Are these the root causes: <h1>Accident Investigation Case Studies: 5 Whys and Fishbone Analysis</h1> <p>This document presents real-life accident investigation case studies that employ the 5 Whys and Fishbone analysis techniques. These methods are used to determine the root causes of incidents and formulate safety recommendations for management review. The emphasis is on identifying critical safety factors and preventative measures to avoid future occurrences.</p> <h2>Introduction to Accident Investigation Methodologies</h2> <p>The primary goal of incident investigation is to identify the root causes of incidents and prevent similar incidents in the future. It is essential to determine the underlying factors that led to the event, rather than simply recording the steps of the event. The focus should be on finding facts that can lead to corrective actions, not to find fault. Always look for deeper causes. [3] [3]</p> <h3>5 Whys Analysis</h3> <p>The 5 Whys technique is an iterative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal is to determine the root cause of a defect or problem by repeatedly asking the question "Why?". Each answer forms the basis of the next question.</p> <h3>Fishbone Analysis (Ishikawa Diagram)</h3> <p>The Fishbone analysis, also known as the Ishikawa diagram, is a visual tool used to explore the potential causes of a specific effect or problem. It categorizes potential causes into several major categories to identify the root causes. The categories typically include: Task, Material, Environment, Personnel, and Management. [5]</p> <h2>Case Study 1: Fall from Height</h2> <p>Description: A construction worker fell from a scaffold, resulting in a serious injury.</p> <h3>5 Whys Analysis:</h3> <p>Why did the worker fall? Answer: The worker was not properly secured. Why was the worker not properly secured? Answer: The worker's harness was not attached to a secure anchor point. Why was the harness not attached to a secure anchor point? Answer: There were no suitable anchor points available on the scaffold. Why were there no suitable anchor points available? Answer: The scaffold was not erected according to safety standards. Why was the scaffold not erected according to safety standards? Answer: Lack of proper training and supervision.</p> <h3>Fishbone Analysis:</h3> <p>Task: Inadequate safe work procedures for scaffold erection and use. Material: Lack of appropriate anchor points on the scaffold. Environment: Unstable scaffold. Personnel: Insufficient training and competency of workers. Management: Inadequate supervision and enforcement of safety procedures.</p> <h3>Recommendations:</h3> <p>Provide comprehensive training on scaffold erection and safe use. Ensure all scaffolds are equipped with appropriate anchor points. Implement a robust inspection program for scaffolds before each shift. Increase supervision to ensure adherence to safety procedures. Develop and enforce safe work procedures for working at heights.</p> <h2>Case Study 2: Chemical Exposure</h2> <p>Description: A worker experienced chemical burns due to a spill while handling a corrosive substance.</p> <h3>5 Whys Analysis:</h3> <p>Why did the worker experience chemical burns? Answer: The worker was exposed to a chemical spill. Why was there a chemical spill? Answer: The container was dropped. Why was the container dropped? Answer: The worker was not wearing appropriate gloves and lost grip. Why was the worker not wearing appropriate gloves? Answer: The worker was not provided with the correct type of gloves for the chemical. Why was the worker not provided with the correct type of gloves? Answer: Inadequate hazard assessment and PPE selection.</p> <h3>Fishbone Analysis:</h3> <p>Task: Improper handling procedures for corrosive chemicals. Material: Inadequate PPE (gloves). Environment: Spill occurred in an area without proper containment. Personnel: Lack of training on chemical handling and PPE use. Management: Deficient hazard assessment and PPE program.</p> <h3>Recommendations:</h3> <p>Conduct a thorough hazard assessment of all chemicals used in the workplace. Provide appropriate PPE, including chemical-resistant gloves, and ensure proper fit and use. Develop and enforce safe handling procedures for corrosive chemicals. Improve spill containment measures in areas where chemicals are handled. Provide comprehensive training on chemical safety, including hazard communication, handling procedures, and PPE.</p> <h2>Case Study 3: Machine Guarding Incident</h2> <p>Description: A worker's hand was caught in a machine due to a missing guard, resulting in an injury.</p> <h3>5 Whys Analysis:</h3> <p>Why was the worker's hand caught in the machine? Answer: The machine guard was missing. Why was the machine guard missing? Answer: The guard was removed for maintenance and not replaced. Why was the guard not replaced? Answer: There was no procedure in place to ensure guards are replaced after maintenance. Why was there no such procedure? Answer: Management failed to implement a comprehensive machine guarding program. Why did management fail to implement a machine guarding program? Answer: Lack of awareness of machine guarding requirements and potential hazards.</p> <h3>Fishbone Analysis:</h3> <p>Task: Inadequate lockout/tagout procedures during maintenance. Material: Missing machine guard. Environment: Work area not inspected for safety compliance. Personnel: Lack of training on machine guarding and maintenance procedures. Management: Failure to implement and enforce a machine guarding program.</p> <h3>Recommendations:</h3> <p>Implement a comprehensive machine guarding program, including regular inspections and maintenance. Develop and enforce lockout/tagout procedures for all maintenance activities. Provide training to all employees on machine guarding requirements and safe operating procedures. Ensure all machine guards are properly installed and maintained. Conduct regular safety audits to identify and correct machine guarding deficiencies.</p> <h2>Critical Safety Factors and Preventative Measures</h2> <p>Training and Competency: Ensure all workers are adequately trained and competent to perform their tasks safely. This includes training on safe work procedures, hazard identification, and the proper use of PPE. [2] [4]</p> <p>Hazard Assessment and Risk Management: Conduct thorough hazard assessments to identify potential hazards and implement appropriate control measures to eliminate or minimize risks. [2]</p> <p>Safe Work Procedures: Develop and enforce safe work procedures for all tasks, ensuring that workers follow these procedures consistently. [1] [2]</p> <p>Supervision and Enforcement: Provide adequate supervision to ensure that workers are following safety procedures and that hazards are promptly addressed. [2]</p> <p>Equipment Maintenance: Implement a regular maintenance program for all equipment to ensure that it is in safe operating condition. [2]</p> <p>Incident Reporting and Investigation: Establish a system for reporting and investigating all incidents, including near misses, to identify root causes and prevent future occurrences. [1]</p> <p>Hierarchy of Controls: Apply the hierarchy of controls (elimination, substitution, engineering controls, administrative controls, and PPE) to select the most effective control measures.</p> <h2>Management Review and Commitment</h2> <p>Management must demonstrate a strong commitment to safety by providing the necessary resources and support for implementing safety recommendations. Regular reviews of safety performance and corrective actions should be conducted to ensure continuous improvement. [2]</p> <h2>Conclusion</h2> <p>By employing methodologies like the 5 Whys and Fishbone analysis, organizations can effectively identify the root causes of accidents and implement targeted preventative measures. A proactive approach to safety, combined with strong management commitment, is essential for creating a safe and healthy work environment.</p> <p>Safety powered by SALUS</p>

