by executives and the b d f exantP d . . . oar o

t,.n d how that absence was tume mto positive and active leadershi &ectors ~the article "Building a Better Safety Vehicle: Leadership-Driven C~ltcan und 1n ,, bl' h d . th ure be

O General Motors pu ts e 10 e January 2005 issue of 'Professional

change;~ authors were Patrick Frazee and Steven Simon. Excerpts follow. safety,

. ulture change at GM was driven from the top and realized through the safety·~ent and engagement of the leadership at every level. What follows is conuntry of how this was accomplished. Paul O'Neill chair at Alcoa J"oined the the sto . . . . ' , M board of directors m 1993. His commitment to worker safety was key to

~e dramatic ~around at Alco~, where he not only improved safety, but also generated quanufia?ledbotthom-hnthe results. So perhaps GM's directors should ot have been surpnse w en, as ey prepared to adjourn the first board meet-

~ng O'Neill attended, he asked, "Where's the safety report?" There was none. 0'Neill's question-and its exposure of the status of safety at the 'company- would become a watershed in GM's history. The President's· Council ... decided to meet the challenge and take a close look at GM's safety performance and do whatever was necessary to improve it.

What interpretation can be given to the foregoing? For this important aspect of safety management-incident investigation-senior executive direction and involve- ment are needed to drive improvement. In every company with which I am familiar, that bas achieved stellar safety results, incident experience is reviewed regularly at the chief executive officer level.

To conclude on this subject: It is strongly recommended that if practicable, selected categories of incidents be investigated by teams consisting 'mostly of personnel not directly related to the area in which the accident occurred.

In my studies of the quality of investigations, reports prepared by · well-chosen teams that were encouraged to be factual got the highest scores. That's an idea that safety professionals could promote.

CULTURAL IMPLICATIONS THAT MAY IMPEDE Gooo INCIDENT INVESTIGATIONS

. I ,

Throughout this book the significance of an organization's culture and how it affects :ety:related decision making favorably or unfavorably has been ,emphasized. E ere '.

8 a relative and all-too-truthful paragraph in Guidelines for Preventing Human

error in Process Safety where comments are made on the "Cultural Aspects of Data 01iecti s on Ystem Design."

446 INCIDENT INVESTIGATION: SECTION 6.2 OF Z10

A company ' s culture can make or break even a well-designed data collecti system. Essential requirements are minimal use of blame, freedom from fear

0 ~

reprisals, and feedback which indicates that the information being generated~ being used to make changes that will be beneficial to everybody. All thr

18

factors are vital for the success of a data collection system and are all toee ' a certain extent, under the control of management. (p. 259)

In relation to the foregoing, the title of R. B. Whittingham's book, The Bia Machine: Why Human Error ,Causes Accidents, is particularly appropria%~ Whittingham say~ that his research shows that in some organizations, a "blame culture" has evolved whereby the focus in their investigations is on individual human error and that.the .corrective a_ction .stops at that level. That avoids seeking data on and improving the management systems that may hav,e enabled the human error.

What Whittingham wrote is indicative of an inadequate safety culture. As an example of one -aspect of a negative safety culture, consider the following scenario. It represents a culture of fear. , ,

An electrocution occurred. As required in that organization, the corporate safety director visited the location to expand on the investigation. During discussion with the deceased employee's immediate supervisor, it became apparent that the supervisor knew of the design shortcomings in the lockout/ tagout system, of which there were many at the location.

When asked why the design shortcomings were not recorded as causal factors in the investigation report, the supervisor's response was: "Are you crazy? I would get fired if I did. that. Correcting all these lockout/tagout prob- lems will cost money and my boss doesn't want to hear about things like that."

This culture of fear arose from the system of expected performance that management created. The supervisor completed the investigative report in accord with what he believed management expected. He recorded the causal factor as "employee failed to follow the locko_ut/tagout . procedure," and the investigation stopped there.

Overcoming such a culture of fear in the process of improving incident investiga- tion processes, wherever and to what extent it exists, will require careful analysis and much persuasive diplomacy.

Whittingham wrote: "Organizations, and sometimes whole industries, become unwilling to look too closely at the system faults which caused the error. Instead_ tbe attention is focused on the individual who made the error and blame is brought into the equation." (p. xii) . 1 by Actions necessary to remove error-provocative system faults can be taken on Y ust management. For an incident investigation system. to be effective, management mare demonstrate by what it does that it wants to know what the contributing causal fa~tot: ons:

Assume that the safety culture does not require effective incident inves~~au telY Consider the following examples, limited to ten, of statements that coul~ le~ium~ore be made in investigation reports but may be perceived as self-incriminaung.

