PSM Focus Group

Kuwait Chapter

Training
Process Safety Management

Incident Investigation
Session 2; April 7, 2020

Ujwal Ritwik
CRSP, QEP, REM, LA ISO 45001/14001/9001

PSM Expert
Objectives

Participants will -
 Get an overview of Causal Analysis
 Get to know what is Root Cause Analysis
 What are the techniques used for RCA
 Use of ‘Five Whys’ technique for simpler problems
 Cause and effect process for investigating deep
 Learn incident investigation and problem solving steps
 View use of RCA technique as heart of incident investigation
 Learn how to ensure quality investigations
Agenda for Session 2

 Revisit of Problem solving process and RCA

 Incident investigation steps and approach
 Investigation tools and techniques
 RCA methods – importance of cause and effect charting
 Solution Development - Corrective action plan and Report
 Good company procedure
 RCA Quality control
 Question - answer
Why I am interested
– I remain deeply interested in Process Safety
– Background of Nuclear Industry where public risk perception is critical
– Process improvement was part of my study while pursuing Business
Administrations program
– My first general manager Mr. Rapial
– Dr. Bill Corcoran
– ISO standards, auditing and continual improvement

Training on RCA : Ujwal Ritwik

What did we do in Session 1 (RCA)
• Problem solving process
• Cause and effect understanding
• Root cause and Root Cause Analysis
• RCA methods
• Five Whys example

Training on RCA : Ujwal Ritwik

Revisit Problem Solving and
RCA
I keep six serving men
(They taught me all I know);

Their names are What and Why and When

and How and Where and Who.

- Rudyard Kipling
Training on RCA : Ujwal Ritwik
Types of Problems

• Problems can occur in any sphere of a person’s life and take any shape
• Personal problems
• Organizational problems
• Two types of problems
• Rule based problems
• Event based problems

Training on RCA : Ujwal Ritwik

Rule Based Problems

Problem Answer Based on

What is 1+1? 2 Math fundamental

What PPE required Hard hat Work procedure

What is the speed limit on 120kmph Govt. law

highway?
When the game is a Equal # of Rule of the game
draw? goals
Event Based Problems

Problem Answer Based on

Seal leaked ? ?

PPE not worn ? ?

Speed limit exceeded ? ?

Goalkeeper did not stop ? ?

the ball

Answer could be many, based on cause and effect relationship

How to solve a problem?
• Identify the cause or causes of the problem
• Find ways to eliminate these causes and prevent them from
recurring

• Applying rule-based solutions to causal relationships is generally

ineffective
• Issue penalty ticket
• Disciplinary action
• Retrain employee

Training on RCA : Ujwal Ritwik

What is Root Cause Analysis (RCA)

• A collective term used to describe a wide range of approaches, tools

and techniques used to uncover causes to problems
• Various tools suited for various jobs

Training on RCA : Ujwal Ritwik

Training on RCA : Ujwal Ritwik
 Visible Problem SYMPTOMS

First level cause

Higher level cause

Root
Cause
Training on RCA : Ujwal Ritwik
How to remove
the weed
Permanently?

• Root - the point of growth

• Original Latin word for root is ‘radical’
• In use since pre-historic times, part of human development process
Best strategy to deal with a problem

ELIMINATE
ROOT CAUSE

MONITOR SYMPTOMS

Training on RCA : Ujwal Ritwik

 SYMPTOMS
Without monitoring
symptoms/visible
cause
we are blind!

Training on RCA : Ujwal Ritwik

The management process of
Continual Improvement requires un-stopped
problem identification and resolution

ACT

CHECK PLAN

DO

Training on RCA : Ujwal Ritwik

 1
Solution 1 recognize there is a problem, if
5 monitor symptoms you consider it normal it will never
signaling presence of Implementation Incident
& Capture improve;
problem call the problem by its real name -
Monitoring
define

Solution
Development
5 Data
Gathering &
processing

4 attack and eliminate

2 thoroughly understand the
root cause C&E nature - basis for ultimately
Charting solving it
3 find the root
causes Training on RCA : Ujwal Ritwik
Quiz 1
1. Applying rule-based solutions to causal relationships is generally
ineffective
2. As per preceding discussions there are five steps in problem solving
3. Eliminate symptoms and monitor root causes

