INCIDENT. INVESTIGATION Third Edition

Transcription

1 INCIDENT INVESTIGATIN Third Edition

2 INCIDENT INVESTIGATIN Third Edition National Safety Council Itasca, Illinois

3 Project Editor: Phyllis Crittenden Design and Composition: Jennifer Villarreal Cover Photo: 2010 Getty Images CPYRIGHT, WAIVER F FIRST SALE DCTRINE The National Safety Council s materials are fully protected by the United States copyright laws and are solely for the noncommercial, internal use of the purchaser. Without the prior written consent of the National Safety Council, purchaser agrees that such materials shall not be rented, leased, loaned, sold, transferred, assigned, broadcast in any media form, publicly exhibited or used outside the organization of the purchaser, or reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise. Use of these materials for training for which compensation is received is prohibited, unless authorized by the National Safety Council in writing. DISCLAIMER Although the information and recommendations contained in this publication have been compiled from sources believed to be reliable, the National Safety Council makes no guarantee as to, and assumes no responsibility for, the correctness, sufficiency, or completeness of such information or recommendations. ther or additional safety measures may be required under particular circumstances by the National Safety Council All rights reserved. Electronic edition published 2010

4 Contents Preface Incident Investigation: A Management Commitment Principles of Incident Investigation Investigation Report A Guide for Identifying Causal Factors and Corrective Actions Case Study Summary of Causal Factors Glossary

5 Preface Many safety professionals believe that incident investigation procedures now used in industry are weak in identifying causal factors of incidents. Existing methods tend to focus on the results of an incident rather than on identifying causal factors and selecting effective corrective actions. The objective of this manual is to provide an improved, systematic approach to incident investigation that will identify causal factors and suggest corrective actions that will reduce or eliminate the probability of recurrences. It is designed primarily for people who investigate workplace incidents supervisors, other in-line management, and occupational safety and health personnel or specialists. It also should be helpful to others concerned with accident prevention, including people in labor organizations and government agencies and those involved in developing standards

6 Chapter 1 Incident Investigation: A Management Commitment A systematic approach to incident investigation, identification of causal factors, and implementation of corrective actions is essential to a good safety and health program and management system. A less orderly approach can increase the potential for injury and financial loss. Good incident investigation procedures: Provide information to determine injury rates, identify trends or problem areas, permit comparisons, and satisfy workers compensation requirements Indentify, without placing blame, the basic causal factors that contributed directly or indirectly to each incident Identify deficiencies in the management system Suggest corrective action alternatives for a given incident Suggest corrective action alternatives for the management system This manual provides line supervisors, middle management, and safety personnel a way to focus on determining those factors that cause incidents so they can recommend effective corrective actions. Its emphasis on causal factors and corrective actions sets this manual apart from most other guides on investigative techniques. It provides management with a powerful tool to improve safety performance and reduce workplace injuries and financial loss caused by incidents. The fact that an incident occurred usually means something went wrong in the management system. There was an oversight, an omission, or a lack of control of circumstances that permitted the incident to occur. The incident investigation process must determine not only the causal factors that contributed to a given incident, but also the deficiencies in the management system that permitted the incident in the first place. A good incident investigation will typically yield a number of causal factors and corrective actions. The corrective actions selected should include both the specific measures needed to eliminate or reduce the probability of recurrence of a given type of incident and the measures needed to improve the management system. As the management system improves, the overall safety and health performance also should improve. When management insists on excellence in safety performance, it shows its respect for human values. It also is likely to achieve greater productivity, improved quality, lower production costs, and increased profits the bottom line for any organization

7 Incident Investigation: A Management Commitment An effective incident investigation requires strong management commitment and involvement. Management must support the investigation process and act on the results. It must ensure that the investigators are capable and have sufficient resources for an adequate investigation. therwise, the investigation may fail to uncover serious problems, including defects in the management system that could lead to other incidents and to production inefficiencies. When management fails to show strong support, employees are likely to believe that it is not seriously committed to safety. Management s commitment is demonstrated by a vigorous, objective investigation; high management visibility; a focus on uncovering causal factors rather than placing blame; and decisive action to correct deficiencies. This demonstration of management s attitude can enhance productivity and encourage employee cooperation and interest in maintaining a safer workplace. Management should designate a safety and health professional, or another qualified individual, to evaluate the quality of all incident investigations. The elements to be evaluated should include: accuracy and completeness of the information clarity and completeness of the description of the sequence of events leading to the incident corrective identification of all causal factors clarity and completeness of the description of causal factors corrective actions already taken recommendations made for corrective actions to reduce or eliminate the probability of recurrence of a similar incident recommendations for corrective actions to improve the management system proper review and sign-offs timeliness A thorough evaluation is necessary to ensure management that it is getting a high-quality investigation that offers adequate, but not excessive, recommendations for corrective action

8 Chapter 2 Principles of Incident Investigation An incident is an injury, illness, near miss, or other situation that has the potential to cause harm; personal injury or damage to property, equipment, or environment; or an event that has the potential to result in such consequences. An incident adversely affects completion of tasks. All accidents are incidents (Figure 2 1). Within this context, incidents include all occurrences, regardless of degree. In this manual the term injury includes any illness that results from a single or identifiable event, and the use of the term safety refers to occupational health. An incident investigation should determine what happened, how it happened, why it happened, and what should be done to prevent similar incidents from happening. Investigation Criteria Figure 2 1. All incidents should be investigated, regardless of the extent of the injury or property damage. An incident that involves injuries requiring medical attention and one that involves significant property damage typically requires a more extensive investigation. However, even incidents that require only first aid or very minor property damage should be investigated, especially if there is potential for more serious consequences. The method of investigation presented in this manual is flexible. It allows considerable latitude in the makeup of an investigation team and its activities. Flexibility, however, does not mean abandoning common sense. The scope of the investigation should be carefully defined at the outset by specifying the beginning and the end of the incident. The investigation should be limited to factors that relate directly to the incident. The investigation should follow a sound plan that was developed and tested before an incident occurs. The plan should guide the investigators from the moment they learn of the incident until they release the final report. Although unusual circumstances may dictate occasional deviations from the tested, structured approach, following an investigative plan will lead to the best results