11111

HAVIN.G COMPASSION FOR SUPERVISORS 447

h could be interpreted .as being accu~atory of management levels t t ey 'd d . 0rtan , isor-and thus avo1 e . .

bove . a did not take the time to train this employee because we were too busy.

1. We . ·ured employee mentioned the hazard to me, but it was the kind of fhe 1nJ ed 2. . that we have tolerat . t111ng . . &

have bad work orders m mamtenance 1or three months to fix the wiring on 3 We · . . . · . uipment. ·

tlUSeg • 1. dh did not do pre-Job p annmg, an azardous situations came up that we did 4 We

· not expect. . . It was the kind of a rush situation that often happens, and we understand that 5

· sometimes the workers take ~hort~uts a~d don't follo~ the SQPs. , The work is overly stressful and risky. Hazards were not properly considered 6. . in the design process. , .

7_ The equipment i~ being run beyond its normal life cycle, and the risks in operating it are high. . . • . , .

S. What we are asking our people to do is exhausting, ·and they make mistakes. 9. We haven't had time to write a Standard Operating Procedure for this job.

to. The stuff that purchasing bought is cheaply made,. and it falls apart. . 1,

Not doing thorough incident investigations is n9rmal in organizations where management is not fact based and ~oes not promote and require that hazard and risk problems be identified and acted upon. Situations of that sort defme safety culture problems.

If safety professidnals' promote improving the quality of incident investigation, the reality of the safety culture in place must be evaluated and defined accurately as an action plan for improvement is being formulated.

HAVING COMPASSION FOR SUPERVISORS

In a huge number of published inve·stigation procedures, it is said that the first-line supervisor is best qualified to complete incident inve~tigations because he or she is closest to the work and knows the most about the hazards and risks. That premise needs rethinking . . A safety professional should ask: How much training with respect to hazards and

do supervisors get, does the training make them kno~ledgeably and technically q ;lilied, and how often is training provided? · and ?0ubt that supervisors become exceptionally knowledgeable about h~ards 0 nsks and thus well qualified to make good incident investigations after taking a ne. or two-day co . .d . . . A . urse on mc1 ent investigation. in 'd qu~sti0n that logically follows pertains to all personnel at all levels who do

ci ent inve t' · · · · · · d d the s igations. How often do they complete mc1dent mvestlgatlons, an °

ll .

448 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

forms and procedure manuals provide adequate support? It is unusual for a supervj . . . . Th al sor to complete two or three incident mvestigations m a year. at may so be the case £

members of teams that are given the responsibility to investigate accidents. or Also, consideration needs to be given to the time lapse between when supervisors

and others attend a training session and when they complete an incident investigation report. It is generally accepted that knowledge obtained in a training session will not be retained without frequent use. .

Supervisors, and others, should be provided with readily available reminder references, the content of which should be comparable to a combination of the two addenda to this chapter.

HOW SERIOUS CAN THE PROBLEM BE?

What follows is an extraction from material sent to me recently by a colleague who has had extensive experience with incident investigation and who tries to influence managements to examine and improve their systems .

. This colleague made a presentation on incident investigation to a leadership group for one of the largest manufacturers iµ the world. The group consisted of about 150 to 175 plant managers, pers<;>nnel directors, union presidents, and union bargaining chairs.

Participants were asked to choose as many of the subjects in Table 22.1 that they .l;>elieved could be contributing factors for the occurrence of accidents in the opera- ti<?ns in which they were inv9lved.

Subjects from 1 to 7 received positive scores at varying levels, indicating that they could be contributing factors in accidents. Then the group was asked to record-How often these subjects appear in incident investigation reports? Results are shown in Table 22.2.