Training on RCA : Ujwal Ritwik

Incident Investigation Steps
and Approach
Incident is a Problem – approaches for
investigation are similar
• Fatality • No loss dangerous occurrence
• Injury, illness, first aid • Business continuity
• Oil spill • Crisis handling
• Effluent discharge • Adverse image
• Release to air • Failure to achieve an objective
• Adverse environmental impact • Concerns and issues
• Equipment/plant damage • Threat
• Asset / property damage • Any problem
• Defect elimination
• Near Miss Training on RCA : Ujwal Ritwik
Management Involvement in Investigation
• Problems, their resolution and path to continual improvement are
management responsibility
• It is a culture building exercise
• Every manager must drive the process
• Get involved in improvement of RCA and investigation process
• Your role to ensure - Incidents and problems are reported,
unhindered data gathering occurs, professional analysis done,
corrective actions are followed through to completion

Training on RCA : Ujwal Ritwik

Incident Management
Best practice –
Pre
• Analysis and lessons always
Planning continue all the time
• Investigation team is standby
Emergency at all times
Response

Recovery

Analysis &
Lessons
Training on RCA : Ujwal Ritwik
Incident Investigation – 5 steps
1
1 recognize there is a problem, if
5 monitor symptoms Solution you consider it normal it will never
signaling presence of Incident improve;
Implementation
problem Capture call the problem by its real name -
&
Monitoring define

Solution
Development
5 Data
Gathering &
processing

4 attack and eliminate

2 thoroughly understand the
root cause C&E nature - basis for ultimately
Charting solving it
3 find the root
causes Training on RCA : Ujwal Ritwik
Investigation Issues
• Investigation policy, purpose and philosophy
• Standards and guidelines for investigations and reports
• Investigative aids and equipment
• Witness interviewing and evaluation
• Evidence collection and examination
• Relationship to other investigative agencies and individuals
• Sources and types of special assistance
• Public relations; social media, media; employee relatives; good will
• Preparation, review and measurement of reports
• Closing of investigation and follow up

Training on RCA : Ujwal Ritwik

Incident Ranking

• Not all incidents/issues are same - deploy resources thoughtfully

• Identify the most critical incidents with the most impact on the
business
• Decide on the appropriate depth of investigation and level of
management attention
• Assign responsibility for solution development
• Set target date for completion

Training on RCA : Ujwal Ritwik

Risk Ranking Matrix
CONSEQUENCE PROBABILTY
A Never B Heard of C Occurred D Several E Several
People Asset Environment Reputation
heard of in in our times per times
in industry Co. year in per year
industry Co. in
location

First aid/ Slight Slight Slight Impact

MTC Damage Effect 1
<$10k
Lost Time Minor Minor Limited
Accident Damage Effect Impact 2
$10-100k
Permanen Limited Localized Considerable
t Disability damage Effect Impact 3
$100-1M
Single Major Major Major
fatality damage Effect national 4
$1M-10M
Multiple Extensive Massive Major
fatality damage Effect International 5
>$10M

Full analysis required

Full analysis with multidiscipline team
Analysis by department using simple RCA
Local analysis
Training on–RCA
No analysis required manage via normal quality procedure
: Ujwal Ritwik
Investigation Pre-Planning

• Management role
• Investigator Kits
• Investigator competencies
• An Investigator Training Program
• Preservation and security of accident evidence
• Public Relations
• Gathering and Preserving Data

Training on RCA : Ujwal Ritwik

Quiz 2
1. approaches for investigating accident and problem solving are
similar
2. Purpose of risk ranking is to decide on the appropriate depth of
investigation and level of management attention
3. Preservation and security of scene of accident is necessary to
preserve the evidences

Training on RCA : Ujwal Ritwik

Data Gathering Tools and
Techniques
Investigation and Analysis Tools
Beware of the problem solver who owns only one tool
• Problem Understanding Tools e.g. Flowcharts, Spider Charts
• Cause Generation and Consensus Reaching Tools e.g.
Brainstorming, Brainwriting
• Possible Cause and Data Collection Tools e.g. Sampling
• Possible Cause Analysis Tools e.g. Pareto Charts
• Cause and Effect Analysis Tools e.g. Cause and Effect Charts, Five
Whys