9 Principles of Incident Investigation bjectivity The goals of any incident investigation are to identify the causal factors and recommend corrective actions that will eliminate or minimize them. Investigators should avoid any emphasis on identifying the individuals who may be blamed for the incident. Looking for blame jeopardizes investigators credibility and effectiveness and will usually reduce the quantity and accuracy of the information received. This does not mean, however, that oversights or acts of omission or commission on the part of any employee, including supervisors and management personnel, should be ignored. Many incidents result from actions someone did or did not do, know about, or judge correctly. The supervisor has a major role in every investigation and is also likely to have a major role in carrying out the corrective actions. The supervisor may be the only investigator or may be a member of the investigative team. Most supervisors have the objectivity needed to carry out effective investigations in their own departments. But if the incident investigators encounter a supervisor who is not objective, the investigators or safety personnel should independently determine the facts and identify any supervisory and management system defects. Investigation Team The size and makeup of the investigation team should be dictated by the seriousness and complexity of the incident. The supervisor, with the help of the employees involved, usually investigates cases resulting in minor injury or property damage. The team for a major investigation involving a serious injury, a fatality, or extensive property damage might include the employee(s) directly involved, the supervisor, safety personnel, technical specialist, and employees familiar with the process or operation. The team also might include members of middle and upper management, such as a general foreman, a department superintendent, and a facility manager. If there is a fatality or major property damage, the team should include corporate safety and health staff and corporate officers. A team can add more members as the investigation uncovers complications, injury, or damage potential that was not recognized when the team was formed. The qualifications needed by the members of the incident investigation team include: technical knowledge objectivity inquisitiveness and curiosity familiarity with the job, process, or operation tact in communicating with others intellectual honesty an analytical approach to problems The chairperson of the team should be designated as soon as possible after the incident occurs. The manager should designate, or approve the designation of, the chairperson and other members of the team. If a written procedure is established, designation can be carried out automatically. The chairperson should have management status, the authority to get the job done, and the experience to do it right. The chairperson s duties should include: - 8 -

10 Principles of Incident Investigation calling and presiding over meetings controlling the scope of team activities by identifying the line of investigation to be pursued assigning tasks and establishing a schedule ensuring that no potentially useful data source is overlooked keeping interested parties advised of the investigation s progress overseeing the preparation of the final report arranging liaison with employee representatives, government agencies, and news media Action Plan When an incident occurs, the investigators must be ready to act immediately to turn chaos into order. There s no time for training immediately after the incident. Investigators need advance training and preparation so they can act promptly and effectively. Management should adopt a written action plan for team investigations that provides: identification of the individual in charge and who assigns responsibilities authority to conduct the investigation prompt notification of team members that specifies when and where they should report instructions on the personal protective clothing or special equipment to be worn or brought to the scene provisions for work area and administrative support transportation and communication, if needed securing the site for the duration of the investigation after rescue and damage control are complete provision for access of the team members to the incident site photographic support or capability procedures and equipment to ensure the observation and recording of fragile, perishable, or transient evidence (e.g., instrument readings, control panel settings, weather and environmental conditions, chemical spills, stains, skid marks) development of a comprehensive report Notification Procedure Management should adopt a formal notification procedure to ensure all appropriate people receive prompt notification when an incident occurs. The procedure should specify who is responsible for notifying each person involved. The severity of the incident or injuries should dictate how far the communication process should go. It also should dictate when the information is to be communicated, such as, at any time of the day or night, or only during working hours. The notification procedures must be kept upto-date; no one can predict when the team will be needed. Supervisors are usually responsible for initiating communications on incidents of all kinds. Line management with a vested interest may include the general foreman, the superintendent, the manager of the business, the general manager or vice president of operations, and, in some cases, the organization s president. Staff members who normally would be notified include the nurse or trained first-aid responder, safety personnel, public relations or communications specialists, and industrial relations personnel. It may be appropriate to notify the employee representative in the event of a serious injury or incident

11 Principles of Incident Investigation Some organizations provide an internal emergency telephone number. People who handle such calls receptionists or security personnel should have standing instructions on how to respond and whom to notify. To avoid delays or other interference, a special hotline number can be reserved exclusively for emergency calls. Immediate Action The safety and health of employees, visitors, and the community must be the primary concern immediately following an incident. Activities related to the investigation are important, but they are secondary. The first response must be to: Take all steps necessary to provide emergency rescue and medical help for the injured. Take those actions that will prevent or minimize the risk of further incidents, injuries, or property damage. These immediate actions are stopgap measures to prevent further adverse consequences. Most incidents will require one or more of the following actions as soon as possible: secure, barricade, or isolate the scene collect transient or perishable evidence determine the extent of damage to equipment, material, or building facilities restore the operating functions Determining the Facts As mentioned earlier, the level of effort involved in the investigation largely depends on the seriousness or complexity of the incident. Investigators should perform only those tasks that are pertinent to identification of the causal factors. For a major investigation, the incident investigation team should: Visit the scene before the physical evidence is disturbed Take samples of unknown chemical spills, vapors, residues, dusts, and other substances, noting conditions that may have affected the sample Make comprehensive visual records. No one can predict which data will be useful, so photographs should be taken from many different angles and accurate and complete sketches or diagrams should be made before the scene is restored. Determine which incident-related items should be preserved. These may become critical evidence if there is litigation later. When the investigation reveals that an item may have failed to properly operate or was damaged, arrangements should be made to preserve the item as it was found or to document carefully any subsequent repairs or modifications. Identify the people who were involved in the incident. Also identify all eyewitnesses, including those who saw the events leading to the incident, those who saw the incident happen, and those who came upon the scene immediately following the incident. Identify others who may have useful information. The people listed above should be interviewed as soon as possible. The validity of their statements is highest immediately following the incident. Immediate interviews minimize the possibility that witnesses will subconsciously adjust their stories to fit the interviewer s concept of what occurred or to protect someone involved. Witnesses should be interviewed individually and in private so the comments of one do not influence the responses of others

12 Principles of Incident Investigation Conduct interviews with everyone who was involved or can provide information. Tactful, skilled investigators usually get uninhibited cooperation from employees by eliminating any apprehension they may have about incriminating themselves or others. Witnesses must be convinced that the investigators want to find the cause of the incident and don t want to place blame. If witnesses provide misleading information, the purpose of the investigation is thwarted and a similar incident will likely occur again. Carefully document the sources of the information. This documentation avoids an unwarranted impression that information actually obtained from third parties is based on the investigator s own observations or analysis. Documentation of sources can prove valuable if the investigation is expanded at some point or reopened later. Note any contradictory statements or evidence and attempt to resolve discrepancies. If resolution is not possible, indicate which statements or evidence is considered most reliable. Review all sources of potentially useful information. These may include original design; design specifications; drawings; operating logs; purchasing records; previous reports; procedures; equipment manuals; verbal instructions; maintenance, inspection, and test records; alteration or change of design records; design data; job safety analyses; records indicating the previous training and job performance of employees and supervisors involved; computer simulations; and laboratory tests. Facts must be separated from opinions, direct evidence from circumstantial evidence, and eyewitness statements from hearsay testimony. Investigators should divide the data into the following categories: Hard evidence: Data that usually cannot be disputed, such as time and place of the incident, logs and other written reports, and the position of physical evidence (providing investigators can establish that it has not been moved). Witness statements: Statements from people who saw the incident happen and from those who came upon the scene immediately following the incident. Circumstantial evidence: The logical interpretation of facts that leads to a single, but unproven, conclusion. Investigators should be cautious when handling physical evidence such as pieces of equipment and tools. After visual assessment of the extent of damage or defects, it may be necessary to send such evidence to a laboratory for further analysis for failures or fractures. In some cases, the equipment should be identified, tagged, and secured. Investigators should not attempt to reassemble failed or damaged equipment at the incident site. Such attempts might prevent an accurate laboratory analysis. It is also unwise to disassemble damaged equipment unless the correct reassembly procedure is known. In most cases, the investigator should determine what analysis is needed and leave the actual analysis of the equipment or tool to someone qualified to conduct the test. If a fatality is involved, investigators should not attempt to determine the cause until a coroner or medical examiner issues a preliminary report indicating a cause. Investigators must understand that the accuracy and thoroughness with which they obtain and record data will largely determine the quality of the final report and the effectiveness of the corrective actions

