Behavioral Based Safety and Root Cause Analysis in Accident Investigation

1. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis inAccident Investigation Andrew S. Kovacs, Jr., MBA, CWCP

2. Office of Risk Management Annual Conference Making Common Sense –Common Practice! • Unsafe Acts vs. Unsafe Conditions

3. Office of Risk Management Annual Conference When was the last timeyou were asked . . . What Were You Thinking?

4. Office of Risk Management Annual Conference Making Common Sense –Common Practice! There are 3 Basic Types of Behaviors • Intentional Behavior (conscious) • Habitual Behavior • Unintentional Behavior Avoiding Accidents is about being aware of our Behaviors. - or to be more specific... Our At Risk Behaviors It’s about how to prevent mistakes or errors you never wanted to make in the first place.

5. Office of Risk Management Annual Conference Making Common Sense –Common Practice! 3 Basic Types of Behaviors • Intentional Behavior (conscious) • Habitual Behavior • Unintentional Behavior Most of our injuries occur because of our Habitual or our Unintentional Behaviors It boils down to a lack of awareness or not thinking about the consequences of our actions

6. Office of Risk Management Annual Conference Making Common Sense –Common Practice! Our “State of Mind” influences our behavior State of mind Errors Cause, Contribute and Lead to The State to Error Pattern

7. Office of Risk Management Annual Conference Making Common Sense –Common Practice! Being in one or more of the States of Mind can lead to an Error… Like Standing on a chair “just for a second” to reach something. This increases our risk of injury. . . If it’s a Critical Error, you risk Serious Injury Your employees are your Agency’s most precious resource, we need Each and Everyone of you Every Day!

8. Office of Risk Management Annual Conference 3 Distinct Elements of Safety • Human Attributes: (Knowledge, Skills, Ability, Intelligence, Motives, Etc.) ….What do you know? ….What can you do? ….Doing it well versus just doing it

9. Office of Risk Management Annual Conference 3 Distinct Elements of Safety 2.Work Environment: (Equipment, Tools, Machines, Procedures, Facilities, Etc.) ….Indoors/Outdoors (e.g., no shade provided & not enough drinking water)

10. Office of Risk Management Annual Conference 3 Distinct Elements of Safety 3. Behavior: (What People Do) • We are attracted to negative behavior • Who drove the speed limit this weekend/today? • Who texted or talked on their cellphone while driving here today? • We push the envelope

11. Office of Risk Management Annual Conference What is Behavior Based Safety? • Human behavior causes most accidents – Comfort – Saving time – Convenience – Lack of understanding and training – Complacency – Wrong safety focus – Celebrating production over safety

12. Office of Risk Management Annual Conference Behavior Based Safety … • It cannot be successful standing alone • It is an element to be used in combination with other elements • Can’t be the flavor of the month • It’s not a Magic Bullet or Shortcut…

13. Office of Risk Management Annual Conference By The Numbers: Accident/Incident Incidents…….600 Property Damage... 30 Minor Injury…10 Lost-Time Injury….1 Change Behavior at “600” Level & you can prevent the other 3 resulting items

14. Office of Risk Management Annual Conference $$$$ The Cost $$$$ For EVERY $1.00 of Direct Costs for Injury/Illness, There are up to $100 of Indirect Costs

15. Office of Risk Management Annual Conference Behavioral Analysis I • What are Behaviors? • Are Behaviors Observable? • Are Behaviors inherently “Good” or “Bad”?

16. Office of Risk Management Annual Conference Typical Behaviors • Complacency • Apathy • Ignorance versus Stupidity • Time Constraints/Rushing • Fatigue • Lead by Example

17. Office of Risk Management Annual Conference Behavioral Analysis II • Behaviors result in Positive or Negative Consequences for Workers. • Immediate, Sure & Good Consequences Reinforced. • Immediate, Sure & Bad Consequences Refuted.

18. Office of Risk Management Annual Conference Unsafe Acts vs. Unsafe Conditions • 80-85% of all incidents are the result of unsafe acts. • 15-20% of all incidents are the result of unsafe conditions. • Question: If true, why are most efforts geared towards unsafe conditions? • Answer: It’s easier to deal with unsafe conditions than unsafe acts.