Training on RCA : Ujwal Ritwik

Gathering and Preserving Data
Fragility of data

• People data Most fragile

• Physical data
• Parts
• Position
• Patterns
• Properties
• Paper Least fragile

• (Paradigms) – beliefs; can be dangerous

Training on RCA : Ujwal Ritwik

People Analysis
• Human Factors in Design of Equipment and the Environment
• Communications
• Physical Aptitude, fitness and behavior
• Self-Imposed Stresses
• Fatigue
• People-System Interfaces and Error-Provoking Systems.
• Metabolic or Circadian Rhythm Cycle Analysis
• Biorhythm Analysis of People
• Perceptual Distortion
• Perceptual Illusions

Training on RCA : Ujwal Ritwik

Training on RCA : Ujwal Ritwik
Paradigms are measure of Culture
• A paradigm is a set of rules that define boundaries – the mindset of a
population
• Even if they are false they represent the beliefs and affect judgment in
decision making

For instance – How these paradigms affect our problem solving

Paradigms abilities?
We do not have time to perform RCA If we see RCA as another burden (and not a tool),
then we will not give it a high priority
We say safety is number one but when it If we believe that management values profit more
comes to reality cost is number one than safety, then we may rationalize that bending
the safety rules is really what management wants
us to do
Training on RCA : Ujwal Ritwik
Quiz 3
1. A good problem solver should have only one good tool
2. In evidence gathering ‘people data’ is least fragile

Training on RCA : Ujwal Ritwik

RCA Methods
Importance of Cause and Effect
Charting
RCA methods
 Why Analysis
 Barrier Analysis
 Change Analysis
 Causal Factor Tree Analysis
 Failure Mode and Effects Analysis
 Fish-Bone Diagram or Ishikawa Diagram
 Pareto Analysis
 Fault Tree Analysis
 Tripod – Bowtie Analysis

Training on RCA : Ujwal Ritwik

Training on RCA : Ujwal Ritwik
Fishbone or Ishikawa diagram

Training on RCA : Ujwal Ritwik

Improving Investigation Quality
 Analysis – RCA – is the heart of any investigation or problem solving
process
 Techniques like Five Whys and Fishbone are not based on scientific
and structured models, results are not consistent
 More evolved techniques required
 Cause and effect charting is a popular technique, used by high hazard
industry e.g. Defect Elimination by Shell

Training on RCA : Ujwal Ritwik

Characteristics of Cause & Effect
• Things just don’t happen
• There are no such things as mystic and magic there
are only cause and effect and the unknown
• Cause and effect are the same thing
• Cause and effect are part of an infinite continuum
of causes
• Each effect has at least two causes - action and
conditions
• An effect exists only if causes exist at the same
point in time and space

Training on RCA : Ujwal Ritwik

 Frontline
personnel –
Momentary pilot, operator,

Action causes
surgeon -
Human error

Caused
Primary by
effect
Cause that Management
Condition exist prior and
organizational
weakness
to action

Training on RCA : Ujwal Ritwik

Condition 1+ Condition 2 + Action < Time + Space >

Training on RCA : Ujwal Ritwik

Creating Cause & Effect Chart
 For each primary step ask why
 Take baby steps
 Look for causes in actions and conditions
 Connect all causes with ‘caused by’
 Support causes with evidence or use a ‘?’.
• Sensed evidence
• inferred evidence
• Intuition
• Emotional evidence
• Fact = A cause supported by evidence
Training on RCA : Ujwal Ritwik
 Cause 1
evidence
Cause 1
Cause 2 evidence
Caused
evidence
Effect
by
Cause 2
Caused
by evidence
Cause 3
evidence
Cause 3
evidence
Training on RCA : Ujwal Ritwik
Why Butterfly?

Training on RCA : Ujwal Ritwik

Root Cause Analysis
Cause 1
evidence
Cause 1
Cause 2 evidence
Caused
evidence
Effect
by
Cause 2
Caused
by evidence
Cause 3
evidence
Cause 3
evidence
Training on RCA : Ujwal Ritwik
Quiz 4
1. Cause and effect charting is a popular technique, used by high
hazard industry
2. There are no such things as mystic and magic there are only cause
and effect and the unknown
3. While doing cause and effect chart we should take baby steps

Training on RCA : Ujwal Ritwik

Solution Development
Corrective Action and Report
Develop Corrective Action
• Corrective action matrix
• Occasionally you might choose not to correct the root cause - not
worth
• Management involvement
• Generic causes correction more effective
• Hierarchy of controls
• Smart correction

