Group # 3
CAUSAL ANALYSIS: RECOGNITION OF
ROOTCAUSE / IDENTIFICATION OF
CORRECTIVE ORPREVENTIVE ACTIONS
INTRODUCTION
Identifying the root causes of accidents is crucial
for preventing them from happening in the future.
Accidents occur in various settings, including
workplaces, transportation, and everyday life.
While the specific root causes may vary depending
on the context, here are some common factors that
can contribute to accidents:
What are Accidents?
•Accidents are unprecedented occurrences
that may or may not result in personal injury,
work stoppage, property damage, interference,
or any combination thereof.
•What causes them to occur?
Root Causes of
Accidents
“Remember PEME"
Unsafe Acts: The Human Factor.
Actions or behaviors that endanger
yourself and put others at risk.
Unsafe Conditions: Multiple
Factors. Environment, Materials,
and Equipment. Creates a
workplace that is not conducive to
workers
Root Cause Analysis
•Risk Assessment: The process of identifying and
evaluating the risks associated with a given hazard and
determining appropriate ways to control or eliminate
risk.
•Can be broken down into methods to identify the
sequence of events or factors involved in an accident.
A successful root cause analysis identifies all possible
root causes of an accident.
Accident Investigation
To look beyond the immediate causes of an
accident and identify the underlying root
causes of the accident.
Helps identify necessary systemic changes
and preventative measures to prevent future
accidents.
.
ADVANCED TECHNIQUES
Gather Information and Determine the
Sequence of Events or Critical
Factors involved.
Analyse the Root Cause.
Events and Causal (or Conditional) Factors Charting
A process that first identifies a sequence of events and aligns them with the
conditions that caused them. These events and respective conditions are aligned in a
time-line.
Chart Format:
All events are enclosed in rectangles, and conditions in ovals
All events are connected by solid arrows
All conditions are connected to other conditions and/or events by dotted arrows
Each event or condition should be based upon valid evidence or, if presumptive,
shown by dotted rectangles or ovals
The primary sequence of events is depicted in a straight horizontal line (bold
arrows are suggested)
Secondary event sequences are presented at different levels
Relative time sequence is from left to right
Example of Events and Causal (or Conditional) Factors Charting
Critical Events
Change Analysis
Change Analysis is a root cause analysis technique that focuses on a specific
problem or problematic event.
Change Analysis is a six-step process
Describing the event or problem
Describing the same situation without the problem
Comparing the two situations
Writing down all the differences
Analyzing the differences
Identifying the consequences of the differences
Barrier Analysis
An investigation of an occurrence that reveals the safeguards put in
place to keep a target safe and examines what happened to determine
whether the barriers were successful, unsuccessful, or somehow
compromised the threat's path from the harmful activity to the target.
Procedure Barrier Analysis
- Have a technical understanding of the system in which the incident occurred
and enough information about the sequence of events to allow analysis to
begin
- Identify the harmful agent or energy that threatens or actually damages a
target that is exposed to it
- Identify the target that is being protected from the harmful agent or energy
- Identify the barriers and controls that separate the energy and target
- Trace meticulously all the interactions between the energy and target and
make them available for analysis
- Create a Barrier Analysis table with several rows, each corresponding to a
distinct episode of energy interaction with a target.
Example of Barrier Analysis
Reality Charting
Root Causes It involves asking "why" of a problem and answering with
Why-why Chart at least two causes in the form of an action and
Five-Why’s Method condition.
Asking “Why” five times The process continues by asking "why" of each answer
Tree Diagram until there are no more answers.
