Page 69 - Root Cause Failure Analysis

60 Root Cause Failure Analysis

misinterpretation or prejudice on the part of the interviewer. The use of two interview-
ers will help avoid problems later.

In addition to the questions provided in the section on Identifying Root Cause, acci-
dent or potential safety problems need additional clarification of several factors: phys-
ical impairment, personal problems, and repetition. Many accidents are the direct
result of one or more of these factors. Therefore, the interview process must be con-
figured to address these potential forcing functions and every effort made to deter-
mine if they contributed to the accident.

The investigator should use caution and empathy when addressing these issues with
plant personnel. Many will be reluctant to discuss them with their peers, and even
more so with an investigator who may be perceived as one who would use the infor-
mation to punish the employee.

FATIGUE
Work records should be checked to verify the total hours, including overtime, that the
employee had worked prior to the incident. This review should include a period of at
least six weeks prior to the incident.
However, on-site work records may not always provide a clear picture of the
employee’s fatigue, as some employees work outside the plant. This work may be a
second job or could be nonpaid work such as farming, building or remodeling a
house, attending school, or other activities that limit the amount of rest that the indi-
vidual had prior to the accident.

PHYSICAL IMPAIRMENT
Without the employee’s permission, the investigator cannot verify his or her physical
condition. Unless the company’s policy specifically grants it the right to check medical
records both internally and outside the facility to venfy the worker’s physical condition,
the only way this factor can be judged is on information provided by the employee.

If the employee had a prior accident, there should be a record of any treatment and
work release, which usually is required before he or she can return to full-duty status.
These records should be available to the investigating team. If the employee was on
restricted duty, the investigator also should determine if the restriction had any bear-
ing on the incident.

PERSONAL PROBLEMS
Distractions caused by personal problems are a leading cause of work-related acci-
dents. However, extreme caution must be exercised when trying to ascertain if it was a