19. Office of Risk Management Annual Conference Accident InvestigationWhat Should You Investigate? • All job-relatedaccidents(injury and/or property damage) • All job-related incidents(could have caused injury and/or property damage) involving: • Employees • Clients/Visitors • Property

20. Office of Risk Management Annual Conference Purpose of Investigation • Document facts/findings at the scene • Determine the cause • Implement corrective action to prevent future occurrence

21. Office of Risk Management Annual Conference Identify Corrective Measures & Tools: Root Cause Analysis • Unsafe Act • Unsafe Condition • Contributing Factors

22. Office of Risk Management Annual Conference Definitions • Unsafe Act - A behavioral departure from an accepted, normal, or correct procedure or practice--which has produced injury or property damage or has the potential for doing so; an unnecessary exposure to a hazard; conduct that reduces the degree of safety normally present in an activity. • Unsafe Condition - Any physical state which deviates from that which is acceptable, normal, or correct as regards past or potential future production of injury/illness and property damage; any physical state which reduces the degree of safety. • Contributing Factors - Uncontrollable Events; Nature; Animals/wildlife; Other people

23. Office of Risk Management Annual Conference Root Cause Analysis • Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. • RCA is based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms.

24. Office of Risk Management Annual Conference Principles of RCA? • Aiming corrective actions at root causes is more effective than just treating the symptoms of a problem. • To be effective, RCA must be performed systematically and conclusions must be backed up by evidence. • There is usually more than one root cause for any given problem and therefore there may be more than one corrective action.

25. Office of Risk Management Annual Conference General process for performingroot cause analysis • Define the problem. • Gather data/evidence. • Identify issues that contributed to the problem. • Find root causes. Identify which causes to remove or change in order to prevent repeated problem. • Develop solution recommendations that effectively prevent repeating the problem. • Implement the recommendations/changes. • Observe the recommended solutions/changes to ensure effectiveness of eliminating the problem.

26. Office of Risk Management Annual Conference Cause Mapping ofRoot Cause Analysis • “ROOT” refers to the causes beneath the surface. It is the system of causes that shows all the options for solutions. • Do not focus on a single cause as this can limit the solutions set, resulting in missing a better solution. • A Cause Map provides a simple visual look at all the elements that produced the problem.

27. Office of Risk Management Annual Conference Three Basis Steps of Cause Mapping • Define the issue by its impact to overall goals. • Analyze the cause in a visual map. • Prevent or mitigate any negative impact of the goals by selecting the most effective solutions.

28. Office of Risk Management Annual Conference 7 Best Practices to Remember • Your root cause analysis is only as good as the info you collect. • Your knowledge (or lack of it) can get in the way of a good root cause analysis. • You have to understand what happened before you can understand why it happened. • Interviews are not about asking questions. • You can’t solve all human performance problems with discipline, training, and procedures. • Often people can’t see effective corrective actions even if they can find the root cause. • All investigations do not need to be equal (but some steps can’t be skipped).

29. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

30. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis

31. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

32. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis

33. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

34. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis

35. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

36. Office of Risk Management Annual Conference Behavioral Based Safety and Root Cause Analysis

37. Office of Risk Management Annual Conference Behavioral Based Safety and Root Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

38. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis

39. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Unsafe Condition? • Unsafe Act? • Both?

40. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis

41. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis Root cause analysis is an approach for identifying the underlying causes of an incident so that the most effective solutions can be identified and implemented.

42. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Within an organization: problem solving, incident investigation, and root cause analysis are all fundamentally connected by three basic questions: • What’s the problem? • Why did it happen? • What will be done to prevent it from happening again?

43. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Root causes are underlying causes. • The investigator’s • Goals should identify specific underlying causes. • Should be more specific about why an event occurred, making it easier to arrive at recommendations that will prevent recurrence.

44. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis • Ultimately taking ALL factors into consideration: • Unsafe Conditions – What physical factors contributed to the accident? • Unsafe Acts – What behavioral factors contributed to the accident? • Both – What combination of factors contributed to the accident?

45. Office of Risk Management Annual Conference Behavioral Based Safety andRoot Cause Analysis Questions?