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# Safeguarding - Working around Machinery (cont.) ## What are some hazards that are associated with machinery and powered equipment? (cont.) <table><tr><th rowspan="2">Possible Hazard</th><th colspan="2">Check One</th><th rowspan="2">Notes</th></tr><tr><td>OK</td><td>Needs Investigation</td></tr><tr><td>Consider tasks associated with different phases of the machine's life start-up and programming loading, packing, transporting, unpacking decommissioning and disposal</td><td></td><td></td><td></td></tr><tr><td colspan="4">Mechanical Components</td></tr><tr><td>At the point of operation, identify the following:</td><td></td><td></td><td></td></tr><tr><td>what parts move</td><td></td><td></td><td></td></tr><tr><td>the range of motion of moving parts</td><td></td><td></td><td></td></tr><tr><td>the type of motion (e.g., rotation, shearing, bending, cutting, punching)</td><td></td><td></td><td></td></tr><tr><td>Note - the point of operation refers to the area of the machine where useful work is performed. Typically this point is where an operator has contact with the machine.</td><td></td><td></td><td></td></tr><tr><td>Identify how power is transmitted to the machine hydraulic pneumatic mechanical</td><td></td><td></td><td></td></tr><tr><td>If present, identify if the machine has a brake or clutch, and how it operates</td><td></td><td></td><td></td></tr><tr><td>Identify all the "in-running nip points" on the machine</td><td></td><td></td><td></td></tr><tr><td>Identify all the pinch points on the machine</td><td></td><td></td><td></td></tr><tr><td>Identify entanglement hazards of the machine as a result of contact with:</td><td></td><td></td><td></td></tr></table> Safeguarding - Working around Machinery CCOHS

