Accident Investigation

UnitVI.pdf

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Course Learning Outcomes for Unit VI

Upon completion of this unit, students should be able to:

3. Apply accident investigation techniques to realistic case study scenarios. 3.1 Develop a cause and effect diagram for an accident investigation.

4. Evaluate analytical processes commonly used in accident investigations.

Reading Assignment

Chapter 10: Tree Analysis

Chapter 11: Cause and Effect Analysis

Chapter 12: Specialized and Computerized Techniques

Access the U.S. Department of Energy resource below, and read the following sections: Cause and Effect Relationships (pp. 1-5 to 1-7) and Analyze Accident to Determine “Why” It Happened (pp. 2-76 to 2-86).

U.S. Department of Energy. (2012). Accident and operational safety analysis: Volume I: Accident analysis techniques. Retrieved from https://www.standards.doe.gov/standards-documents/1200/1208-bhdbk- 2012-v1/@@images/file

Centers for Medicare & Medicaid Services. (n.d.). Five whys tool for root cause analysis. Retrieved from https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fivewhys.pdf

Centers for Medicare & Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis Retrieved from https://www.cms.gov/medicare/provider-enrollment-and- certification/qapi/downloads/fishbonerevised.pdf

Unit Lesson

In this unit, we continue with our examination of techniques that can be used to analyze the accident sequence and to help determine root causes. You may ask why we need so many techniques. Each technique provides a slightly different view, and each can reveal previously unrecognized facts. Each technique also helps us determine which facts are not likely to be causal factors.

In Arthur Conan Doyle’s book, A Study in Scarlet, Sherlock Holmes and Watson are on a camping trip— taking a break from the detective business. They had gone to bed and were lying down, while looking up at the sky.

Holmes said, ‘Watson, look up. What do you see?’

‘Well, I see thousands of stars.’

‘And what does that mean to you?’

UNIT VI STUDY GUIDE

Analytical Techniques II

https://www.standards.doe.gov/standards-documents/1200/1208-bhdbk-2012-v1/@@images/file

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fivewhys.pdf

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf

UNIT x STUDY GUIDE

Title

‘Well, I suppose it means that of all the planets and suns and moons in the universe, that we are truly the one most blessed with the reason to deduce theorems to make our way in this world of criminal enterprises and blind greed. It means that we are truly small in the eyes of God but struggle each day to be worthy of the senses and spirit we have been blessed with. And, I suppose, at the very least, in the meteorological sense, it means that it is most likely that we will have another nice day tomorrow. What does it mean to you, Holmes?’

‘To me, it means someone has stolen our tent.’ (as cited in Ewell, 2012, p. 194).

Like Holmes, an accident investigator needs to be able to identify the facts that are relevant and be capable of disregarding those that are interesting but not useful. A good accident investigator also learns how to identify causes that go beyond the most obvious (such as human error). Finding the deeper, root causes will lead to more effective corrective actions.

Fault tree analysis is a structured technique that acts as a filter for causal factors. The undesired event is listed at the top of the tree. Once the accident is thoroughly investigated, we determine, typically through brainstorming, the events necessary to produce the top event. As we continue to ask why something happened, the tree branches out, revealing additional paths that could lead to the top event. When there are no more events, we have reached a root cause level (Oakley, 2012). A fault tree is an example of deductive reasoning, where we start with a specific event and work down to find the facts that support it. Inductive reasoning starts with the facts and works upward to find a logical conclusion. We used an inductive approach when we developed the events and causal factors chart in Unit IV.

We often think of Sherlock Holmes as using deductive reasoning to solve crimes, perhaps because of his propensity to use the word deduce. Holmes actually used a combination of inductive and deductive reasoning (Kincaid, 2015). So, too, in accident investigation, a combination of approaches should be used.

Recall the accident scenario for Units IV and V where Bob slipped and fell in a pool of water from a leaking pipe. Click here to view a fault tree diagram developed from the information in the scenario.

While much of the information is the same as contained in our earlier change analysis and barrier analysis, the fault tree does reveal some new factors that may require further investigation and action. For example, on the linked fault tree, one of the possibilities that could have caused Sam not to place a warning sign was that there were no warning signs available. A new branch of the tree could be developed from this information, and corrective actions could be identified.

The cause and effect process is another useful tool that, in addition to identifying causal factors, ties the factors to relevant categories, which will help in the identification of corrective actions. When conducting a cause and effect analysis, it is important to remember that accidents have multiple causes, some more evident than others. There is rarely a straight line cause and effect relationship. Just because event B happens after event A does not mean that event A caused event B, even if it happens frequently. It is actually easier to determine that there is no causal relationship (remove event A, and see if event B still happens with the same frequency).

The “Five Whys” technique and the fishbone (Ishikawa) diagram both use the cause and effect process (Oakley, 2012). In the Five Whys, we start with an event and keep asking why until we reach an actionable root cause. Returning again to our scenario involving Bob, it might resemble the following:

 Why did Bob fall and break his leg? Because there was water on the floor.

 Why was there water on the floor? Because a valve was leaking.

 Why was the valve leaking? Because no one submitted a repair order.

 Why did no one submit a repair order? Because no one was given the responsibility.

At this point, we have reached a root cause related to management’s failure to assign responsibility. Note, however, that our line of questioning follows a single path, and each question builds from the one above it. There could be many other starting points. For example, we could start by asking why the spill was not cleaned up. This would reveal the facts about the phone calls and the poor communication. It is not a good

https://online.waldorf.edu/CSU_Content/Waldorf_Content/ZULU/EmergencyServices/OSH/OSH4601/W15Jc/UnitVI_Fault_Tree_Chart.xls

UNIT x STUDY GUIDE

Title practice to use the Five Whys as the single analysis technique, but it can be very helpful when brainstorming causal factors as a part of a barrier analysis or fault tree analysis.

A fishbone diagram is a good tool to help an investigation team focus on causes rather than symptoms (Centers for Medicare & Medicaid Services, n.d). It is much more structured than the Five Whys and adds an additional dimension by sorting ideas into categories. The categories can then be used to group corrective actions by area of responsibility. A fishbone diagram is a particularly useful tool for a team investigation process because it requires a brainstorming effort, enabling many new ideas to be revealed. Click here for an example of a fishbone diagram representing Bob’s injury.

We are now three-quarters of the way through the course and have yet to discuss corrective actions. A mistake often made by accident investigators is to identify corrective actions too soon in the process. It may be difficult to convince upper management that the investigation process takes time. They want to be able to say they quickly fixed the problem that caused the accident. Too often, corrective actions, such as retraining, are taken immediately following an accident, before inadequate training is even established as a causal factor. In the words of Sherlock Holmes, "It is a capital mistake to theorize before one has data. Insensibly, one begins to twist facts to suit theories, instead of theories to suit facts" (Doyle, 1892, p. 7). In the next unit, we finally look at when and how to take specific actions to prevent the accident under investigation from happening again.

References

Centers for Medicare & Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis. Retrieved from https://www.cms.gov/medicare/provider-enrollment-and- certification/qapi/downloads/fishbonerevised.pdf

Doyle, A. C. (1892). Adventures of Sherlock Holmes. New York, NY: Harper & Brothers.

Ewell, B. J. (2012). Family treasures: 15 lessons, tips, and tricks for discovering your family history. Springville, UT: Cedar Fort.

Kincaid, D. K. (2015). The Sherlock Holmes conundrum, or the difference between deductive and inductive reasoning. Retrieved from https://medium.com/@daniellekkincaid/the-sherlock-holmes-conundrum- or-the-difference-between-deductive-and-inductive-reasoning-ec1eb2686112#.gol2daop1

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.