.

New England Kiln Dryers Association Peter Sformo, Loss Prevention Consultant, W.J. Cox Associates Inc. Associates, Inc

Goals /Objectives Goal – Find Root Cause(s) to a incident Objectives: Obj ti 1. Explain what causal factors are. 2. Define intentional/unintentional errors. 3. Given incidents, determine what type off causall factors f are seen. 4. Given Root Cause map, apply causal f t factors to t find fi d roott causes. W. J. Cox Associates, Inc.

Root Cause?

W. J. Cox Associates, Inc.

Root Cause?

Root Cause?

Lets Back Up  What needs to happen for an accident to occur? Human Errors E i Equipment t Failures F il

W. J. Cox Associates, Inc.

Casual Factors

“The human “Th h errors and d equipment i failures that directly lead to the incident i id or make k the h consequences off the incident larger”

W. J. Cox Associates, Inc.

Causes of Accidents Causal Factor #1

 Human Error

What Types of Human E Error Do D W We Have? H ?

Unintentional U e o a Intentional I t ti l W. J. Cox Associates, Inc.

Unintentional Human Error Committed or Omitted w/ NO prior thought typically think of these as ACCIDENTS  bumping wrong switch  misreading a gauge  spilling coffee on control panel W. J. Cox Associates, Inc.

Intentional Human Errors We DELIBERATELY Commit or Omit because we believe that for whatever reasons  our actions are correct  our actions will be better (safer, quicker, quicker etc)  We think our way is better  etc W. J. Cox Associates, Inc.

Causes of Accidents  Causal Factor #2

 Equipment q p Failures

Root Cause Definition  The basic causes of events.  The absence absence,, neglect, neglect, or deficiencies of managementt systems t th t caused that d th the:  causal factor events to occur or  allowed the causal factor conditions to exist.  For the typical causal factor, there are multiple root causes. W. J. Cox Associates, Inc.

1 29 300 1-29-300 1 Serious / Fatal Injuries (0.30%)

29

300

Minor Injuries (8.8%) Near Miss Miss, Holy Smokes ! (90.99%)

Causal Factors Identified  Human H E Errors – Equipment E i t failures f il  Lets put the Root Cause Chart to work!

W. J. Cox Associates, Inc.

After identifying an intermediate cause, proceed to light green to identify root causes.

Start here with each causal factor

Front-line Personnel Issue 3

Equipment/ Software Issue 2

Process/ Manufacturing Equipment Issue

8

Equipment Reliability Program Issue

Design Issue 18 19

Design Input Issue

20

Design Scope Issue

21

Design Input Data Issue

22

Design Output Issue

23

Design Output Incorrect

24

25

26 27

Design Review/ Verification Issue No Review/Verification Review/Verification Issue

30

Critical Equipment Not Identified

32

Risk Acceptance Issue

33

Periodic Maintenance Issue

34

Scope Issue

35

Frequency Specification Issue

No SPAC or Issue Not Addressed in SPAC

227

SPAC Not Strict Enough

228

SPAC Confusing or Contradictory

229

SPAC Incorrect I t

230

Company Standards, Policies and Administrative Controls (SPAC) Not Used

231

Unaware of SPAC

232

SPAC Recently Changed

233

SPAC Enforcement Issue

Equipment Records and Manuals Issue

60

Documentation Content Inaccurate or Incomplete

61

62 63

64

Documents Not Available or Missing Out-of-date Documents Used Operational and Maintenance History Issue Documentation Content Inaccurate or Incomplete