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# Causation Models (cont.) ## Task (cont.) To seek out possible causes resulting from the equipment and materials used, investigators might ask: - Was there an equipment failure? - What caused it to fail? - Was the machinery poorly designed? - Were hazardous products involved? - Were they clearly identified? - Was a less hazardous alternative product possible and available? - Was the raw material substandard in some way? - Should personal protective equipment (PPE) have been used? - Was the PPE used? - Were users of PPE properly educated and trained? Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist. ## Work Environment The physical work environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the incident is what is important, not what the "usual" conditions were. For example, investigators may want to know: - What were the weather conditions? - Was poor housekeeping a problem? - Was it too hot or too cold? - Was noise a problem? - Was there adequate light? - Were toxic or hazardous gases, dusts, or fumes present? ## Personnel The physical and mental condition of those individuals directly involved in the event must be explored, as well as the psychosocial environment they were working within. The purpose for investigating the incident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics or psychosocial factors are considered. Some factors will remain essentially constant while others may vary from day to day: Incident Investigation CCOHS

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# Enclosure and Isolation These methods aim to keep the chemical "in" and the worker "out" (or vice versa). An enclosure keeps a selected hazard "physically" away from the worker. Enclosed equipment, for example, is tightly sealed and it is typically only opened for cleaning or maintenance. Other examples include "glove boxes" (where a chemical is in a ventilated and enclosed space, and the employee works with the material by using gloves that are built-in), abrasive blasting cabinets, or remote control devices. Care must be taken when the enclosure is opened for maintenance as exposure could occur if adequate precautions are not taken. The enclosure itself must be well maintained to prevent leaks. Isolation places the hazardous process "geographically" away from the majority of the workers. Common isolation techniques are to create a contaminant-free or noise-free booth either around the equipment or around the employee workstations. ## Ventilation Ventilation is a method of control that "adds" and "removes" air in the work environment. General or dilution ventilation can remove or dilute an air contaminant if designed properly. Local exhaust ventilation is designed to remove the contaminant at the source so it cannot disperse into the work space, and it generally uses lower exhaust rates than general ventilation (general ventilation usually exchanges the air in the entire room). Local exhaust ventilation is an effective means of controlling hazardous exposures but should be used when other methods (such as elimination or substitution) are not possible. Fan Figure 3 Example of Local Exhaust Ventilation The design of a ventilation system is very important and must match the particular process and product in use. Expert guidance should be sought. It is a very effective control measure but only if it is designed, tested, and maintained properly. Hazard and Risk - Hierarchy of Controls CCOHS

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# Hazard and Risk - Hazard Identification (cont.) ## What types of hazards are there? (cont.) - Biological - bacteria, viruses, fungi, insects, plants, and animals. - Chemical - depends on the physical, chemical, and toxic properties of the product - Ergonomic - repetitive movements, improper setup of workstations, etc. - Physical - radiation, magnetic fields, temperature extremes, pressure extremes (high pressure or vacuum), noise, vibration, etc. - Psychosocial - stress, violence, harassment, etc. - Safety. - slipping or tripping hazards, inappropriate machine guarding, equipment malfunctions or breakdowns. ## How do I know what is a hazard? Another way to look at health and safety in your workplace is to ask yourself the following questions. These are examples only. You may find other items or situations that can be a hazard. List any item that should be examined. During the risk assessment process, the level of harm will be assessed. What materials or situations do I come into contact with? Possibilities could include: - Electricity. - Chemicals (liquids, gases, solids, mists, vapours, etc.). - Temperature extremes of heat or cold (such as working outdoors, bakeries, foundries, or meat processing). - lonizing and non-ionizing radiation (such as x-rays, ultraviolet (sun) rays). - Asphyxiants (oxygen deficiency) - Working on or near water or ice-covered water. What materials or equipment could I be struck by? - Moving objects (such as forklifts, overhead cranes, vehicles). - Flying objects (such as sparks or shards from grinding). - Falling material (such as tools and equipment from above). What objects or equipment could strike or hit my body, or that part of my body might be caught in, on, or between? - Stationary or moving objects. - Protruding objects. - Sharp or jagged edges. Hazard and Risk - Hazard Identification CCOHS