TABLE22.1

1. Safety culture 2. Lack of employee participation 3. Inadequate hazard identification 4. Inadequate hazard controls 5. Inadequate management of change 6. Lack of preventive mainte~ance 7. Inadequate risk sensitivity 8. Don't know

TABLE22.2

1. Very often 2. Often 3. Seldom 4. Never 5. Don't know

7% 22% 44% 20% 7%

O IMPROVEMENT, START WITH A SELF-EVALUATION OF THE CULTURE 449 ..-Hi:WAYT

oN' . . The audience consisted of managers and other upper-level

Phas1s. . . d h S Id for elll orty-four percent md1cate t at e om would the contributing factors rsonnel. _F tigation reports . Twenty percent recorded Never. Is this broadly

pe ·n inves appear~ of reality? JescriP~ive the performance level expected by management for incident investiga-

o~viouslYiow. That is embedded in the organi~ation' s cult~re. And improvement uons 1s very ade until management upgrades · its expectat10ns and provides the

t be 01 b' l' h' th · will no 1

dership and accounta 1 tty to ac 1eve e requrred culture change. 0ecessarY :rs ago, I had an involvement with that company and studied its incident

A ~ew f reports. The culture problem was obvious at that time: Management invesugaduon ry shallow incident investigations-and it was determined that the same condone ve 13 applies in 20 .

NTHE WAY TO IMPROVEMENT, START WITH ~SELF-EVALUATION OFTHE CULTURE

safety professionals who undertak~ to improve the quality of incident investigation bould begin with the first step m the Plan-Do-Check-Act process--define the

5 roblem. They should begin with an evaluation of a sampling of completed incident

~vestigation reports. In my studies the identification entries in incident investigation forms-such as name, department, location of the accident, shift, time, occupation, age, time in the job-got relatively high scor~s for thoroughness of completion.

Thus, it is suggested that the evaluation concentrate on the incident descrip- tions, causal and contributing factor determination, and t)le corrective actions taken. Considering efficient time usage, a safety professional may want to have the evaluation include only incidents resulting in serious injury 9r illness, and incidents and near misses that could have had serious results under slightly different circum,stances.

In chapter 3, "Innovations in Seijous Injury and Fatality Prevention", an outline for such a study was presented under the heading "Proposing a Study of Serious Injuries." Such a study will not be time ~onsuming since the data to be collected and analyzed should already exist or can easily be obtained. To assist in the study, two addenda to this chapter are provided. Both are taken from the fourth edition of On the Practice of Safety. Addendum A describes, a sociotechnical causation model for hazards-related incidents, and Addendum • B is a •reference for causal factors and ~orrective actions. Another good reference for this ·evaluation is Chapter 4 "Human

rror Avoidance and Reduction!1 in this book because of its comments on human errors that b A may e made above the worker le.vel. 1 , outco safe_ty professional who undertakes such a study should keep in mind that its

me 18 to be an analysis of: • A . . I • ,, l I

cttv1ties in whi h · .. · · " hi h t d t' effi . c senous mJunes .occur, 1or w c concentra e preven 10n , orts will be beneficial _

The qu li a ty of causal factor determination and corrective action taking

450 INCIDENT INVESTIGATION: SECTIO.N 6.2 OF 210

• The culture that has been established over time with respect to good or not good causal factor determination and corrective action taking so

• Organizational levels that are to be influenced if improvements are to be made

From that analysis, a plan of action would be drafted to favorably influence th system of performance expected. The organization's safety culture with respect t: the quality of incident investigation will not be changed without support from senior management.

So, the plan of action must be well crafted to convince management of the value of making the changes proposed: avoiding injuries to employees, good business practice, cost reduction, waste reduction (lean), personnel relations, and fulfilling community responsibility.

It is much, much easier to write all this than it will be for safety professionals to get it done. Culture changes are not accomplished easily. They require considerable time and patience to achieve small steps forward.

AN INTERESTING OBSERVATION

In the previous section it was said, among other things, that studies undertaken should identify activities in which serious injuries occur for which concentrated prevention efforts will be beneficial. An example of such an initiative follows.

In certain studies, safety directors in manufacturing operations were asked to have computer runs made of worker compensation cases valued at $25,000 or more. For those studies, safety directors agreed that employees in their organizations who had the following job titles were ancillary and support personnel. They did not work on the production line producing product.

millwright, welder, carpenter service technician, accounting service engineer, storekeeper

maintenance, painter, electrician, machinist administrator, salesperson, janitor, driver warehouse, shipping

Percentages of serious injuries that occurred to nonproduction personnel-that is, to ancillary and support personnel-in six companies were 78%, 72%, 72%, 67%, 63%, and 61 %. All of those companies are large, have good safety management systems, and the statistical base is large enough to have some credibility.

· · s that There were some noted exceptions. In other manufacturing orgamzation . had OSHA rates higher than industry averages, the percentage of serious injuries that occurred to line employees was much higher. Also, if an organization a division that was more inherently hazardous than manufacturing, such as nuning, that operation skewed the statistics. .