13 Chapter 3 The Investigation Report The preceding chapters described general principles and procedures that apply to any incident investigation. This chapter tells how to complete the Incident Investigation Report, a form that serves as an investigative guide and as a record of the facts obtained. The report (Figure 3-1) is one of three key forms presented in this manual. The second form, Causal Factors and Corrective Actions, is described in Chapter 4. The third form, the Summary of Causal Factors, helps investigators to compile and analyze data from many incidents (see Figure 6-1 in Chapter 6). A case history is provided to show, step-by-step, how an actual incident is recorded. When used together, the Incident Investigation Report and the Causal Factors & Corrective Actions Guide tell investigators what questions to ask, what factors to investigate, and what other information to document as part of the permanent record of the incident and its aftermath. They also help investigators identify causal factors and corrective actions to prevent similar incidents from occurring in the future. The Report is designed primarily for investigation of incidents involving injuries, but also can be used to investigate occupational illnesses arising from a single exposure (e.g., dermatitis caused by a splashed solvent or a respiratory condition caused by the release of a toxic gas). All questions on this form should be answered. If no answer is available, or the question does not apply, the investigator should so indicate. Answers should be complete and specific. Supplementary sheets can be used for additional information, such as drawings and sketches, and should be attached to the Report. A separate form should be completed for each employee who is injured in a multiple-injury event. The Report meets the record-keeping requirements specified by SHA. The individual entries are explained below. Department: Enter the department or other local identification of the work area to which the injured is assigned (e.g., maintenance shop or shipping room). In some cases, this may not be the area in which the incident occurred. Location: Enter the location where the incident occurred if different from the employer s mailing address

14 The Investigation Report Incident Investigation Report Case Number Company Department Address Location 1. Name of injured 2. Social Security Number 3. Sex 4. Age 5. Date of incident / / 6. Home Address 9. Employment category Regular, full-time Regular, part-time Temporary Seasonal Non-Employee 7. Employee s usual occupation 10. Length of employment Less than 1 mo. 1-5 mos. 6 mos. - 5 yrs. More than 5 yrs. 8. ccupation at the time of the incident 11. Time in occup. at time of the incident Less than 1 mo. 1-5 mos. 6 mos. - 5 yrs. More than 5 yrs. 12. Nature of injury and part of the body 13. Case numbers and names of others injured in same incident 14. Name and address of physician 15. Name and address of hospital 16. Time of injury A. a.m. p.m. B. Time within shift C. Type of shift 17. Severity of injury Fatality Lost workdays - days away from work Lost workdays - days of restricted activity Medical treatment First Aid ther, specify 18. Specific location of incident n employer s premises? Yes No 19. Phase of employee s workday at time of injury During rest period Entering or leaving plant During meal period Performing work duties Working overtime ther 20. Describe how the incident occurred 21. Incident sequence. Describe in reverse order the occurence of events preceding the injury and accident. Start with the injury and moving backward in time, reconstruct the sequence of events that led to the injury. A. Injury event B. Incident event C. Preceding event #1 D. Preceding event #2, 3, etc. 22. Task and activity at time of incident General type of task Specific activity Employee was working: Alone With crew or fellow worker ther (specify) 23. Posture of employee 24. Supervision at time of incident Directly supervised Indirectly supervised Not supervised Supervision not feasible Figure 3 1. Incident Investigation

15 The Investigation Report 25. Cost estimates Actual estimates Formula-generated average Both A. Actual cost estimate Property and equipment damage $ P roduct spoilage $ Production interruption $ Lost work time (other than injured) $ R etraining $ A dministrative time $ W orkers compensation $ ( medical + indemnity paid + indemnity reserve) To tal $ Total cost $ estimated actual B. Formula-generated average cost Average hourly wage plus fringe benefits for this job $ Injured body part: Head, face Eye Neck, shoulder Hearing loss Chest, lower trunk Heart attack Back Rib Hernia, rupture Arm, elbow Thumb, finger Wrist, hand Hip Leg, knee Foot, ankle Toe ther (estimate work hours lost: hours) Injury type: Burn Amputation Strain, sprain, crush or mash Death Fracture Bruise, abrasion Cut, puncture or laceration ther Formula-generated cost estimate (from computer calculation) $ Yes No Do you use ANSI Z16.2 coding? If no, proceed to Causal factors. Nature of injury code Body part affected code Injury source code Incident type code Hazardous source condition Agency of incident code Agency of incident part code Nature of illness code (BLS) ther code 26. Causal factors. Events and conditions that contributed to the incident. Include those identified by use of the Causal Factors & Corrective Actions form. 27. Corrective Actions. Those that have been, or will be, taken to prevent recurrence. Include those identified by use of the Causal Factors & Corrective Actions form. Prepared by Title Department Date Approved Title Date Approved Title Date Figure 3 1. Concluded

16 The Investigation Report Incident Investigation Report 1. Name of injured: Record the last name, first name, and middle initial. 2. Social Security Number 3. Sex 4. Age: Record the age of the injured at the last birthday, not the date of birth. 5. Date of incident, accident, or initial diagnosis of illness 6. Home address 7. Employee s usual occupation: Give the occupation to which the employee is normally assigned (e.g., assembler, lathe operator, or clerk). 8. ccupation at time of incident: Indicate the occupation in which the injured was working at the time of the incident. In some cases, this may not be the employee s usual occupation. 9. Employment category: Indicate whether the employee is full-time, part-time, seasonal, etc. 10. Length of employment: Check the appropriate box to indicate how long the employee has worked for the organization. 11. Time in occupation at time of incident: Record the total time the employee has worked in the occupation indicated in item Nature of injury and part of body: Describe exactly the kind of injury or injuries resulting from the incident and the part or parts of the body affected. For an occupational illness, give the diagnosis and the body part or parts affected. 13. Case numbers and names of others injured in same incident: For reference purposes, the names and case numbers of all others injured in the same event should be recorded here. 14. Name and address of physician 15. Name and address of hospital 16. Time of injury: In part B, indicate in which hour of the shift the injury occurred (e.g., 1st hour). In part C, record the type of shift (rotating or straight day). 17. Severity of injury: Check the highest degree of severity of injury. The options are listed in decreasing order of severity 18. Specific location of incident: Indicate whether the incident or exposure occurred on the employer s premises. Then record the exact location of the incident (e.g., at the feed end of No.2 assembly line or in the locker room). Attach a diagram or map if it helps to identify the location. 19. Phase of employee s workday at time of injury: Indicate what phase of the workday the employee was in when the incident occurred. If other, be specific. 20. Describe how the incident occurred: Provide a complete, specific description of what happened. Tell what the injured employee and others involved in the incident were doing prior to the incident; what relevant events preceded the incident; what objects or substances were involved; how the injury occurred and the specific object or substance that inflicted the injury; and what, if anything, happened after the incident. Include only facts obtained in the investigation. Do not record opinions or place blame. 21. Incidence sequence: Provide a breakdown of the sequence of events leading to the injury. This breakdown enables the investigator to identify additional areas where corrective action can be taken

