Systemic Root causes!

Follow Me to Understand:

– How a good incident analysis routine looks like

– How to drive a good quality incident analysis

– How to prevent incident reccurrence

 The standard Routine
5
1
Monitoring. Review
Initial
Standard,
Detection,
procedure. Mgt
Management
System review

4
2
Action plan
System Recording,
resolution.
Improvement Classification
MOC
prioritization
acceptance

3
Analysis
diagnosis

3
 Hazard and Controls
HAZARD- source, situation, or act that has a potential
for harm to people in terms of
injury and/ or illness

CONTROL- safety measures taken to prevent

or mitigate risks of injury and/ or illness

CONTROL ~ ROUTINES ~ SYSTEMS

 The Swiss Cheese principle
HAZARD! Hierarchy of
Controls

Management of change
Tagging
Design reviews

Risk assessment, risk prediction

5S, operational review, BFS
Rules & Standards
Competence building;
Standard routines
Supervision

Management
Individual & PPE
Incident
routines

5
 Incident vs Accident
INCIDENT- any occurrence that is
UNEXPECTED,
UNDESIRED, and
UNFORESEEN
which has the potential to cause harm
or have actually caused harm to people
in terms on injury and/ or illness
ACCIDENT- an incident that has already resulted
to harm to people in terms of
injury and/ or illness
The opportunity of an incident
An incident = a gap in
our routines
Not a checkbox exercise!

Find the gap and

improve our
routines!!
7
 An incident analysis is never done alone
Who are but always with a team of
knowledgeable people:
needed for 1) Injured employee as first hand
witness
an analysis? 2) Leadership of the area
3) Systemic experts (SHE/ QA)
4) Employees with experience from the
area/ transport (or SME)

Analysis Heroes!
Why Incident Analysis?

To prevent RECURRENCE
 Definition and purpose
Basic
Cause

Corrective action just

Basic to eliminate the
Cause
Incident
symptoms

Basic
Cause
Repetitive Root causes of the
Incident incident are not
To be investigated
prevented!!

No actions are
Same root causes taken to block
happen again the root causes
Incident:
Any injury, illness or near miss, property damage, environmental
10harm.
14 September 2023 10
But…
A root cause is the outcome of
the 5 why and should answer the
following 2 questions:
1) Which routine(s) could have
prevented this incident, if working
well? (SHE routines)

2) What should we do to make those

routines work well in the future?
WHAT IS a
root cause?
 Finding the root cause: problem solving diamond
Incident!
WHY

WHY Immediate/Basic Cause

e.g. Operator did not follow the
WHY Man procedure
e.g. The machine had a sharp
Machine edge

WHY
Root Cause
e.g. our training approach is not
WHY Routines monitored
Method e.g. the tagging system is not
/systems embraced by line leaders

13
 How to Analyze Incident?
FBD / Ishikawa Diagram- provides breadth

5 Why’s- provides depth

 The 4 M + 1 E
MACHINE MAN

METHOD

MATERIAL
ENVIRONMENT
15
 How to perform a problem
analysis
Problem Why ? Why? Why? Actions
Incident Cause 1 Cause 1.1 Actions 1.1
Cause 2 Cause 2.1 Cause 2.1.1 Actions 2.1.1
Cause 2.2 Cause 2.2.1 Actions 2.2.1
Cause 2.2.2 Actions 2.2.2
Cause 2.2.3 Actions 2.2.3
Cause 3 .................................................................................................................

16
 5 Why : no issues but opportunities
Every time we use 5Why we have the opportunity to improve !

➢ Every “why” we ask brings us closer to the root cause and further away from
the place of the problem

➢ We stop only asking “why” when we have reached a structural problem to be

solved

➢ Solutions do not only limit themselves to 1 or 2 departments, it helps to

include stakeholders in the analysis

➢ For actions over several departments the escalation process can help

➢ We go for 100% removal of the problem, using all available means necessary!

➢ See incident example in the pitfalls (next slides)

➢ Coaching of the 5Why methodology is necessary on a frequent basis (weekly
5Why review?) in order to get good quality analysis.
17
 5 Why : 5 most common pitfalls
Pitfall 1: Definition of the Incident not correct
Incident: The operator slipped and broke his leg

Coaching questions: “What were the circumstances?”

“Which factors influenced the incident on that location?”
“When this incident is prevented, what else can be improved here?”

Better

Incident: The operator on night shift was walking at normal speed in the shop towards the
exit,inside the walkway.
He slipped on a patch of floor that was worn off and slippery and bumped his leg
against a metal piping support resulting in a broken leg

18
 5 Why : 5 most common pitfalls
Pitfall 2: Jumping to conclusions (not enough why’s)
Problem Statement:

Operator slipped and broke leg Action Plan

WHAT WHY 1 WHY 2 WHY 3 ROOT CAUSE COUNTERMEASURE WHO DATE

Slipped and bumped into metal Give operator new safety

Shoe slippery
support shoes

Coaching questions: “what is the reason for this cause?”

“In which sub causes can you split this?”
“ How many times did you ask yourself why?

