AccidentInvestigationRootCauseAnalysisAccidentInvestigationRootCauseAnalysis•Identifythreeconsistentandsystematicapproachestoinvestigatingworkplaceaccidents.•Understandhowtoapplytheseapproachestoaworkplaceaccidentinvestigation.RootCauseAnalysisObjectivesRootCauseAnalysisObjectivesDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisOverviewRootCauseAnalysisOverview•Interviews•Photographs•EquipmentSpecs.•EquipmentManuals•SafetyRules•TrainingRecordsDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisDataCollectionRootCauseAnalysisDataCollection•Organizescollecteddataforanalysis•Sequencediagram•MayuncoverneedsforadditionaldatacollectionDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisEventChartingRootCauseAnalysisEventChartingMarystartscookingMaryleaveskitchenSmokealarmsoundsMaryenterskitchenMaryusesfireext.FEfailsMarythrowswateronfireFirespreadsFirestartsMarycalls911FiredepartmentarrivesFDputsoutfireKitchendestroyedSmokedamagethroughoutrestaurantDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisEventChartingRootCauseAnalysisEventChartingMarystartscookingMaryleaveskitchenSmokealarmsoundsMaryenterskitchenMaryusesfireext.FEfailsMarythrowswateronfireFirespreadsFirestartsMarycalls911FiredepartmentarrivesFDputsoutfireKitchendestroyedSmokedamagethroughoutrestaurantGreaseignitesonburnerALpanmeltsArcingheatspanElectricburnershortsoutFEnotchargedMaryseesfireGreasefireRootCauseAnalysisEventChartingRootCauseAnalysisEventChartingDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisPhoneringsinfrontofrestaurantCasualFactors:1.DirectCause:Immediateevent/conditionthatcausedaccident)2.ContributingCause:Event/conditionthatincreasedprobabilityorseverityoftheaccident3.RootCause:Event/conditionthat,ifcorrected,willpreventrecurrenceDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisCausalFactorAnalysisRootCauseAnalysisCausalFactorAnalysisPotentialCausalFactors:•Lackofawareness•Lackofsafeworkpractices•Lackofadherence/enforcementtosafeworkpractices•Improper/inadequateequipment/materials•Improper/inadequatedesignDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisRootCauseAnalysisCausalFactorAnalysisRootCauseAnalysisCausalFactorAnalysisMarystartscookingMaryleaveskitchenSmokealarmsoundsMaryenterskitchenMaryusesfireext.FEfailsMarythrowswateronfireFirespreadsFirestartsMarycalls911FiredepartmentarrivesFDputsoutfireKitchendestroyedSmokedamagethroughoutrestaurantGreaseignitesonburnerALpanmeltsArcingheatspanElectricburnershortsoutFEnotchargedMaryseesfireGreasefireRootCauseAnalysisCausalFactorAnalysisRootCauseAnalysisCausalFactorAnalysisDataCollectionEventChartingRootCauseIDRecommendationsCausalFactorAnalysisBarrierAnalysisChangeAnalysisElectricburnershortsoutMaryleaveskitchenFEnotchargedMarythrowswateronfirePhoneringsinfrontofrestaurantUsedtoidentifydeviationsfromthenorm•“Whathappened”vs.“Whatshouldhavehappened”•Usedmostlywhenoperationsandstandardized...