17 The Investigation Report Typically the incident event and the injury event are different. For example, suppose a bursting steam line burns an employee s hands or a chip of metal strikes an employee s face during a grinding operation. In these cases the incident event (the bursting of the steam line or the setting in motion of the metal chip) is separate from the injury event (the steam burning the employee s hands or the chip cutting the employee s face). The question is designed to draw out this distinction and to record other events that led to the incident event. Events preceding the incident event may have contributed to the incident. These preceding events can take one of two forms. They can be something that happened that should not have happened, or something that did not happen that should have happened. The steam line, for example, may have burst because of excess pressure in the line (preceding event #1). The pressure relief valve may have been corroded shut, preventing the safe release of the excess pressure (preceding event #2). The corrosion may not have been discovered and corrected because a regular inspection and test of the valve was not carried out (preceding event #3). To determine whether a preceding event should be included in the incident event sequence, the investigator should ask whether its occurrence (if it should not have happened) or nonoccurrence (if it should have happened) permitted the sequence of events to continue through the incident and injury event. Take enough time to think through the sequence of events leading to the injury and to record them separately on the Report. This information can be used in the Causal Factors and Corrective Actions guide to help identify management system defects that contributed to the events in the incident sequence. By identifying such defects, management can help prevent many more types of incidents than the type under investigation. In the example, the failure to detect the faulty pressure relief valve should lead to a review of all equipment inspection procedures. This review could prevent other incidents that might have resulted from failure to detect faulty equipment in the inspection process. Additional pages may be needed to list all of the events involved in the incident. 22. Task and activity at time of incident: First record the general type of task the employee was performing when the incident occurred (e.g., pipe fitting, lathe maintenance, operating punch press). Then record the specific activity in which the employee was engaged when the incident occurred (e.g., oiling shaft, bolting pipe flanges, removing material from press). Finally, check the appropriate box to indicate whether the injured employee was working alone or with a crew or co-worker. 23. Posture of employee: Record the injured employee s posture in relation to the surroundings at the time of the incident (e.g., standing on a ladder, squatting under a conveyor, standing at a machine). 24. Supervision at time of incident: Indicate in the appropriate box whether, at the time of the incident, the injured employee was directly supervised, indirectly supervised, or not supervised. If appropriate, indicate whether supervision was not feasible at the time. Note: Users may add other data elements to the form to fulfill local or corporate regulatory requirements. Types of data elements that might be added include: Information on incident patterns that are specific to a particular industry or organization (e.g., an establishment with many confined-space incidents might wish to add some questions on that type of event)

18 The Investigation Report Information required for special studies (e.g., a study tracing the effectiveness of a specific corrective action). More detailed severity information (e.g., the cost of the incident). Management data for use in performance reviews and in determining training needs. Exposure data for use in calculating incidence rates for injuries associated with certain activities. This data would be estimates or the actual number (or percentage) of hours that employees devote to the activity in a week, month, or year. Incidence rates based on the hours of exposure to specific activities can then be calculated. The use of incidence rates yields a more accurate comparison of activities than methods comparing only the total number of cases associated with each activity

19 Chapter 4 A Guide for Identifying Causal Factors and Corrective Actions The second key form provided in this manual is a Guide for Identifying Causal Factors and Corrective Actions. Completion of this Guide is essential in this method of incident investigation. It focuses on the four elements of a basic system: equipment, environment, people, and management (see Figure 4-1). These four system elements are combined to make products and profits. But sometimes they work together in unexpected ways to produce incidents. The incident investigation method should focus on three key tasks. The first is identification of the causal factors that resulted in the incident. The second is identi fication of the corrective actions that will minimize the likelihood of a similar incident and minimize the severity or adverse consequences of a similar incident if one occurs. The third task is selection of the corrective actions that have the best chance of mitigating the risk. Figure 4-1. Identifying Causal Factors The causal factor identification procedure in Figure 4 2 can be applied to any workplace incident. It is based on a simple Yes or No response to a series of questions. The Guide is divided into four parts: Equipment, Environment, People, and Management. Each part has one or two basic questions. Your answers to these questions determine how you will proceed through the other questions in that part. For example, the first basic question in Part 1, Equipment, is Was a hazardous condition(s) a contributing factor? If the answer is Yes, answer the remaining questions under Causal Factors. If the answer is No, proceed to the next part of the Guide. Answer all questions by placing an X in the Y circle or box for Yes or in the N circle or box for No. Marks in the boxes will signify that the corresponding items are not causal factors

20 A Guide for Identifying Causal Factors and Corrective Actions Marks in the circles will signify that the items are causal factors. Because incidents rarely have one single cause, this process usually yields more than one causal factor for each incident. Use the Comment column to the right of the Causal Factors questions to record specifics about the incident under investigation. Provide a comment for each item identified as a causal factor; that is, items for which Xs appear in circles. Identifying Corrective Actions A corrective action is a response to eliminate a deficiency of some kind. The Guide lists several Possible Corrective Actions for each causal factor. These suggested actions are stated in general terms. They guide the investigators in identifying specific corrective actions that relate to the incident under investi gation. The Possible Corrective Actions are intended to strengthen the overall safety program and eliminate or minimize such management system defects as oversights, omissions, or lack of control. f course, the list of actions in the Guide cannot cover every imaginable contingency. Investigators, therefore, should also consider other corrective actions. In the Recommended Corrective Actions column, list specific corrective actions that can be taken to minimize or eliminate the causal factors that resulted in the incident. The list should include remedies to eliminate defects that have been identified in the management system. Each recommended corrective action should be considered a candidate for implementation. Selecting Corrective Actions Most investigations will suggest several recommended corrective actions. Two or more corrective actions from this list of candidates often will be chosen for implementation. Some are bound to be more effective than others. And some are bound to be more costly than others. Factors that usually influence the selection include: effectiveness cost feasibility effect on productivity time required to implement extent of supervision required Acceptance by employees acceptance by management

