TBT 11: ROOT CAUSE ANALYSISHILLS’ ETHOS:

IMPROVEMENT ENGAGEMENT PREVENTION ACCOUNTABILITYPROGRESSIVE FRONT FOOT

ROLES AND RESPONSIBILITIES

HWS – Toolbox Talk 11 Root Cause Analysis v001 23.12.13

TBT 11 ROOT CAUSE ANALYSIS

 1.ROOT CAUSE ANALYSIS FOR PROBLEM SOLVING

 

A.Nonconformity

B.Accident / Incident / Near-miss / Near-hit

C.Process Problems

D.Environmental Problems

E.Complaints

F.Missed Targets/Goals 1 of 9

TBT11 ROOT CAUSE ANALYSIS

2. : HOW TO CARRY OUT INVESTIGATIONS

 

A. Gathering information

B. Analysing the information

C. Identifying risk control measures

D. The action plan and its implementation

  

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3. GATHERING INFORMATION / THE INVESTIGATION:

A. The investigation team

B. What happened?

C. Where and when did it happen?

D. Why did it happen?

E. Who was involved?

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TBT11 ROOT CAUSE ANALYSIS

TBT11 ROOT CAUSE ANALYSIS

4 ANALYSING THE INFORMATION:

A.Systematic analysis of causes and consequences

B.What information is missing?

C.Immediate causes

D.Root causes

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TBT11 ROOT CAUSE ANALYSIS

5. LIKELY RESULTS OF THE ANALYSIS:

 

A.Job factors

B.Human factors

C.Human failings

D.Organisational factors

E.Plant and equipment factors

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TBT11 ROOT CAUSE ANALYSIS

6. IDENTIFYING RISK CONTROL MEASURESA.Draw up a list of possible control measures

B.Evaluate each of the possible control measures

C.Prioritise the possible control measures

D.Have similar adverse events happen before?E.Can the control measures be applied elsewhere? 6 OF 9

7. THE ACTION PLAN AND ITS IMPLEMENTATION:

A.Who is involved?

B.SMART objectives

C.Risk assessments update

D.Safe working procedures update

E.Full recording and analysis

F.Further investigations7 of 9

TBT11 ROOT CAUSE ANALYSIS

TBT11 ROOT CAUSE ANALYSIS

8. COMMON PROBLEMS IN RCA INVESTIGATIONS:

A.Inexperienced investigators

B.Defensive/forgetful employees

C.Failure to find immediate cause(s)

D.Failure to find the root cause(s)

E.Unable to find / devise a solution

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TBT11 ROOT CAUSE ANALYSIS9. REVISION

1.Root cause analysis for problem solving

2.How to carry out investigations

3.Gathering information/the investigations

4.Analysing the information

5.Likely results of the analysis

6. Identifying risk control measures

7.The action plan and its implementation

8.Common problems in RCA investigations

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TBT 11: ROOT CAUSE ANALYSIS

Statistically, waste management and recycling has a very high accident rate

Do NOT walk on by!

Report accidents, incidents & near-misses!

“See it – sort it”

Do NOT become a statistic!

HILLS’ ETHOS: IMPROVEMENT ENGAGEMENT PREVENTION

ACCOUNTABILITY PROGRESSIVE FRONT FOOTROLES AND RESPONSIBILITIES