80

Material/Parts Issue

95

81

Purchasing Specification Issue

Readiness Review Issue

96

Review Not Performed

82

Packaging/ Transportation Issue

97

Implementation Issue

98

Change Control Issue

Acceptance Criteria Issue

99

Acceptance Testing Implementation Issue

100

83

84

85

Handling and Storage Issue

86

Inventoryy Level Issue

87

Product Control and Acceptance Issue

148

Appropriate Tools/ Equipment Not Used

125

Procedure Difficult to Obtain

149

Tools/Equipment Not Functioning Properly

175

Change Identification Issue

126

Procedure Use Discouraged

150

Workplace Layout Issue

176

No Change Assessment Performed

127

Procedure Difficult to Use

151

Individual Control/ Display/Alarm Issue

177

Change Assessment Issue

128

Language Issue

152

Change Assessment Timing Issue

129

Procedure Difficult to Identify

103

Risk Acceptance Issue

130

Wrong Revision Used

Proactive Risk/Safety/ Reliability/Quality/ Security Analysis Issue

131

104

Correct Procedure Used Incorrectly

132

Format Inappropriate

133

Confusing/Complex/ Difficult to Use

134

More than One Action Per Step

135

Inadequate Checklist

136

Graphics/Drawing Issue

137

Language/Wording Issue

138

Insufficient or Excessive References

159

Protective Clothing/ Equipment Issue

139

Too Much/Too Little Detail

160

101

102

Documents Not Available or Missing

88

Product Specification Issue

38

Scope Issue

66

Out-of-date Documents Used

89

Product Acceptance Criteria Issue

39

Event Specification Issue

67

Risk Assessment Records Issue

90

Inspection Issue

91

Packaging, Handling, Transportation Issue

106

Analysis Issue

92

Storage Issue

107

93

Inventory Level Issue

Recommendation Identification Issue

42

Detection Method Issue Monitoring Issue

46

Data Interpretation Issue Fault-finding Maintenance and Inspection Issue

48

Scope Issue

49

Scheduling/Frequency Issue

50

Implementation Issue

51

Corrective Maintenance Issue

52

69

Scope Issue

45

47

68

Troubleshooting/ Corrective Action Issue

53

Repair Implementation Issue

54

Routine Inspection and Servicing Issue

55

Scope Issue

56

Scheduling/Frequency Issue

57

Troubleshooting/ Corrective Action Issue

70 71

72

Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date O t f d t Documents D t Used Personnel Records Issue Documentation Content Inaccurate or Incomplete

73

Documents Not Available or Missing

74

Out-of-date Documents Used

75

76

77

78

Other Documents and Records Issue Documentation C t t Inaccurate Content I t or Incomplete Documents Not Available or Missing Out-of-date Documents Used

122

105

108 109 110

111

Analysis Not Performed

Recommendation Implementation Issue Risk Acceptance Issue Reactive Risk/Safety/ Reliability/Quality/ Security Analysis Issue Problem/Incident Reporting/Identification Issue

112

Investigation Issue

113

Recommendation Identification Issue

114

Recommendation Implementation Issue

115

Risk Acceptance Issue

124

140

141

142

Appropriate Procedure Incorrect/ Incomplete Wrong Action Sequence/Ordering Facts Wrong, Requirements Incorrect, or Content Not ot Updated

155

Awkward/Inconvenient/ Inaccessible Equipment Location Poor/Illegible Labeling of Control/Display/ Alarm or Equipment

197

173

Decision Not to Train

187

174

Training Need Not Identified

Job Plan/Instructions to Workers Issue

No Communication or Not Timely

198

188

Ineffective Walkthrough

Method Unavailable or Inadequate

189

Job Scheduling Issue

199

178

179

180

181

182

157

Housekeeping Issue

184

Ambient A bi t Conditions C diti Issue

Physical Workload Issue Sustained High Workload/Fatigue

162

High Transient Workload

163

Mental Workload Issue

164

Knowledge-based Behavior Issue

143

Inconsistent Procedural Requirements

165

Requirements Not Identified

144

Missing Steps/Content/ Situation Not Covered

166

Skill-based Behavior Issue

118

Implementation Issue

145

167

Unrealistic Monitoring Requirement

119

Recommendation Identification Issue

Overlap or Gaps Between Procedures

168

Error Mitigation Issue

Issue Tracking/ Implementation Issue

169

Errors Not Detectable

120

170

Errors Could Not Be Corrected/Mitigated

Risk Acceptance Issue

Preparation Issue

158

Inspection/Audit/ Measurement Issue

121

186

183

161

185

No Training

Work Environment Issue

156

117

116

Training Implementation Issue Training Program Design/Development Issue Classroom Training g Issue Laboratory/Practical Training Issue