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# Causation Models (cont.) ## Personnel (cont.) - Did the worker follow the safe operating procedures? - Were workers experienced in the work being done? - Had they been adequately educated and trained? - Can they physically do the work? - What was the status of their health? - Were they tired? - Was fatigue or shiftwork an issue? - Were they under stress (work or personal)? - Was there pressure to complete tasks under a deadline, or to by-pass safety procedures? ## Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation. These factors may also be called organizational factors. Failures of management systems are often found to be direct or indirect causes. Ask questions such as: - Were safety rules or safe work procedures communicated to and understood by all employees? - Were written procedures and orientation available? - Were the safe work procedures being enforced? - Was there adequate supervision? - Were workers educated and trained to do the work? - Had hazards and risks been previously identified and assessed? - Had procedures been developed to eliminate the hazards or control the risks? - Were unsafe conditions corrected? - Was regular maintenance of equipment carried out? - Were regular safety inspections carried out? - Had the condition or concern been reported beforehand? - Was action taken? Incident Investigation CCOHS

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# How do I "identify potential hazards"? (cont.) <table><tr><th>Sequence of Events</th><th>Potential Incidents or Hazards</th><th>Preventive Measures</th></tr><tr><td>1. Park vehicle</td><td>a) Vehicle too close to passing traffic b) Vehicle on uneven, soft ground c) Vehicle may roll</td><td></td></tr><tr><td>2. Remove the spare tire and tool kit</td><td>a) Strain from lifting spare tire</td><td></td></tr><tr><td>3. Pry off the hub cap and loosen lug bolts (nuts)</td><td>a) Hub cap may pop off and hit you b) Lug wrench may slip</td><td></td></tr><tr><td>And so on</td><td>a)</td><td></td></tr></table> Again, all participants should jointly review this part of the analysis. ## How do I "determine preventive measures?" The next step in a job safety analysis is to determine ways to eliminate the hazards or control the risks identified. Hazards should be controlled using the hierarchy of controls. The hierarchy of controls is a step-by-step approach to eliminating or reducing workplace hazards. For more information, please see the OSH Answers on Hierarchy of Controls. Following the same principles as the hierarchy of controls, you would implement preventive measures in the following order of preference: ## 1. Eliminate the hazard Elimination is the most effective measure. These techniques should be used to eliminate the hazards: - Choose a different process - Modify an existing process - Substitute with less hazardous product - Improve environment (e.g., ventilation) - Modify or change equipment or tools In the hierarchy of controls, these would be elimination or substitution controls. 2. Contain the hazard Job Safety Analysis CCOHS

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# Causation Models (cont.) ## What should be done if the investigation reveals human error? (cont.) Failing to point out human failings that contributed to an incident will not only downgrade the quality of the investigation, it will also allow future incidents to happen from similar causes because they have not been addressed. However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures. ## How should follow-up be done? Management is responsible for acting on the recommendations in the investigation report. The health and safety committee or representative, if present, can monitor the progress of these actions. Follow-up actions include: - Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not). - Develop a timetable for corrective actions. - Monitor that the scheduled actions have been completed. - Check the condition of injured worker(s). - Educate and train other workers at risk. - Re-orient worker(s) on their return to work. Fact sheet last revised: 2019-11-26 ## Disclaimer Although every effort is made to ensure the accuracy, currency and completeness of the information, CCOHS does not guarantee, warrant, represent or undertake that the information provided is correct, accurate or current. CCOHS is not liable for any loss, claim, or demand arising directly or indirectly from any use or reliance upon the information. Incident Investigation CCOHS