21 A Guide for Identifying Causal Factors and Corrective Actions Causal Factors & Corrective Actions Case Number Answer questions by placing an X in the Y circle or box for yes or in the N circle or box for no. A marked circle indicates a possible causal factor. PART 1 EQUIPMENT 1.0 Was a hazardous condition(s) a contributing factor? If no, proceed to Part 2. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 1.1 Did any defect(s) in equipment/ tool(s)/material contribute to hazardous condition(s)? 1.2 Was the hazardous condition(s) recognized? If yes answer A and B. If no, proceed to 1.3. A. Was the hazardous condition(s) reported? B. Was the employee(s) informed of the hazardous condition(s) and the job procedures for dealing with it as an interim measure? 1.3 Was there an equipment inspection procedure(s) to detect the hazardous condition(s)? 1.4 Did the existing equipment inspection procedure(s) detect the hazardous condition(s)? 1.5 Was the correct equipment/tool(s)/material used? 1.6 Was the correct equipment/ tool(s)/material readily available? 1.7 Did employee(s) know where to obtain equipment/tool(s)/ material required for the job? Review procedure for inspecting, reporting, maintaining, repairing, replacing or recalling defective equipment/tool(s)/material used. Perform job safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipment/tool(s)/ material. Train employees in reporting procedures. Stress individual acceptance of responsibility. Review job procedures for hazard avoidance. Review supervisory responsibility. Improve supervisor/ employee communications. Take action to remove or minimize hazard. Develop and adopt procedures to detect hazardous conditions. Conduct test. Review procedures. Change frequency or comprehensiveness. Provide test equipment as required. Improve employee ability to detect defects and hazardous conditions. Change job procedures as required. Specify correct equipment/tool(s)/ material in job procedure. Provide correct equipment/tool(s)/ material. Review purchasing specifications and procedures. Anticipate future requirements. Review procedures for storage, access, delivery or distribution. Review job procedures for obtaining equipment/tool(s)/material National Safety Council Page 1 Figure 4-2. Causal Factors and Corrective Actions

22 A Guide for Identifying Causal Factors and Corrective Actions Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 1.8 Was substitute equipment/ tool(s)/material used in place of the correct one? Provide correct equipment/tool(s)/ material. Warn against use of substitutes in job procedures and in job instruction. 1.9 Did the design of the equipment/tool(s) create operator stress or encourage operator error? 1.10 Did the general design or quality of the equipment/ tool(s) contribute to a hazardous condition? 1.11 List other causal factors in Comment column. Review human factors engineering principles. Alter equipment/tool(s) to make it more compatible with human capability and limitations. Review purchasing procedures and specifications. Check out new equipment and job procedures involving new equipment before putting into service. Encourage employees to report potential hazardous conditions created by equipment design. Review criteria in codes, standards, specifications and regulations. Establish new criteria as needed. PART 2 ENVIRNMENT 2.0 Was the location of equipment/materials/employee(s) a contributing factor? If no, proceed to Part 3. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 2.1 Did the location/position of equipment/material/employee(s) contribute to a hazardous condition? Perform job safety analysis. Review job procedures. Change the location, position or layout of the equipment. Change position of employee(s). Provide guardrails, barricades, barriers, warning lights, signs or signals. 2.2 Was the hazardous condition recognized? If yes, answer A and B. If no, proceed to 2.3. A. Was the hazardous condition reported? B. Was employee(s)informed of the job procedures for dealing with the hazardous condition as an interim action? 2.3 Was employee(s) supposed to be in the vicinity of the equipment/material? Perform job safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipment/tools/materials. Train employees in reporting procedures. Stress individual acceptance of responsibility. Review job procedures for hazard avoidance. Review supervisory responsibility. Improve employee/ supervisor communications. Take action to remove or minimize hazard. Review job procedures and instructions. Provide guardrails, barricades, barriers, warning lights, signs or signals National Safety Council Page 2 Figure 4-2. Continued

23 A Guide for Identifying Causal Factors and Corrective Actions Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 2.4 Was the hazardous condition created by the location/position of equipment/material visible to employee(s)? 2.5 Was there sufficient workspace? 2.6 Were environmental conditions a contributing factor (illumination, noise levels, air contaminant, temperature extremes, ventilation, vibration or radiation)? Change lighting or layout to increase visibility of equipment. Provide guardrails, barricades, barriers, warning lights, signs or signals or floor stripes. Review workspace requirements and modify as required. Monitor, or periodically check, environmental conditions as required. Check results against acceptable levels. Initiate action for those found unacceptable. 2.7 List other causal factors in Comment column. PART 3 PEPLE 3.0 Was the job procedure(s) used a contributing factor? If no, proceed to Part 3.6. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 3.1 Was there a written or known procedure for this job? If yes, answer A, B, and C. If no, proceed to 3.2. A. Did job procedures anticipate the factors that contributed to the accident? B. Did employee(s) know the job procedure? C. Did employee(s) deviate from the known job procedure? 3.2 Was employee(s) mentally and physically capable of performing the job? 3.3 Were any tasks in the job procedure too difficult to perform (excessive concentration or physical demands)? Perform job safety analysis and develop safe job procedures. Perform job safety analysis and change job procedures. Improve job instruction. Train employees in correct job procedures. Determine why. Encourage all employees to report problems with an established procedure to supervisor. Review job procedure and modify if necessary. Counsel or discipline employee. Provide closer supervision. Review employee requirements for the job. Improve employee selection. Remove or transfer employees who are temporarily, either mentally or physically, incapable of performing the job. Change job design and procedures. 3.4 Is the job structured to encourage or require deviation from job procedures (incentive, piecework, work pace)? Change job design and procedures National Safety Council Page 3 Figure 4-2. Continued

24 A Guide for Identifying Causal Factors and Corrective Actions Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 3.5 List other causal factors in Comment column. 3.6 Was lack of personal protective equipment or emergency equipment a contributing factor in the injury? If no, proceed to Part 4. Note: The following causal factors relate to the injury. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 3.7 Was appropriate personal protective equipment specified for the task or job? If yes, answer A, B and C. If no proceed to 3.8. A. Was appropriate PPE available? B. Did employee(s) know that wearing specified PPE was required? C. Did employee(s) know how to use and maintain the PPE? 3.8 Was the PPE used properly when the injury occurred? 3.9 Was the PPE adequate? 3.10 Was emergency equipment specified for this job (emergency showers, eyewash fountains)? If yes, answer A, B and C. If no, proceed to Part 4. A. Was emergency equipment readily available? B. Was emergency equipment properly used? C. Did emergency equipment function properly? 3.11 List other causal factors in Comment column. Review methods to specify PPE requirements. Provide appropriate PPE. Review purchasing and distribution procedures. Review job procedures. Improve job instruction. Improve job instruction. Determine why and take appropriate action. Implement procedures to monitor and enforce use of PPE. Review PPE requirements. Check standards, specifications and certification of the PPE. Provide emergency equipment as required. Install emergency equipment at appropriate locations. Incorporate use of emergency equipment in job procedures. Establish inspection/monitoring system for emergency equipment. Provide for immediate repair of defects National Safety Council Page 4 Figure 4-2. Continued