Better
Why-Why Analysis
Problem Statement:

Operator slipped and broke leg Action Plan

W
WHAT WHY 1 WHY 2 WHY 3 ROOT CAUSE COUNTERMEASURE WHO DATE
H
no standard for conditions
Slipped and bumped into Operator did not recognize Create shoe standard, yeste
Shoe slippery Shoe worn out of the shoes defined, no TvH
metal support it was worn out define max wearing time rday
max age

19
 5 Why : 5 most common pitfalls
Pitfall 3: not thinking wide enough (only 1 option/why)
sometimes= dismissing possibilities (not writing down)
Why-Why Analysis
Problem Statement:

Operator slipped and broke leg Action Plan

W
WHAT WHY 1 WHY 2 WHY 3 ROOT CAUSE COUNTERMEASURE WHO DATE
H
no standard for conditions
Slipped and bumped into Operator did not recognize Create shoe standard, yeste
Shoe slippery Shoe worn out of the shoes defined, no TvH
metal support it was worn out define max wearing time rday
max age

Coaching questions: “what else can cause this point?”

“What other possibilities did you consider?”
“Is this the only reason why that can happen?”
“ And why else?”
WHAT Better
WHY 1 WHY 2 WHY 3

Slipped and bumped into

metal support
Shoe slippery Shoe worn out
Operator did not recognize
it was worn out
…
what-----03 conn-013-02 conn-052-01 conn-053-01 5Why is also a tool for
wrong type of shoe training others.
conn-058-00

Floor slippery Floor worn out …Be clear on the thinking

conn-049-02 conn-050-01 conn-051-00 process!
Wrong floor application
conn-057-00
20
Operator running
 The 4 M + 1 E
MACHINE MAN

METHOD

MATERIAL
ENVIRONMENT
21
 5 Why : 5 most common pitfalls
Pitfall 4: Quality/quantity of actions insufficient to prevent incident in future
WHAT WHY 1 WHY 2 WHY 3

Slipped and bumped into metal Wrong floor application for this Existing standard not
support
Floor slippery
area mentioning specs A
W
WHY 4 ROOT CAUSE COUNTERMEASURE WHO DATE
H
Current standards not specific SOP for creating standard not TvH Yeste
A enough sufficient
Replace floor
rday

Coaching questions: “Are these actions ensuring 100% the incident never happens again?”
“How can it still happen again after these actions?”
“What actions can we do on top of this to make sure it can never happen again?”
“What is the chance of this happening again after these actions, why not 0%?”

Better
WHAT WHY 1 WHY 2 WHY 3

Slipped and bumped into metal Wrong floor application for this Existing standard not
support
Floor slippery
area mentioning specs A
…

…
W
WHY 4 ROOT CAUSE COUNTERMEASURE WHO DATE
H Replace floor
Include specs in floor standard TvH
Review all standards TvH
Current standards not specific SOP for creating standard not Yeste
Upgrade standards SOP SC
A
…
…

enough sufficient rday

retrain Technical and SHE SB
22 depts TvH
 5 Why : 5 most common pitfalls
Pitfall 5: Backlog on the action plan: going for 80% instead of 100%
Responsible Conclusion
Nr. Origin Start Description of Action Date Day Status Warning light Conclusion
person Date
01 BDA Replace floor TvH 10-фев-10 -198 8-fev-10 OK CONCLUDED ON TIME
02 BDA Include specs in floor standard TvH 15-фев-10 -193 DELAYED
03 BDA Review all standards WS 20-фев-10 -188 18-fev-10 OK CONCLUDED ON TIME
04 BDA Upgrade standards creation SOP WS 25-фев-10 -183 DELAYED
05 BDA Retrain technical and SHE department TvH 28-фев-10 -180 27-fev-10 OK CONCLUDED ON TIME

Coaching questions:“What prevents you from executing all the actions?”

“How do you assess the priority of these incompleted actions?”
“When can we close this analysis?”
“By when are we sure the problem has been permanently removed?”

Better
Responsible Conclusion
Nr. Origin Start Description of Action Date Day Status Warning light Conclusion
person Date
01 BDA Replace floor TvH 10-фев-10 -198 8-fev-10 OK CONCLUDED ON TIME
02 BDA Include specs in floor standard TvH 15-фев-10 -193 10-fev-10 OK CONCLUDED ON TIME
03 BDA Review all standards WS 20-фев-10 -188 18-fev-10 OK CONCLUDED ON TIME
04 BDA Upgrade standards creation SOP WS 25-фев-10 -183 24-fev-10 OK CONCLUDED ON TIME
05 BDA Retrain technical and SHE department TvH 28-фев-10 -180 27-fev-10 OK CONCLUDED ON TIME

For this reason it is important to track the actions completion for incident analysis
seperately from Non-conformities elimination found through other sources.
23
 Finding the missing piece

24 ?Questions?
 EXERCISE

Practice an
analysis
Instructions:

1) Each group will receive an incident + description

2) Analyze the incident (fishbone +5why)
3) Define the routines/ controls that have failed
4) Define corrective actions (for root causes)

25
15 minutes