. . f analyses Data such as m the foregomg prompt the observation that the type 0 suggested in the ZlO ·advisory column for incident investigation could produ~: meaningful results from which proposals can be made on where activities cou profitably be focused.

INCIDENT INVESTIGATION FORMS 451

SJECTS TO BE REVIEWED oftU;FI sU .

of the improve~en~ end:avor, _oth~r evaluations should be made, such as A-5 a part. taught about mc1dent mvestigation, what guidal).ce is given in procedure wbat is betn~ whether the content ·and structure of the incident investigation form manuals, der thorough investigations. assist or~ wing define real-world situations as discovered in the sti.idies made.

~e foh;W such situations would affect the quality of investigations. consider

urses taught on incident investigation, the instructor leads attendees to • In colude that 80 to 90% of accidents are caused principally by the unsafe acts

cone of workers. In trUction is plainly given that the corrective actions proposed in incident

• in~estigation forms should focus on improving worker behavior . • In the incident investigation procedure manual 'the same thought is conveyed

and little guidance is given on causal factors at levels above the worker. • After a description of an incident is recorded, the first instruction in an incident

investigation form is identify the unsafe act committed by the worker . • Instructions for a · computer-based data-entry system with respect to accidents

say: "Enter the unsafe act code." The system allows the entry of only one causal factor code.

When there is a lack of understanding of the fundam~ntals of incident causation and there is no need to identify contributing causal factors, supervisors, upper levels of management, and safety professionals put their signatures on forms, indicating approval, when the reality is that investigations are shallow and of llttle value. Making the · additional reviews proposed in this chapter will help a safety profes- sional define the extent of the problem and assist in crafti~g a course of action for improvement.

INCIDENT INVESTIGATION FORMS

~P~ndix Kin ZlO provides a brief dissertation on th~ . value and outcome of an '.ncide_nt investigation-to prevent similar incidents from occurring-. and a sample mvestigation form. This form presents a good basic outline, and its conte~t can serve

a resource from which to craft an incident investigation form particularly suited 0 an organ· · • · · h · · h fi t r . izatton s operations. It has several positivy c aractenstics t at sa e Y P 01ess1onals sh Id . . . . . fi . ou consider as they draft or revise mvest1gat10n orms.

1. No tr · · , · k . en Y 1s required that would lead an investigator to focus on what a wor er dido d"d · ·

2 r 1 not do, to the exclusion of other causal factors .

. Provision is made to enter observations concerning the incident at three levels: supervisor, witnesses, and employees with insight.

452 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

. . . • determining possible causal factors by listing maior 3 Assistance 1s given m d · • E · t· Tools· Environment; Procedure; an Personnel, categones: qmpmen , • . . . .

R . d d Orrective actions are to be listed along with the originator's 4 ecommen e c d/R · d " A · · A • · · made to enter "Accepte eJecte . ctions or rationale name. prov1s1on 1s

and completion dates are to be recorded. . 5. A sign-off is required by the "Responsible/Approvmg Department Manager/

Process Owner." 6. The report ends with the investigator's signature and recordings of the persons

to whom the report is sent.

THE FIVE-WHY TECHNIQUE

As incident investigation procedures are improved, the goal is to have contributing causal factors determined and acted upon properly. As a beginning step where the incident investigation system needs much improvement, it is suggested that a problem-solving process be considered for which the training and administrative requirements are not extensive; that is the five-why technique.

Highly skilled incident investigators may say that the five-why process is inad- equate because it does not promote the identification of causal factors resulting from decisions made at a senior executive level. That is not necessarily so. Usually, when inquiry gets to the fourth "why," considerations are at the management levels above the supervisor and may consider decisions made by the board of directors.

For many organizations, achieving competence in applying the five-why technique for incident 'investigations will be a major step forward.

The origin of the five-why pr9cess is attributed to Taiichi Ohno while he was at T?yota. He develop~d and promoted a practice of asking "why" five times to determine what caused a problem so that root causal factors could be identified and effective countermeasures could be implemented. The five-why process is applied in a large number of settings for a huge variety of problems.

Since the premise on which the five-why concept is based is uncomplicated, it can easily be adopted in the incident investigation process, as some safety professionals h~ve done. For the complex incident situation occasionally encountered, starting with the five-why system may lead to the use of event trees or fishbone diagrams or more sophisticated investigation systems.

Given an in~ide~t description, the investigator Would ask "why" five tim'.'5 to get to the contributing causal factors and outline the necessary corrective act1ons. A not-overly-complex example follows.