25 A Guide for Identifying Causal Factors and Corrective Actions PART 4 MANAGEMENT 4.0 Was a management system defect a contributing factor? If no, proceed to Part 5. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 4.1 Was there a failure by supervisor to detect, anticipate or report a hazardous condition? 4.2 Was there a failure by supervisor to detect or correct deviations from the job procedure? 4.3 Was there a supervisor/ employee review of hazards and job procedures for tasks performed infrequently? (Not applicable to all incidents.) 4.4 Was supervisor responsibility and accountability adequately defined and understood? 4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? 4.6 Was there a failure to initiate corrective action for a known hazardous condition that contributed to this accident? 4.7 List other causal factors in Comment column. Improve supervisor capability in hazard recognition and reporting procedures. Review job safety analysis and job procedures. Increase supervisor monitoring. Correct deviations. Establish a procedure that requires a review of hazards and job procedures (preventative actions) for tasks performed infrequently. Define and communicate supervisor responsibility and accountability. Test for understandability and acceptance. Train supervisors in accident prevention fundamentals. Review management safety policy and level of risk acceptance. Establish priorities based on potential severity and probability of recurrence. Review procedure and responsibility to initiate and carry out corrective actions. Monitor progress. PART 5 CCUPATINAL HEALTH SUPPLEMENTAL INFRMATIN 5.0 Was an adverse occupational health environment a potential contributing factor? If yes, identify adverse environments below and elaborate in comment box. If no, form is complete. Causal Factors Comment 5.1 Physical agent. If yes, check applicable causal factor and explain in comment box. Noise, vibration Temperature extremes Ionizing radiation (X, gamma, beta and alpha rays) Nonionizing radiation (microwaves, lasers, ultraviolet rays, infrared radiation, RF) 2006 National Safety Council Page 5 Figure 4-2. Continued

26 A Guide for Identifying Causal Factors and Corrective Actions Causal Factors Ergonomic (repetitive motion trauma, lighting, glare, incorrect or insufficient tooling) Comment ther Type of agent 5.2 Chemical agent. If yes, check applicable causal factor, name the chemical agent and explain in comment box. Solvents Name: Acids, bases Name: Laboratory reagents ther toxic chemicals Name: Name: Unknown or combination 5.3 Biological agent. If yes, check applicable causal factor, name the biological agent and explain in comment box. Microorganism Name: Insect Animal Name: Name: 5.4 Medical problem. If yes, explain in comment box. Figure 4-2. Concluded

27 Chapter 5 Case Study This chapter shows how to complete the Incident Investigation Report and Causal Factors and Corrective Actions Guide in an actual incident investigation. The step-by-step explanations show how this incident investigation method identifies causal factors. They also show how this method guides the investigators toward a number of possible corrective actions from which they can select those most likely to satisfy the criteria listed in Chapter 4. Case #504 (Figure 5 1) describes an industrial incident. Figure 5 2 shows a completed Incident Investigation Report for this incident. Note how carefully investigators have distinguished between the incident event and the injury event and how many causal factors and corrective actions they have listed. Case #504 Injured: Incident Description: Injuries: ther Information: Maintenance pipefi tter with 14 years experience, working the third shift, 12 8 am. At about 6 am on December 14, the injured climbed a 20-foot straight ladder to repair a leaking oil valve on a pipe bridge located in aisle 13, a lighted, but narrow aisle in Building A used by forklift trucks on rare occasions. After the injured climbed the ladder, he started to tie it off. A glance at the valve revealed he would need a special wrench. He told his helper, who had cleaned up the oil on the floor, to go to the tool crib and get the special wrench. A moment after the helper left, and while the injured was in the process of tying off the ladder, a forklift truck, properly loaded, suddenly approached and struck the ladder, knocking the injured and the ladder to the concrete floor. Broken arm, fractured ribs, and multiple contusions. The forklift operator claimed he could not stop in time to avoid hitting the ladder because of faulty brakes. A later examination confi rmed worn brakes, but no other defect in the brake system. The operator stated he thought he could have stopped in time to avoid hitting the ladder if the brakes had been in good working order. He said he experienced some brake problems earlier in the shift but did not report the problems because he felt they were not serious enough to constitute a hazardous condition. He did, however, know the reporting procedure. Although there were procedures for inspection of forklifts by the maintenance department, there had been frequent reports of faulty brakes on forklifts in the past. The repair of the leaking oil valve was a nonrecurring task. There was no written job procedure, but the established job procedure was known by the maintenance employees and by the supervisor. The supervisor did not discuss or review the potential hazards associated with the job, or the job procedure, with the maintenance employees before they started the job. The job procedure did not call for barricades, warning signs, or signals to be placed around the ladder to warn any traffi c of the obstruction. Both maintenance employees were wearing hard hats. The maintenance supervisor had experienced earlier problems in recognizing or anticipating hazardous conditions in maintenance operations. Figure 5-1. A case study of an industrial incident provides an exercise in how to use the Causal Factors and Corrective Actions Guide.

28 Case Study Figure 5-2. A completed sample of the Incident Investigation Report

29 Case Study Figure 5-2. Concluded

30 Case Study The following pages illustrate how investigators would use the Causal Factors and Corrective Actions Guide to analyze Case #504. Figure 5 3 shows a completed guide for this case, which yields a list of causal factors and possible corrective actions. To complete the investigation, the investigators would list the causal factors identified in item 26 of the incident investigation report form provided in Chapter 3. They would list the corrective actions selected for implementation in item 27 of that same form. How to Use the Guide for Identifying Causal Factors and Corrective Actions The following example shows how the Guide for Identifying Causal Factors and Corrective Actions would be used for Case #504. Reminder: An X in a circle identifies a causal factor. An X in a box indicates that the item is not a causal factor. PART 1 EQUIPMENT 1.0 Was a hazardous condition(s) a contributing factor? If no, proceed to Part 2. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 1.1 Did any defect(s) in equipment/ tool(s)/material contribute to hazardous condition(s)? Review procedure for inspecting, reporting, maintaining, repairing, replacing or recalling defective equipment/tool(s)/material used. A hazardous condition existed. The answer to question 1.0 is an X in the Yes circle. The forklift s brakes were defective. The answer to question 1.1, an X in the Yes circle, identifies a causal factor. Recommended Corrective Action: Remove the forklift from service and repair the faulty brakes. To avoid faulty brakes on this and other forklifts in the future, review procedures for inspecting and maintaining brakes on all forklifts and 1.2 Was the hazardous condition(s) recognized? If yes answer A and B. If no, proceed to 1.3. implement changes to improve these procedures. A hazardous condition was not recognized. The forklift operator did not consider the faulty brakes a hazardous condition. An X in the No circle identifies another causal factor. Recommended Corrective Action: Improve the ability of all forklift operators to identify defects and hazardous conditions with respect to their equipment. Provide an inspection checklist and maintenance log for each forklift. Require all operators to inspect in accordance with the checklist and sign off at the beginning of each shift. Note that this corrective action goes beyond the one forklift operator who was involved in the incident. The corrective action is applied to all forklift operators because other defects on other forklifts should be identified to avoid future incidents