190

200

209

Personnel Hiring Issue

210

Resource/Staffing Issue

Communication Not Timely/Not Performed

211

Rewards/Incentives Issue

Communication Misunderstood/ Incorrect

212

Detection of Individual Performance Problem Issue

Responsibility/Authority Issue

201

Standard Terminology Not Used

213

Individual Issue

192

Supervision During Work Issue

202

Language/Translation Issue

214

Sensory/Perceptual Abilities Issue*

215

Mental Capabilities Issue*

193

Improper Performance Not Corrected

203

Verification/Repeatback Not Used

194

Teamwork/ Coordination Issue

204

Long Message

216

Physical Capabilities Issue*

195

Too Much/Too Little Supervision

205

Other Misunderstood Communications

217

Personal Problem*

206

Wrong Instructions

218

Prescribed Drug Interaction Issue*

219

Horseplay*

220

Off-the-job Rest/Sleep (Fatigue) Issue*

221

Disregard for Company Procedures/Policies*

222

Drug/Alcohol Abuse* Abuse

223

Internal Sabotage or Criminal Activity*

Continuing Training Issue Training Resources Issue Qualification Issue

Root Cause Map™ Shape

Description Causal Factor Type Problem Category Major Root Cause Category Near Root Cause Intermediate Cause

Root Cause Type Root Cause

See Appendix E of ABS Consulting's Root Cause Analysis Handbook for guidance on using this Map.

AN ABS GROUP COMPANY www.ABSConsulting.com/RCA (865) 966-5232

207

Company Issue

191

On-the-job Training Issue Self Study and Computer-based Training Issue

Personnel Selection/ Assignment/Scheduling Issue

Personnel Performance Issue

208

Notes

Available Now!

Peter Sformo, W. J. Cox Associates, Inc.

154

Awkward/Inconvenient/ Inaccessible Location of Control/Display/ Alarm

Rule-based Behavior Issue

Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation by ABS Consulting ISBN #978-1-931332-51-4 See http://www.rothstein.com/new/nr388.htm for book details and ordering Rothstein Associates Inc., Publisher 203.740.7444 or 1.888.ROTHSTEin (1.888.768.4763) www.rothstein.com [email protected]

153

Control/Display/Alarm Integration/ Arrangement Issue

Verbal and Informal Written Communication Issue 196

Supervision Issue

172

Training Requirements Not Completed

Cause Cannot Be Determined 6

External Sabotage and Other Criminal Activity 17

16

Training/ Personnel Qualification Issue 171

Human Factors Issue 146

5

External Events

15

No Procedure for Task/ Operation

65

Implementation Issue Condition-based Maintenance Issue

Natural Phenomena

Tools/Equipment Issue

Event-based Maintenance Issue

Monitoring Issue

Third-party Personnel Issue 14

Procedure Issue

123

Tolerable Risk 4

147

Implementation Issue

41

External Factors

Correct Procedure Not Used

37

40

Contract Personnel Issue 13

Hazard/Defect Identification and Analysis Issue 94

Material/Parts and Product Issue 79

36

44

226

No or Inappropriate Maintenance Selected

59

Company Personnel Issue 12

Other Equipment Issue 11

Utility/Support Equipment Issue 10

Documentation and Records Issue 58

28

Equipment Reliability Program Design Issue

43

Company Standards, Policies and Administrative Controls (SPAC) Issue

9

29

31

Design Output Unclear or Inconsistent

Enter here with each intermediate cause 224

225

Material/Product Issue

Software Issue 7

1

Visit our web site for node descriptions. Copyright 2008, Rev. 11 (06/08)

* These items are for descriptive purposes only. Code only to Personnel Performance - Individual Issue.

Lets Look at the Accident Again g

Another Accident Scenario

Conclusion  ALL accidents should be investigated  Causal factors (human errors and/or equipment failures) should be identified  Root Cause(s) should be identified pp  Corrective actions applied W. J. Cox Associates, Inc.

Thank YOU !

W. J. Cox Associates, Inc.