The ~tten incident description says that a tool-carrying wheeled cart tipped over on to an employee while she · tr.,· . · · ed

was ~1mg to move 1t. She was seriously mJur · 1. Why did the cart tip ove ? Th d' d the

. r · e iameter of the casters is too small an carts are tippy. .

WHAT THIS CHAPTER IS NOT 453

. th diameter of the casters too small? They were made that way in WbY is e. z. f bricauon shop. . the a did the fabric~tion s?op ~alee carts with cast~rs that are too small?

3, WbY 'ollowed the d1mens10ns given to them by engineering. 'fheY 1' • b . . d ' .

did engineering give 1a_ nca~on _ imensions _1or casters that have been 4. WbY to be too small? Engmeenng did not consider the hazards and risks

proven uld result from using small casters. that WO • • • .

did engineering not consider those hazards and nsks? It never occurred to 5. :~esigner that use of the small casters would create hazardous situations.

conclusion: I [the dethpartment managerd] Jia~e maladde. engi~e~ring, aware of the . n problem. In at process, an e ucation 1scuss10n took place with

:;!ct to the ne~d to f ~cus ,on hazards and risks ~n de~ign pro~ess. Also, ineering was asked to study the matter an~ has given new design parame-

eng Th d' . b . 1 -. rs to fabrication: e caster 1ameter 1s to e tnp ed. On a high-priority basis, }:brication is to re~lace all casters on similar carts. A _3..0-day _ completion date for that work was set. _ _

I have also alerted supervisors to the problem 'in areas w)lere carts of that design are used. 1Jley have been advis~~d, to g~ther ,ail persoime~ who use the carts and instruct them that larger casters are bemg placed o_n tool carts and that until that is done, moving the carts is to be a two-person effort. I have asked our safety director to alert her associates at other locations of this situation and how we are handling it.

Sometimes, asking "why" as few as three times· gets to the root of a problem: on other occasions, may be necessary to ask "why" six times. Having analyzed incident reports in which the five-why system was used, these precautions are offered:

. ,\

• Management commitm_ent to identifying the reality of causal factors is an abso- lute necessity.

• Take caie that the first "why" is really a "why" and not a "what" or a diversionary symptom. · •-

• Expect that repetition' of five-why exerci~es will be necessary to get the idea across: doing so in group meetings at several levels, but particularly at the management level, is a good idea. · · ' ·· · '·

1

~e sure that management is prepared to acf on 'ilie systemic causal factors identified as skill is developed ih applying the five-why pro6ess, particularly those that · f · .. ' · k ' 1 1 anse rom human errors made above the wor er eve .

>' I ,

WHAT THIS CHAPTER IS NOT Since the r , . . . . abund iterature g1vmg guidance on incident investigation techmques 1s especially · ant comm · · · ·t · 1rnrnea· ' ents are not being made here on such items as mvest1gat1on en ena,

iate actions to be taken, fact determination, objectivity, interviewing witnesses,

454 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

developing incident investigation teams, or action plans. The chapter "Designer lncid Investigation" in the 4th edition of On the Practice of Safety gives a detailed rev·ent of the methodology. Similar incident investigation procedure outlines appear in

1~w resources described below. · e

For safety professionals who choose to be educated on more sophisticated in . dent investigation methods, the following reso~ces provide informatiqn on b~;; analysis, change analysis, event tree analyses, failure moqe and effects analysis, and fishbone (Ishikawa) diagrams.

INCIDENT INVESTIGATION .RESOURCES .

Since the names of the authors and publishers for each of the resources listed here are shown, as well as the websites for some of them, they are not repeated in the reference list at the end of this' c\Iapter. The first two resources listed are highly recommended for their content. Also, ·they are well worth the price. They are available on the Internet and can be downloaded at no cost. ·

"Root Cal;lseAnalysis Guidance Document, DOE-NE-STD-1004-92." Washington, DC,: Us Department of Energy, 1992. Also at h~://us.yhs4.search.yahoo.com/yhs/ search ?p=DOE-NE-STD-1004-92&h,spart=att&hsimp=yhs-att_OO 1 &tyj>e=att_lego_ portal_home.

This is a 69-page highly informative document. It is an instructive read. Various incident investigation techniques are discussed in an "Overview of Occurrence Investigation." Thus, . it is a resource on events and causal factor analysis, change analysis, barrier analysis, tbe management oversight and risk tree (MORT) analytical logic diagram, human performance evaluation, and Kepner-Tregoe problem s_olving and decision making.