31 Case Study A. Was the hazardous condition(s) reported? Questions 1.2A and 1.2B cannot be answered because the hazardous condition was not recognized. B. Was the employee(s) informed of the hazardous condition(s) and the job procedures for dealing with it as an interim measure? 1.3 Was there an equipment inspection procedure(s) to detect the hazardous condition(s)? The investigation established that inspection procedures in effect for forklifts were carried out by the maintenance department only. The Yes box is marked. 1.4 Did the existing equipment inspection procedure(s) detect the hazardous condition(s)? The routine inspection procedure failed to detect faulty brakes on the forklift. Also, the investigation revealed frequent reports of faulty brake problems on forklifts in the past. This indicates that something may be wrong with the maintenance department s existing procedures for detecting this kind of defect. An X in the No circle identifies another causal factor. Recommended Corrective Action: Review the frequency and procedures for inspection and maintenance of brakes by the maintenance department that services forklift trucks. Implement changes to remove any deficiencies. 1.5 Was the correct equipment/tool(s)/material used? The correct equipment was used for this job The Yes box is marked. 1.6 Was the correct equipment/ tool(s)/material readily available? The correct equipment was readily available. The Yes box is marked. 1.7 Did employee(s) know where to obtain equipment/tool(s)/ material required for the job? 1.8 Was substitute equipment/ tool(s)/material used in place of the correct one? Both maintenance employees knew where to obtain the equipment and tools necessary to do this job. The Yes box is marked. Substitute equipment or tool was not used. The No box is marked. 1.9 Did the design of the equipment/tool(s) create operator stress or encourage operator error? This question concerns human factors engineering criteria (ergonomics). Poor equipment design can encourage an operator error. For example, rotating an electrical control clockwise will normally cause something to increase. A counterclockwise rotation normally will cause something to decrease

32 Case Study If the design of the equipment required an operator to increase something by rotating a control counterclockwise, this would encourage operator error, especially in an emergency situation. The investigation should not ignore the design of the equipment as related to human factors engineering principles. Poor design can be a significant causal factor in an incident Did the general design or quality of the equipment/ tool(s) contribute to a hazardous condition? An examination of the braking system revealed only worn brakes, no other defects. Therefore the brake design was not a causal factor. The No box is marked. An X in the Yes circle for 2.0 shows the location of the ladder was a contributing factor. Placing a ladder, without perimeter warnings, in an aisle used by forklifts created a hazard. An X in the Yes circle for 2.1 identifies a causal factor. PART 2 ENVIRNMENT 2.0 Was the location of equipment/materials/employee(s) a contributing factor? If no, proceed to Part 3. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 2.1 Did the location/position of equipment/material/employee(s) contribute to a hazardous condition? Perform job safety analysis. Review job procedures. Change the location, position or layout of the equipment. Change position of employee(s). Provide guardrails, Recommended Corrective Action: A review of the job procedures revealed the overhead work performed from ladders and scaffolds did not require perimeter barriers or warnings of any kind. The corrective action is to change the job procedures for all overhead work involving ladders and scaffolds to require barricades, warning lights, or similar devices to protect the work area when there is a possibility of pedestrian or vehicular traffic. Neither the maintenance pipefitter nor his helper realized 2.2 Was the hazardous condition recognized? If yes, answer A and B. If no, proceed to 2.3. that a hazardous condition had been created by placing the ladder in an aisle used by forklifts. The No circle is marked to identify another causal factor. Recommended Corrective Action: All employees, especially maintenance personnel, should possess some skills that enable them to recognize existing or potentially hazardous conditions. The corrective action is to improve the ability of all maintenance employees to recognize existing or potentially hazardous conditions created by the location or position of equipment or material. Note that the corrective action applies to all maintenance employees, not just the injured worker and his helper. A. Was the hazardous condition reported? B. Was employee(s)informed of the job procedures for dealing with the hazardous condition as an interim action? In accordance with the instructions, questions 2.2A and 2.2B cannot be answered because the placement of the ladder was not recognized as a hazardous condition

33 Case Study 2.3 Was employee(s) supposed to be in the vicinity of the equipment/material? In order to repair the leaking valve, the maintenance employees were required to be on a ladder in the aisle where the incident occurred. The Yes box is marked. Causal Factors 2.4 Was the hazardous condition created by the location/position of equipment/material visible to employee(s)? The hazardous condition created by the ladder in the aisle was seen by the forklift operator, but because of the faulty brakes, not in time to avoid hitting the ladder. The Yes box is marked. 2.5 Was there sufficient workspace? There is no indication that there was sufficient workspace to repair the leaking valve. The Yes box is marked. 2.6 Were environmental conditions a contributing factor (illumination, noise levels, air contaminant, temperature extremes, ventilation, vibration or radiation)? No adverse environmental conditions were revealed in the investigation. The No box is marked. PART 3 PEPLE 3.0 Was the job procedure(s) used a contributing factor? If no, proceed to Part 3.6. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 3.1 Was there a written or known procedure for this job? If yes, answer A, B, and C. If no, proceed to 3.2. Perform job safety analysis and develop safe job procedures. The job procedure was a contributing factor. Investigation showed that the supervisor and maintenance employees knew the procedures for repair of the leaking oil valves. The Yes boxes are marked for 3.0 and 3.1. A. Did job procedures anticipate the factors that contributed to the accident? The job procedures did not anticipate vehicular traffic in the aisle where the ladder was placed. The job procedures were deficient. An X in the No circle identifies another causal factor. Recommended Corrective Action: The corrective action recommended for item 3.1 addresses this causal factor. B. Did employee(s) know the job procedure? The employees knew the job procedures, but did not know the procedure was defective. The Yes box is marked

34 Case Study C. Did employee(s) deviate from the known job procedure? The employees did not deviate from the known job procedures. The No box is marked. 3.2 Was employee(s) mentally and physically capable of performing the job? All employees involved were capable of performing the job. The Yes box is marked. 3.3 Were any tasks in the job procedure too difficult to perform (excessive concentration or physical demands)? There were no excessive tasks involved in this job. The No box is marked. 3.4 Is the job structured to encourage or require deviation from job procedures (incentive, piecework, work pace)? The job was not structured to encourage deviation from the job procedures. The No box is marked. 3.6 Was lack of personal protective equipment or emergency equipment a contributing factor in the injury? If no, proceed to Part 4. Note: The following causal factors relate to the injury. Lack of personal protective equipment or emergency equipment was not a contributing factor in the injury. The No box is marked. If the answer were Yes, the 10 questions for this section would require answers. Because the answer is No, go directly to Part 4 of the form. PART 4 MANAGEMENT 4.0 Was a management system defect a contributing factor? If no, proceed to Part 5. Causal Factors Comment Possible Corrective Actions Recommended Corrective Actions 4.1 Was there a failure by supervisor to detect, anticipate or report a hazardous condition? Improve supervisor capability in hazard recognition and reporting procedures. A management system defect was a contributing factor. The answer to 4.0 is an X in the Yes circle. The maintenance supervisor did not anticipate that placing a ladder in an aisle used by forklift trucks would create a hazardous condition. An X in the Yes circle for 4.1 identifies a causal factor. Recommended Corrective Action: Supervisory skills in hazard recognition need to be upgraded. The corrective action recommended is to improve the ability of maintenance supervisors on all shifts to recognize and anticipate hazardous conditions

