Page 67 - Root Cause Failure Analysis

SAFETY-RELATED ISSUES

An incident or event that results in injury or death must be fully investigated using
RCFA techniques. Figure41 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.

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