NRI MORT '!]s(!r's Manual, NRI-1 (2002), a Generic Edition For Use with the Management Oversight and Risk Tree Analytical Logic Diagram, is published by The Noordwijk Risk ~tiative .Foun~ation in The Ne~erl,ands ..

In a discussion as to ''What is MORT," these <;omments are made: "By ~e of public domain documentation, MORT has spawned several variants, many of the~ translations of the' MORT_ Use(s Manual i~to other languages. ·The du~ability of MORT 1s a testament to its construction and content; it is a highly _logical expression of the functions required for an organization to manage risks effec- tively." They say that this 2002 version of the MORT User's Manual aims to:

• Rephrase the questions in British English • Improve guidance on the investigative application of MORT • Restore "freshness" to the 1992 MORT question set • Simplify the system of transfers in the chart

<

INCIDENT INVESTIGATION RESOURCES 455

DOE-specific references Rernove . .

• s tailor the questlon set to their own organizations • J-Ielp user

. they accomplished their purposes-to improve guidance on the investi- 1 believe "fr h " d t · · f r ation, to restore es ness, an ° Slmph Y the system. What they have

gatio~ ar!:~nating. The 69-page docµment is· available on the Internet at http ://www. done 1s rnJNR11.pdf#search='NRl%20Mort%20User%27s%20Manual'. nri,eu,co mend that safety professionals who want to identify the reality of causal

I recom uire an understanding of the thinking on which MORT is based. , ctors acq · eel d ill · ia . w of the aforementlon ocuments w provide an inexpensive and valuable

A ~vte Now, to extend the resource list, three books .on incident investigation and educaU00· · · d al · li eel Th · causal factor identification an an ysis are st . ere are other resources besides these.

, Guidelines for Preventing Human Error in Process Safety. New York: Center for Chemical Process Safety of the American Institute of Chemical Engineers, 1994.

This is a highly recommended text. Chapter 6 deals with data collection and incident analysis methods. Elsewhere~ comments are made on types of human error causal factors, their nature, and how to identify and analyze them .

• Hendrick, Kingsley and Ludwig Benner, Jr. Investigating Accidents With STEP. New York: Marcel Dekker, 1987.

Hendrick and Benner have developed an incident investigation system called "Sequentially Timed Events Plotting." Several authors refer to this thought-provoking system. This book is devoted entirely to the STEP system.

• Oakley, Jeffrey. Accident Investigation Techniques: Basic Theories, Analytical Methods and Applications. Des Plaines, IL: American Society of Safety Engineers, 2003.

This is a relatively short and inexpensive book in which comments are made on the incident investigation process generally, and on several investigation and analytical techniques, such as events and causal factors analysis, change analysis, tree analysis, and specialized computerized techniques.

• Although an internet search will reveal a large number of companies offering consulting services on root causal factor analysis, I am listing two that have published books on the subject and which have a known history with respect to occupational safety and health.

Gano, Dean L. Apollo Root Cause Analysis: A New Way of Thinking. Portland, OR: Apollonian Publications, 1999. Dean Gano has been a

456 INCIDENT INVESTIGATION: SECTION 6.2 OF 210

consultant in root-cause analysis for many yea,rs. His technique and his literature are well regarded.

TapRoot Manual. Knoxville, TN: System Improvements, Inc. This book describes the root-cause identifying and analysis methods developed by the staff at Systems Improvements. This company has also offered consulting services on root-cause analysis for several years.

CONCLUSION

My studies on , incident investigation ·prompt the, conclusion that significant risk reduction, can be achieved if investigations are done well. If incident investigations are thorough, the reality of the technical, organizational, methods of operation, and cultural causa1 factors will be revealed .

. If safety professionals want to · select leading indicators for safety management system improvement, they would have a good data source for that purpose if incident investigation reports identify causal factors realistically. I now believe that the quality of incident investigation is · one of the principal markers in evaluating an organiza- tion's safety culture.

Assume that a safety professional decides to take action to improv~ the quality of incident investigation. It is proposed that the following comments about inci- dent investigation as excerpted from the August 2003 "Report of the Columbia Accident Investigation Board" be kept in mind as a base for reflection throughout the endeavor. The report pertains to the Columbia spaceship disaster. It is accessed at http://www.nasa.gov/columbia/home/CAIB_ Voll .html. ·

Many accident investigations do. not go far enough. They identify the technical cause of the accident, and then connect it to a variant of "operator error." But this is seldom the entire issue.

