Fishbone diagram

Root Cause Analysis Using Fishbone Diagram: Safety Procedures =============================================================

This document outlines the safety procedures for conducting a root cause analysis (RCA) using a fishbone diagram, also known as an Ishikawa diagram. The goal is to identify potential hazards, prevent future incidents, and improve overall workplace safety. This process involves a systematic approach to determine the underlying causes of an incident or potential hazard, allowing for the implementation of effective corrective actions.

1\. Preparation and Planning

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1\. Define the Problem Statement: Clearly and concisely define the incident or potential hazard that needs to be analyzed. This statement will form the 'head' of the fishbone.

2\. Assemble a Diverse Team: Include individuals with different perspectives and expertise related to the incident or process. This ensures a comprehensive analysis.

3\. Gather Information: Collect all relevant data related to the incident, including witness statements, equipment maintenance records, environmental conditions, and any other pertinent information.

2\. Constructing the Fishbone Diagram

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1\. Draw the 'Backbone': Draw a horizontal arrow pointing to the right. This represents the main process or issue being investigated.

2\. Identify Major Categories: Determine the main categories that could have contributed to the problem. Common categories include:

• Manpower: Human factors, training, experience, and competence.

• Methods: Procedures, work instructions, and processes.

• Machines: Equipment, tools, and technology.

• Materials: Raw materials, components, and supplies.

• Measurement: Data collection, analysis, and accuracy.

• Environment: Workplace conditions, temperature, lighting, and external factors.

3\. Add 'Bones' for Each Category: Draw angled lines (bones) extending from the backbone for each category. Label each bone with the corresponding category.

4\. Brainstorm Potential Causes: For each category, brainstorm potential causes that could have contributed to the problem. Ask 'why' repeatedly to drill down to the root causes.

5\. Add Sub-Branches: For each potential cause, add sub-branches to explore contributing factors or more specific details. Continue to ask 'why' to uncover deeper layers of causation.

3\. Analysis and Hazard Identification

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1\. Review the Diagram: Systematically review the completed fishbone diagram to identify all potential causes and contributing factors.

2\. Identify Hazards: Determine which potential causes represent actual or potential hazards that could lead to future incidents or injuries.

3\. Assess Risk: Evaluate the likelihood and severity of each identified hazard to prioritize corrective actions. Risk assessment methodologies (e.g., risk matrix) can be used.

4\. Developing and Implementing Corrective Actions

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1\. Prioritize Actions: Focus on addressing the root causes that pose the greatest risk and have the highest potential for preventing future incidents.

2\. Develop Action Plans: Create detailed action plans for each corrective action, including specific tasks, responsible parties, timelines, and required resources.

3\. Implement Controls: Implement appropriate control measures to eliminate or mitigate the identified hazards. These may include:

• Engineering controls (e.g., machine guarding, ventilation)

• Administrative controls (e.g., safe work procedures, training)

• Personal protective equipment (PPE) (e.g., gloves, safety boots, eye protection)

4\. Communicate Changes: Ensure that all employees are informed about the identified hazards, the implemented corrective actions, and any changes to work procedures.

5\. Monitoring and Evaluation

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1\. Monitor Implementation: Track the progress of the action plans to ensure that corrective actions are implemented as scheduled.

2\. Evaluate Effectiveness: After implementation, evaluate the effectiveness of the corrective actions in reducing or eliminating the identified hazards. This may involve:

• Incident data analysis

• Workplace inspections

• Employee feedback

3\. Adjust as Needed: If the corrective actions are not effective, revise the action plans and implement additional controls as necessary.

6\. Documentation and Record Keeping

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1\. Document the RCA Process: Maintain detailed records of the entire RCA process, including the problem statement, fishbone diagram, identified causes, corrective actions, and evaluation results.

2\. Retain Records: Keep the records readily accessible for future reference, audits, and continuous improvement efforts.

7\. Training and Competency

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1\. Provide Training: Ensure that all employees involved in the RCA process are properly trained in the use of the fishbone diagram and other RCA techniques.

2\. Verify Understanding: After a suitable interval, workers should be briefed to ensure they understand the rules applicable to their work. [1]

2\. Promote a Safety Culture: Foster a workplace culture where employees are encouraged to report incidents and potential hazards without fear of reprisal.

Compliance with health and safety rules should be considered a condition of employment. Rules must be explained to new workers when they start work or if they are transferred or retrained. [1]

Accident Prevention

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Use protective clothing and safety equipment. Always use approved safety equipment such as: gloves, safety boots, safety hard hats/ goggles and ear protection when necessary. [2]

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