35 Case Study 4.2 Was there a failure by supervisor to detect or correct deviations from the job procedure? There was no failure to detect or correct deviations from the job procedure. The No box is marked. 4.3 Was there a supervisor/ employee review of hazards and job procedures for tasks performed infrequently? (Not applicable to all incidents.) The maintenance supervisor did not review existing or potential hazards or the job procedures with the two maintenance employees before they started the repair job. An X in the No circle identifies another causal factor. Recommended Corrective Action: Establish a procedure that requires all supervisors to review hazard potential and job procedures on tasks that are performed infrequently. The investigation established that the maintenance supervisor fully understood his responsibility and accountability as related to incident prevention. The Yes box is marked. The investigation revealed that the maintenance supervisor had previous problems in recognizing or anticipating hazardous conditions. This would indicate that training in this area was inadequate. An X in the No circle identifies another causal factor. Recommended Corrective Action: In addition to the corrective action recommended in 4.1, there should be a review of the supervisor training program concerning hazard recognition. The changes necessary to improve the training program should be implemented. There was no failure to initiate corrective action for 4.4 Was supervisor responsibility and accountability adequately defined and understood? 4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? 4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? known hazardous conditions that contributed to this incident. The No box is marked. The exercise in identifying causal factors and corrective actions, using the Guide for Case #504, is completed. Figure 5 3 shows a completed sample guide for review

36 Case Study Figure 5-2. Causal Factors and Corrective Actions Guide

37 Case Study Figure 5-2. Continued

38 Case Study Figure 5-2. Continued

39 Case Study Figure 5-2. Continued

40 Case Study Figure 5-2. Concluded

41 Chapter 6 Summary of Causal Factors The purpose of summarizing causal factors is to identify those that have contributed most frequently to a group of incidents being analyzed. When causal factors are repeatedly found in a number of investigations, they generally reveal patterns that suggest changes in the management system or in the safety and health program. Repeated analysis over months or years will show long-term trends. These also can be used to evaluate the impact of changes in the management system and the impact of corrective actions taken. The third key document presented in this manual, Summary of Causal Factors (Figure 6 1), suggests a way to summarize causal factors. Each statement in the Summary corresponds to a question in the Guide for Identifying Causal Factors and Corrective Actions. The six columns of boxes next to the statements are provided for tallies of the frequency of occurrence of the causal factors. Essentially a tabulation form, the Guide facilitates the tallying of causal factors by whatever general category and subcategories the analysts selects. A two-step procedure can help identify causal factors in a given category. First, the general category and subcategories are selected, and then the number of cases is recorded on the Summary. Safety personnel usually carry out this kind of analysis. Selecting Categories Many different categories can be selected for analysis. For example, an entire facility or establishment can be treated as a single category. The analysis would then tell management which causal factors were identified most frequently in the incident cases that occurred throughout the establishment in a given period. This information could suggest priorities for general changes in the management system to improve the overall safety and health performance. It is often useful to analyze the causal factors for subcategories within a general category. For example, if the entire plant is the general category, then departments or occupations could be subcategories. r, if the occupation assembler is the general category, then the various amounts of time in the occupation could be the subcategories. If total incidents in a specific department is the general category, subcategories can deal with such factors as occupation or job category, age of worker, number of injuries, or parts of body injured. Many of the items included in the Incident Investigation Report form can be selected as categories for analysis. The general category selected should be written on the Summary form on the line provided, and all of the cases that fall into this category should be tallied in the column

42 Summary of Causal Factors labeled Category Total. If subcategories are used, they should be entered in the other columns. (Add more columns if necessary.) Cases that fall into the general category should be tallied in the Category Total column just as before, but the cases that also fall into one of the subcategories should be tallied again in the appropriate subcategory column. ne advantage of the Summary is its flexibility. The analyst is encouraged to select any general category and any set of subcategories they will all be related to causal factors. Figure 6 1 illustrates a completed Summary. The general category in the illustration is the entire company and the subcategories are the departments within the company. Creating the Summary nce the general category and subcategories have been selected, it is a simple task to tally the causal factors identified in the Guide for each case that falls within the selected category. (Recall: an X in a circle indicates a causal factor whether the response is Yes or No.) The totals in each box in the Summary indicate the number of cases in which the causal factor was found. They should not be added because more than one causal factor is usually identified in each incident. These summaries reveal which causal factors vary from one category to another. This information can suggest priorities for specific changes in the management system or in the safety program. Using the Summary The completed Summary of Causal Factors summarizes 28 incident cases (Figure 6 2). In this example, the entire company was selected as the general category, and its three departments were selected as subcategories. The Summary for the company in the Category Total column highlights the following: A hazardous condition was a contributing factor in 26 of the 28 cases. In 21 of these cases, there was a defect in the equipment, tools, or materials. In 17 of these cases, the hazardous condition was not recognized. (This could account for the high number of defects.) In 13 of these cases, the existing equipment inspection procedures did not detect the hazardous condition. (This could account for the high number of cases in which the hazardous condition was not recognized.) The job procedure was a contributing factor in 25 of the 28 cases. In 13 of these cases, a job procedure existed, but did not anticipate the factors contributing to the incident. A management system defect was a contributing factor in 25 of the 28 cases. In 21 of these cases, a supervisor failed to detect, anticipate, or report a hazardous condition. In 15 of these cases, the supervisor responsibility and accountability were not defined or understood. In 18 of these cases, the supervisor was not adequately trained to fulfill the assigned responsibility in incident prevention

43 Summary of Causal Factors Figure 6 1. Summary of Causal Factors

44 Summary of Causal Factors Figure 6 1. Concluded

45 Summary of Causal Factors Taking Corrective Action The findings in the completed Summary of Causal Factors suggest that management should implement the following changes to improve the establishment s overall safety and health performance. 1. Improve employee skills in recognizing existing or potential hazardous conditions. Focus on hazardous conditions brought about by any changes or modifications, intended or unintended, that may have occurred in equipment, tools, or materials. 2. Upgrade existing equipment inspection procedures to detect defects or hazardous conditions. Consider increasing the frequency or comprehensiveness of the inspections. 3. Review existing job safety analysis (JSA) to determine additional potential causal factors. Conduct JSAs on other jobs that are performed on a regular basis. Change job procedures as indicated by the JSA. Provide job instruction training based on the new job procedures. 4. Provide supervisory training to enable the supervisors to carry out their incident prevention responsibilities. The training should: emphasize the supervisor s role in incident prevention increase the supervisor s skills in detecting and anticipating hazardous conditions specifically define the supervisor s responsibility and accountability The implementation of the four recommended corrective actions derived from the Summary can contribute significantly to improvement in the overall safety of the entire company. The Summary indicates that implementation of the corrective actions should zero in on Department A, where most of the problems are apparent. A summary of the causal factors by occupation or job classification will help to establish priorities and further pinpoint where the corrective actions should be implemented. Much can be learned by looking at the causal factors that contributed to a single incident. Even more can be learned by looking at groups of incidents. The procedures suggested in this manual enable the analyst to do both

46 Summary of Causal Factors Figure 6 2. Sample completed Summary of Causal Factors

47 Summary of Causal Factors Figure 6 2. Concluded