When the determinations of.the causal chain are limited to the technical flaw and individual failure , typically the actions taken to prevent a similar eyent in the future are also limited: fix the technical problem and replace or retrain the individual responsible . Putting these corrections in place leads to another mistake-the belief that the problem is solved.

Too often, ~ccident investigations blame a failure only on the last step in a complex process, "".hen a more comprehensive understanding of that process could reveal that earlier steps might be equally or even more, culpable. In this Board's opinion, unless the technical, organizational, and cultural recommendations made in this report are implemented, little will have been accomplished to lessen the phanc~ t~at another accident will follow. (Vol. 1, Chap. 7 ,, p. 177)

For emphasis, I paraphrase: If the cultural, technical, organizational, and methods of operation causal factors are not identified, analyzed, and resolved, u,tle will be done to prevent recurrence of similar incidents.

REFERENCES 457

REFERENCES AJHA zl0-2012. American National Standard, Occupational Health and Safety

J\NS~gement Syste~- Fai~ax, VA: American Industrial Hygiene Association, 2012. ASSE now the secretanat. Available at https://www.asse.org/cartpage.php?link=z10_2005.

is . H E . p id I' es for Preventing uman rror m rocess Safety. New York: Center for Chemical Gu ;

0 :ess Safety of the American Institute of Chemical Engineers, 1994.

Manuele, Fred A. Ont~ Practice ~f S~fety, 4th ed. Hoboken, NH: Wiley, 2013. NASA. Columbia Accident lnvestiga~on Report, Vol. 1, Chap. 7. Washington, DC: NASA,

200 3, http://www.nasa.gov/columb1a/home/CAIB_ Voll .html.

Reason, James. Human Error. New York: Cambridge University Press, 1990. s·mon, Steven I., and Patrick R. Frazee. "Building a Better Safety Vehicle: Leadership-Driven 1 Culture Change at General Motors." Professional Safety, Jan. 2005.

Toe Five-Why System: http://www.mapwright.com.au/newsletter/fivewhys.pdf and http:// www.moresteam.com/toolbox/5-why-analysis.cfm. ., ,

Whittingham, R. B. The Blame Machine, Why Human Error Causes Accidents. Burlington; MA: Elsevier-Butterworth-Heinemann, 2004. ' ·

ADDENDUM A

A.DEPICTION OF A SOCIO-TECHNICAL CAUSATION MODEL FO R HAZARDS- RELATED INCI DENTS IS PRESENTED O N THE FOLLOWING PAGE

Advanced Safety Management: Focusing on ZJO and Serious Injury Prevention Second Edition. Fred A. Manuele. ' © 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc .

458

11111

A DEPICTION OF A SOCIO-TECHNICAL CAUSATION MODEL 459

A socio-technical causation model for hazards-related lncidents An organization's culture

ii.,established by the board of directors and senior mana&ement +

Management commitment or non-commitment to providing the controls ro achieve and maintain acceptable risk levels is an expression of the culture

+ Causal factors may derive from shortcomin_gs in controls when safety policies, ~dards, procedures. the accountability system. or their implementation, are

+ Inadequate with respect to • The design process and operational risk management

and the inadequacies impact neeatively on

J • Providing resources

• Risk assessment

• Competency and adequacy of staff ' J •

• Maintenance for system integrity

• Management of change/ pre-job planning

• Procurement - safety specifications

• Risk-related systems

• Organization of work

• Training-motivation

• Employee participation

• Infonnation -communication

•Permits ·

• Inspections • Incident investigation and analysis 1

• Providing personal protective equipment

• Third party services

• Emergency planning and management

• Conformance/compliance assurance

• Performance measures ' • Management reviews for continual improvement

Multiple causal factors derive from the inadequate controls - , I I f · I ·I

Th The incident process begins with an initiating event. ere are _unw_anted energy flows or exposures to harmful substances. ~Ultiple interacting events occur sequentially or in parallel.

i r s lted in sli htl diffe r ent circum st nces.

r ADDENDUM B

A REFERENCE FOR THE· SELECTION OF CAUSAL FACTORS , AND CORRECTIVE ACTIONS FOR INCIDENT INVESTIGATION PROCEDURES AND REPORTS

!

Designers of incident investigation· systems· should understand that the causal factors and corrective actions included within inve•stigation forms or as separate informational documents must be appropriate for the operations being conducted. The material presented here should not be used without modification to suit needs.