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# Safeguarding - Working around Machinery (cont.) ## What are some hazards that are associated with machinery and powered equipment? (cont.) <table><tr><th rowspan="2">Possible Hazard</th><th colspan="2">Check One</th><th rowspan="2">Notes</th></tr><tr><td>OK</td><td>Needs Investigation</td></tr><tr><td>rotating and moving parts materials in motion projections or gaps</td><td></td><td></td><td></td></tr><tr><td>Identify where a worker could come in contact with parts moving at a high velocity (e.g., abrasion or friction hazards)</td><td></td><td></td><td></td></tr><tr><td>Identify cutting or severing hazards where a worker could come in contact with cutting tools, saws, routers, knives, or sharp materials</td><td></td><td></td><td></td></tr><tr><td>Identify shearing hazards where a worker could be severely cut by being between two machine parts or between a machine part and a workpiece or stationary object</td><td></td><td></td><td></td></tr><tr><td>Identify crush hazards where a worker could be caught between parts of a machine moving against one another</td><td></td><td></td><td></td></tr><tr><td>Identify if it is possible to be struck or punctured by flying objects</td><td></td><td></td><td></td></tr><tr><td>Review the machine's operation to determine if a worker could come into contact with pressurized liquids or gases</td><td></td><td></td><td></td></tr><tr><td>Identify any sharp edges and angular parts that protrude (stick out) from the machine</td><td></td><td></td><td></td></tr><tr><td>Identify situations where harm may occur if there was a fault or break in the machine or material (breakage point)</td><td></td><td></td><td></td></tr><tr><td>Identify situations where harm may occur if the machine's operating software (if applicable) fails.</td><td></td><td></td><td></td></tr><tr><td colspan="4">Worker specific considerations</td></tr><tr><td>Identify all work that a worker must perform while operating the machine, including:</td><td></td><td></td><td></t…

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# Incident Investigation (cont.) ## What is an incident and why should it be investigated? (cont.) The information that follows is intended to be a general guide for employers, supervisors, health and safety committee members, or members of an incident investigation team. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event. Reasons to investigate a workplace incident include: - most importantly, to find out the cause of incidents and to prevent similar incidents in the future - to fulfill any legal requirements - to determine the cost of an incident - to determine compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.) - to process workers' compensation claims The same principles apply to an inquiry of a minor incident and to the more formal investigation of a serious event. Most importantly, these steps can be used to investigate any situation (e.g., where no incident has occurred yet) as a way to prevent an incident. ## Who should do the investigating? Ideally, an investigation would be conducted by someone or a group of people who are: - experienced in incident causation models, - experienced in investigative techniques, - knowledgeable of any legal or organizational requirements, - knowledgeable in occupational health and safety fundamentals, - knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation, - able to use interview and other person-to-person techniques effectively (such as mediation or conflict resolution), knowledgeable of requirements for documents, records, and data collection; and - able to analyze the data gathered to determine findings and reach recommendat…

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# Incident Investigation (cont.) ## Why look for the root cause? (cont.) - Was a safe work procedure being followed? If not, why not? - Were safety devices in order? If not, why not? - Was the worker trained? If not, why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction. ## What are the steps involved in investigating an incident? First: - Report the incident occurrence to a designated person within the organization. - Provide first aid and medical care to injured person(s) and prevent further injuries or damage. The incident investigation team would perform the following general steps: - Scene management and scene assessment (secure the scene, make sure it is safe for investigators to do their job). - Witness management (provide support, limit interaction with other witnesses, interview). - Investigate the incident, collect data. - Analyze the data, identify the root causes. - Report the findings and recommendations. The organization would then: - Develop a plan for corrective action. - Implement the plan. - Evaluate the effectiveness of the corrective action. - Make changes for continual improvement. As little time as possible should be lost between the moment of an incident and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera or recording device, tape measure, etc.) should be immediately available so that no time is wasted. What should be looked at as the cause of an incident? Incident Investigation CCOHS