Training on RCA : Ujwal Ritwik

Hierarchy of Methods
 Design
 Remove human
 Guard
 Warn
 Train
 Qualitative analysis of
barriers
 Quantitative e.g. eng.
design, QRA
 Prioritize - risk based
 Strengthen old barriers
 Erect new barriers
Training on RCA : Ujwal Ritwik
Corrective Action

SMART
• S specific
• M measurable
• A accountable
• R reasonable
• T timely

Training on RCA : Ujwal Ritwik

Accident Reports and Remedial Action Plans
 General Report
 Rejection of Inferior Accident Report
 Reports of Extensive or Special Investigations
 Remedial/Corrective Action Alternatives
 Upper Management Report
 Data Analysis Report
 Quality Measurement Report

Training on RCA : Ujwal Ritwik

Poor investigations
 Team members are assumed to be ‘born investigators’
 Investigators lack good training and experience
 Leader chosen as per hierarchy and not competence
 Reports are required quickly
 Report writing is a collateral responsibility
 Too many investigations
 Not important enough
 Not reviewed by peers and management

Training on RCA : Ujwal Ritwik

Quiz 4
1. Control by removing the human intervention is better than
elimination of hazard
2. SMART action should indicate responsibility of action taker
3. A good report is not required to be reviewed by peers and
management

Training on RCA : Ujwal Ritwik

Conclusion
Company Procedure
 The process should lead to effective problem identification and effective
system improvements
 Should be reasonable in cost
 Should be thorough and credible
 You want people to report to you, not to newspaper
 Keep reporting simple
 Make reporting accessible
 Keep definition broad – include incident, accident, near miss, all adverse
events
 Encourage by definite feedbacks and incentives
Training on RCA : Ujwal Ritwik
RCA Quality Control
 Criteria for thorough and credible RCA
 Do the people who completed RCA have first hand knowledge of the
incident and process involved in the incident?does an organization
leadership support investigations findings
 Do the findings identify system related defects rather than blaming
human error or individuals
 Is the analysis consistent (do some part of report contradict or raise
questions about others)?
 Does the investigation include a review of the relevant literature – to
ensure organization draws on lessons learnt elsewhere?

Training on RCA : Ujwal Ritwik

Training on RCA : Ujwal Ritwik
Training on RCA : Ujwal Ritwik
Books

 Root Cause Analysis Handbook (ABS Group) A Guide to Effective Incident

Investigation, by Risk & Reliability Division, ABS Group, Inc. Root Cause Map. 2005
 Root Cause Analysis: Improving Performance for Bottom-Line Results, by Robert J.
Latino and Kenneth C. Latino
 Apollo Root Cause Analysis: A New Way of Thinking, by Dean Gano
 Root Cause & Program Performance Analysis, by D.B. Fulbright
 Root Cause Analysis for Higher Education, by Sherrie A. Tromp & Diana Warner
 The Root Cause Analysis Handbook: A Simplified Approach to Identifying, Correcting,
and Reporting Workplace Errors, by Max Ammerman

Training on RCA : Ujwal Ritwik

What did we do?
 Revisit of Problem solving process and RCA
 Incident investigation steps and approach
 Investigation tools and techniques
 RCA methods – importance of cause and effect charting
 Solution Development - Corrective action plan and Report
 Good company procedure
 RCA Quality control

Training on RCA : Ujwal Ritwik

 1
Solution 1 recognize there is a problem, if
5 monitor symptoms you consider it normal it will never
signaling presence of Implementation Incident
& Capture improve;
problem call the problem by its real name -
Monitoring
define

Solution
Development
5 Data
Gathering &
processing

4 attack and eliminate

2 thoroughly understand the
root cause C&E nature - basis for ultimately
Charting solving it
3 find the root
causes Training on RCA : Ujwal Ritwik
Training on RCA : Ujwal Ritwik
Training on RCA : Ujwal Ritwik
Thank you for being with us
• Next topics-
1 April 9, Risk 7:30p* Pre-requisite - Complementing
2020 Management Knowledge of OSHA requirement to OSHA
Plan, EPA PSM – 29CFR1910.119 PSM
2 April Metrics 7:30p* Pre-requisite - API 754 and other
11, Knowledge of OSHA practices
2020 PSM – 29CFR1910.119

* Kuwait Time (12:30p ET); Please register in advance and log in 15

minutes before the start of session
Ask any further concerns
uritwik@gmail.com

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