Workplace Design Considerations i " .

1. Hazards derive from basic design of facilities,, ~ardware, equipment, or tooling. 2. Hazardous materials need attention. ·

' I

3. Layout or position of hardware or equipment presents hazards. 4. Environmental factors (heat, cold, noise, lighting, vibration, ventilation, etc.)

presented hazards. . . /

5. Work space for ,operation,. m.ain~na,nce, or storage is insufficient. 6. Accessibility for maintenance work is .haza,rdous.

Work Method Considerations 1. Work methods are overly stressful. 2. Wor~ methods are error-pro~~cative. 3. Job is overly difficult, unpleasant or· dang . 4 J b · • erous. . o requrres performance b 5. Job induces fatigue. eyond what an operator can deliver.

Advanced Safety Management· R . Second Edition. Fred A. Man~el:cusmg on ZJO and Serious Injury Prevention © 2014 John Wile & s · '

Y oµs~ Inc. Published 2014 by John w·1 & 460 · · 1 ey_ Sons, Inc.

FERENCE ,ARE FOR THE SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS 461

.1: te work situation encouraged · riskier actions than prescribed work IJ111IleUJa 6. d metbo s.

k flow is hazardous. 7 wor . . 1 . ' · . . ing of employees m re anon to equipment and materials is hazardous. s. pos1uon ..

__ ..... ~ure Partlculars Job PfV'iV"'

No written or known job procedure. 1. Job procedures existed but did not address the hazards .. ~: Job procedures existed but employees did not know of them. 4_ Employee knew job procedures but deviate~ from them: s. Deviation from job procedure not observed by superyision. 6. Employee not capable of doing this job (physically, work habits, or behaviorally). 7. Correct equipment, tools, or materials were not used. 8. Proper equipment, tools, or materials were not available. 9. Employee did not know ·where to obtain proper equipment, tools, or materials.

10. Employee used substitute equipment, tools, or materials. 11. Defective or worn-out tools were used.

Hazardous Conditions

1. Hazardous condition had not been recqgnized. 2. Hazardous condition was recbgnized but not report~d. 3. Hazardous condition was reported but no~ corrected.

1~ , I

4. Hazardous condition was recognized but employees were not informed of the appropriate ~nterimjob procedure.

Personal Protective Equipment

1. Proper personal protective equipment (PPE) not specified for job. 2 · PPB specified for job but not available. · . · 1 3 · PPB specified for job, but employee did not know requirements. 4 · PPB specified for J. ob but employees did not know how to use or maintain. 5 PP '

6· p E ~ot used properly. · PE •nadequate.

Managem ent and Supervisory Aspects 1· Genera}· .

2. In inspection program is ineffective. 8Pectio 3. l'r . . n procedure did not detect the hazards. 4. ~ning as respect identified hazards not provided, inadequate, or didn't take.

ai.ntenanc ·th · d t e Wt respect to identified hazards was ma equa e.

462 SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS A REFERENCE FOR THE

. d f hazards and right methods before commencing work c 5. Review not ma e o 1or a job done infrequently. . .

6. This job requires a job hazard/task/ergonomics analysis., 7. Supervisory responsibility and accountab~ity not defined or u~d~~stood. 8. Supervisors not adequately trained for assign~d safe~y responsibility. 9_ Emergency equipment not specified, not readily available, not used, or did not

function properly.

Corrective Actions To Be Considered

1. Job study to be recommended: job hazard/task/ergonomics analysis needed. 2. Work methods to be revised to make them more compatible with worker

capabilities and limitations. , 3. Job procedures to be changed to reduce risk. 4. Changes are to be proposed in work space, equipment location, or work:flow. 5. Improvement ~s to be recqmmended for environmental conditions. 6. Proper tools to be provided along with information on obtaining them and

their use.

7. Instruction to be given on the hazards of using improper or defective tools. 8. Job procedure to be written or amended. 9. Additional training to be given concerning hazard avoidance on this job.

10. Necessary employee counseling will be provided. 11. Disciplinary actions deemed 'necessary. and will be taken. 12. Action is to be recommended with respect to employee who cannot become

suited to the work. I,

13. For infrequently performed jobs, it is to be reinforced that a pre-job review of hazards and procedures is to take place.

14. Particular physical hazards discovered will be eliminated. 15. Improvement in inspection procedures to be initiated or proposed. 16. Maintenance inadequacies are to be addressed. 17 · Personal protective equipment shortcomings to be corrected.