Cap _04 Safety Related Issues

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SAFETY RELATED ISSUES

An incident or event that results in injury or death must be fully investigated using

RCFA techniques. Fi gure41 is a logic tree for investigating such an accident or

injury. Refer to Chapter 5 for a detailed discussion of Occupational Safety and Health

Administration requirements for such an investigation.

Because of potential liability and to facilitate the investigation, the accident scene

must

be isolated and preserved until the investigation is complete. In the section

on

preservation of evidence in Chapter 3, preserving the scene was optional, but in the

case of an accident it is required. The entire area surrounding the accident should be

locked-off and barriers erected to prevent access by unauthorized personnel.

Once secured, the scene must be fully documented. Photographs, sketches, and other

documentation are needed to “freeze” all the parameters that may have directly or indi-

rectly contributed to the accident. These data must

be

gathered for analysis at a later time.

The majority of events or incidents, excluding catastrophic equipment failure, can be

directly traced to one

or

more of the generic root cause classifications illustrated in

Figures 3-8 through 3-15. The investigation process first will define which of these

major classifications contributed to the event, then it will isolate the specific root

cause s) that resulted in the incident. The logic used to investigate accidents or events

that resulted in, or could have caused, personal injury is shown in Figure 4-1. This

process identifies those issues most likely to have contributed to this type of incident.

In those safety-related events that also result in equipment failure, these steps should

be used in conjunction with those outlined in the section on Equipment Troubleshoot-

ing in Chapter 3.As in all RCFA, the first step is classifying the incident or event. The

steps outlined in the section on Failure Analysis or Cause and Effect Analysis should

be used for this task. Clear concise answers to the questions in the section on Problem

Clarification will provide a clear definition of the event.

58



Safety Related Issues

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Logic tree illustration

The primary tool for this initial task is the interview process defined in Chapter 3 The

process should use the two-on-one interview technique. Because of potential liability

claims that may result from any incident involving personnel injury or death extreme

care must be taken to ensure accuracy of the acquired data and eliminate any hint of



60 Root Cause

FailureAnalysis

misinterpretation or prejudice on the part of the interviewer. The use of two interview-

ers will help avoid problems later.

In addition to the questions provided in the section on Identifying Root Cause, acci-

dent or potential safety problems need additional clarification of several factors: phys-

ical impairment, personal problems, and repetition. Many accidents are the direct

result of one or more of these factors. Therefore, the interview process must be con-

figured to address these potential forcing functions and every effort made to deter-

mine if they contributed to the accident.

The investigator should use caution and empathy when addressing these issues with

plant personnel. Many will be reluctant to discuss them with their peers, and even

more so with an investigator who may be perceived as one who would use the infor-

mation to punish the employee.

F TIGUE

Work records should be checked to verify the total hours, including overtime, that the

employee had worked prior to the incident. This review should include a period of at

least six weeks prior to the incident.

However, on-site work records may not always provide a clear picture

of

the

employee’s fatigue, as some employees work outside the plant. This work may be a

second job or could be nonpaid work such as farming, building or remodeling a

house, attending school, or other activities that limit the amount of rest that the indi-

vidual had prior to the accident.

PHYSIC LMP IRMENT

Without the employee’s permission, the investigator cannot verify his or her physical

condition. Unless the company’s policy specifically grants it the right to check medical

records both internally and outside the facility to verify the worker’s physical condition,

the only way this factor can be judged is on information provided by the employee.

If the employee had a prior accident, there should be a record of any treatment and

work release, which usually is required before he or she can return to full-duty status.

These records should be available to the investigating team. If the employee was on

restricted duty, the investigator also should determine if the restriction had any bear-

ing on the incident.

PERSON LROBLEMS

Distractions caused by personal problems are a leading cause of work-related acci-

dents. However, extreme caution must be exercised when trying to ascertain if it was a



Safety Related Issues

61

contributing factor to the incident. If the employee does not respond to a question, the

interviewer should not pursue that subject further.

An employee cannot be forced to discuss his or her personal life. If the employee does

not voluntarily provide the information, the interviewer should seek guidance from

the Human Resources manager or the company’s legal advisor.

REPETITION

Repetitive tasks often contribute to accidents. Jobs that require constant repetitive

motion or movement may lead to boredom, inattentiveness, and premature fatigue.

Therefore, the investigator should evaluate the functional requirements of the

employee involved in the accident or safety violation to determine if repetition was a

contributing factor in the incident.

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