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# Safeguarding - Working around Machinery (cont.) ## What are some hazards that are associated with machinery and powered equipment? (cont.) <table><tr><th rowspan="2">Possible Hazard</th><th colspan="2">Check One</th><th rowspan="2">Notes</th></tr><tr><td>OK</td><td>Needs Investigation</td></tr><tr><td>how stock is fed into the machine how final products are removed from the machine removal of scrap periodic cleaning of the point of entry and other parts of the machine pre-shift safety checks</td><td></td><td></td><td></td></tr><tr><td>Identify if the machine needs to be locked out before any adjustments or repairs occur</td><td></td><td></td><td></td></tr><tr><td>Identify all work that must be done when performing maintenance</td><td></td><td></td><td></td></tr><tr><td>Identify all work that must be done to change a tool or die</td><td></td><td></td><td></td></tr><tr><td>Identify any potential slip or fall hazards in and around the machine as a result of the floor surface, or due to material spills (e.g., lubricating oils, grease, water, saw dust, plastic pellets)</td><td></td><td></td><td></td></tr><tr><td>Identify other possible hazards, for example vibration or noise</td><td></td><td></td><td></td></tr><tr><td>Identify potential ergonomic issues in the operation of the machine. Make sure that the: worker does not have to reach excessively worker does not have to use excessive force worker does not have to perform high frequency movements machine cycle is based upon worker capacity, not visa versa</td><td></td><td></td><td></td></tr></table> Safeguarding - Working around Machinery CCOHS

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# How do I "identify potential hazards"? (cont.) ## 1. Eliminate the hazard (cont.) If the hazard cannot be eliminated, contact might be prevented by using enclosures, machine guards, worker booths or similar devices. These are generally engineering controls. ## 3. Revise work procedures Consideration might be given to modifying steps which are hazardous, changing the sequence of steps, or adding additional steps (such as locking out energy sources). Work procedures and training fall under administrative controls. ## 4. Reduce the exposure These measures are the least effective and should only be used if no other solutions are possible. One way of minimizing exposure is to reduce the number of times the hazard is encountered. An example would be modifying machinery so that less maintenance is necessary. The use of appropriate personal protective equipment may be required. To reduce the severity of an incident, emergency facilities, such as eyewash stations, may need to be provided. This preventive measure is also an administrative control. Reducing the exposure may include using personal protective equipment. It is important to note that personal protective equipment can limit exposure to the harmful effects of a hazard, but only if the personal protective equipment is worn and used correctly. In listing the preventive measures, do not use general statements such as "be careful" or "use caution." Specific statements which describe both what action is to be taken and how it is to be performed are preferable. The recommended measures are listed in the right-hand column of the worksheet, numbered to match the hazard in question. For example: Job Safety Analysis CCOHS

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# How is a risk assessment done? (cont.) - The methods and procedures used in the processing, use, handling, or storage of the substance, etc. - The actual and the potential exposure of workers (e.g., how many workers may be exposed, what that exposure is or will be, and how often they will be exposed). - The measures and procedures necessary to control such exposure by means of engineering controls, work practices, and hygiene practices and facilities. - The duration and frequency of the task (how long and how often a task is done). - The location where the task is done. - The machinery, tools, materials, etc., that are used in the operation and how they are used (e.g., the physical state of a chemical or lifting heavy loads for a distance). - Any possible interactions with other activities in the area and if the task could affect others (e.g., cleaners, visitors, etc.). - The lifecycle of the product, process, or service (e.g., design, construction, uses, decommissioning). - The education and training the workers have received. - How a person would react in a particular situation (e.g., what would be the most common reaction by a person if the machine failed or malfunctioned). It is important to remember that the assessment must take into account not only the current state of the workplace but any potential situations as well. By determining the level of risk associated with the hazard, the employer and the health and safety committee (where appropriate) can decide whether a control program is required and to what level. See a sample risk assessment form. ## How are the hazards identified? Overall, the goal is to find and record possible hazards that may be present in your workplace. It may help to work as a team and include both people familiar with the work area, as well as people who are not - this way you have both the experienced and fresh eye to conduct inspections and evaluations. In either case, the person or team should be competent to carr…