Ishikawa Fishbone Diagram The process is repeated several times until a complete
Story-Telling Method cause and effect chart.
problem definition All causes are then examined to find a way to change
a description of the event them with a solution that is within your control, prevents
who made a mistake recurrence, and meets your goals and objectives.
what is going to be done to The result is clear causal connections between your
prevent recurrence. solutions and the defined problem
Mort Analysis
TECHNIC (TECHNIQUE) OF OPERATIONS REVIEW
(TOR)
The TOR worksheet is divided into eight functional areas, namely:
1. Coaching
2. Responsibility
3. Authority
4. Supervision
5. Disorder
6. Operational
7. Personality Traits
8. Management
TECHNIC (TECHNIQUE) OF OPERATIONS REVIEW
(TOR)
There are four basic steps in the TOR analysis process:
• Establish the facts.
• Trace the root causes.
• Eliminate insignificant causes.
• Identify realistic actions.
Corrective and
Preventative
Actions:
Preventive
action
These actions are taken to prevent incidents from
occurring in the first place. It aims to prevent
future issues by proactively identifying potential
safety hazards or risks.
Corrective
Action
These actions are taken after an incident has taken
place. They aim to address the root causes of these
events and prevent their recurrence.
Accident: Machine Operator Injury in a
Example: Manufacturing Plant
Preventive Actions:
1. Proper Training: Ensure all machine operators receive comprehensive training on machine
operation and safety protocols.
2. Safety Guards and Sensors: Install safety guards and sensors on machines to prevent accidental
contact with moving parts.
3. Regular Maintenance: Implement a strict maintenance schedule to keep all machines in optimal
working condition.
4. Personal Protective Equipment (PPE): Mandate the use of appropriate PPE, such as gloves,
goggles, and ear protection, when operating machinery.
Example: Accident: Machine Operator Injury in a
Manufacturing Plant
Corrective Actions:
1. First Aid and Medical Attention: Provide immediate first aid and arrange for medical attention for the injured
operator.
2. Machine Inspection: Conduct a thorough inspection of the machine to identify any faults or malfunctions that might
have contributed to the accident.
3. Root Cause Analysis: Investigate whether the injury was caused by operator error, machine malfunction, or
inadequate training.
4. Training and Retraining: Provide additional training to the operator if lack of knowledge or negligence was a factor.
Retrain other operators as necessary.
5. Machine Repairs: Repair the machine, replace faulty parts, or decommission it if it cannot be made safe for
operation.
6. Documentation: Document the incident, the actions taken, and include the incident in regular safety training sessions
as a cautionary tale.
Rule 1090-1096 (Coverage of Hazardous Materials in the workplace)
Rule 1090: Hazardous Materials
Rule 1091: Definitions
Rule 1092: Hazardous Chemicals
Rule 1093: Hazardous Substances
Rule 1094: Hazardous Waste Operations and Emergency Response
Rule 1095: Hazard Communication
Rule 1096: Storage and Handling of Hazardous Materials
Rule 1960-1966 (Occupational Health Services)
Rule 1960: Occupational Health Services
Rule 1961: General Provisions
Rule 1962: Hazardous Workplace
Rule 1963: Emergency Health Services
Rule 1964: Training and Qualifications
Rule 1965: Duties of Employers
Rule 1966: Occupational Health Program
Rule 1967: Physical Examination
Rule 1980-1986
Rule 1980: Authority of Local Government
Rule 1981: General Provisions
Rule 1982: Authority to Chartered Cities
Rule 1983: Authority of Municipalities
Rule 1984: Authority of Other Government Agencies
Rule 1985: Application of this Standard of Existing Plans and
Authorities
Rule 1986: Duplication of Inspection
Thank you
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References:
ACCIDENT AND INCIDENT ROOT CAUSE ANALYSIS. (2018). ciobacademy.org.
https://www.ciobacademy.org/wp-content/uploads/2017/07/Root-Cause-
Analysis-2018.pdf
Occupational Safety and Health Standards. (2017). dole.gov.ph.
https://www.dole.gov.ph/php_assets/uploads/2019/04/OSH-Standards-2017-
2.pdf
Hierarchy of Controls | NIOSH | CDC. (n.d.).
https://www.cdc.gov/niosh/topics/hierarchy/default.html
