WHY TREE AND ROOT

CAUSE ANALYSIS
INCIDENT INVESTIGATION
WHY INVESTIGATE INCIDENTS

• Determine Facts, Avoid Blame

• Find Root Causes

• Prevent Recurrence
• Share Lessons

• Meet Legal / Company requirements

 Which Incidents?
An Incident could be : • Release
• Injury • Permit violations
• Fatality • Equipment breakdown
• Fire • Legal liability
• Major Loss
• Media attention
• Business interruption • Near miss
How to conduct investigations

Incident Occurs
How to conduct investigations

Collect facts
How to conduct investigations

Form investigation team

How to conduct investigations

Develop time line

How to conduct investigations

Identify protective systems

How to conduct investigations

Determine root causes

How to conduct investigations

Develop recommendations
How to conduct investigations

Document investigation
How to conduct investigations

Share lessons learned

When to start investigation

• As soon as possible

• within 48 hours

• when it is safe to do so
Gather data as soon as possible
• Interviews and written statements
• weather , job and process status
• written data: permits, JSAs, procedures,
control data, log sheets
• physical data:parts, equipment, photos,
videotapes, sketches
 interviews
• Conduct interviews as soon as possible

• comfortable setting - try walking through

the plant

• put interviewee at ease before questioning,

explain that your purpose is fact finding,
NOT fault finding
 interviews
• Ask open ended, non-leading questions and
listen
• avoid speculation or implying blame in your
questions
• use timeline and keep notes
• analyze what is said and obtain agreement
• close interview and thank interviewee
 Incident investigation team

• Facilitator • Specialists

• supervisor • contractors

• employee/contractor • process operatives

involved
 Develop timeline
• Use to organise facts
- put all known facts on the timeline
- start timeline as far back as needed to identify
all potential causes
- include all responses to the incident
• helps to prevent jumping to conclusions

• non-intimidating technique, helps focus on

facts
 Example timeline

date/time activities
1/4 9:34am received low flow alarm
1/4 9:35am notified operator
1/4 9:37am operator observed major leak
1/4 9:37am operator activated ESD
Identify protective systems

Definition: any management system or

hardware system which reduces the
potential for having the incident or the
consequences of the incident
 Identify protective systems
• Shutdown/alarms • Procedures
• inert gas • training
• purging • preventative
maintenance
• fire suppression
• permit to work
• hazard detection
• management of
• emergency block change
valves • PPE
 Root Causes

Root Cause : the most basic cause(s) that can

reasonably be identified and that we have
control to fix
 Type of Causes
• PHYSICAL - equipment or device changes
or fails

• HUMAN - human action or lack of action

• SYSTEM - processes failed to support

desirable human action
 The Why Tree
Has many different forms namely:

• block diagrams
• logic diagrams
• spread sheet
 Why Tree Construction
• Use timeline to determine primary event at
the top of the tree

• Identify the actions or conditions (and failed

protections) which caused the primary event
 Identify protective systems
(continued)
• Brainstorm all of the PHYSICAL causes (or
causal factors) which reasonably could have
caused the initial actions or conditions

• Systematically rule out possible physical

causes
 Identify protective systems
(continued)
• Identify the HUMAN causes for each
possible physical cause
• identify the system causes for each human
cause:
-why did the inappropriate action occur?
-what protective system failed to work to
allow the action to occur?
Verify Each Causal factor
• Visual

• Test / data

• Expert theory

• Conventional wisdom
 When to Stop Asking Why

• When you reach a “normal condition”

or

• when a system cause which we can fix has

been identified
 recommendations
• Agree on how to eliminate the immediate hazard

• Develop “actionable” recommendations for each

root cause

• Prioritize recommendations based on the potential

for eliminating the incident in the future
Recommendations (continued)

• Assign responsibility for each

recommendation

• Implement and track status to completion

 Protective System Review

• Confirm that why tree includes protective

systems identified
 document
• Team Membership
• Investigation Results
-summary or incident
-timeline
-root causes (including how they were
determined)

• follow up recommendations
• Communicate lessons learned
 Recommended Categories for
Why Tree
• Management commitment • Designs & reviews

• Hazard analysis & risk • pre-startup safety

based decision making review

• procedures and safe work

practices • inspection / quality
control
• communications
• training
 Recommended Categories for
Why Tree (continued)
• Preventative • Incident and near miss
maintenance & repeat investigations
failure
• contractor safety
• human factors
• emergency response
• management of
change • audits
How to build an Events & Causal Factors Chart

Incident
1 Decide what is being investigated

2 Establish a sequence of "events"

3 What are causal factors & conditions for each event?

Very simple Events & Causal Factors chart example
1 - 4 causal factors/conditions
reasons for an event or amplifying information

EVENTS
progress from left to right,
actions that describe what Reason for investigation
happened during incident

PERSON
WALKS SPRAINS
STEPS IN
HOME ANKLE
A HOLE

LEAVES LATE - NO BARRICADE OR

AFTER DARK MARKINGS FOR HOLE
1 3

DECIDES TO TAKE A STREETLIGHT

NEW ROUTE BROKEN
(SHORTCUT) 4
2
 Exercise 1
Lube oil spill
A spill of 18 gallons of lube oil resulted from the
equipment failure, specifically the failure of a 3/4”
pipe nipple. The failure occurred due to excessive
weight and size of the gauge installed on the
nipple and vibration when fluid flows through the
line. Excessive stress was placed on the nipple,
resulting in metal fatigue.
The gauge was not part of the original design detail
and Management of Change was not used when
the gauge was installed.
 Lube oil spill
Lube oil spill
occurs

3/4" nipple
failed

Metal fatigue

AND
Excessive weight
and inadequate Vibration
nipple
Normal Condition
Piping detail was not designed
Or installed properly

Design standards
Not understood

Installed as a field change

Without proper review

MOC was not

followed

MOC process
not
In place
 Exercise 2
lube oil fire
On 19/5, a new Waukeshaw engine was installed for
the main generator on a high priority. The job was
inspected and turned over to operations on the
20/5. At 2:20PM, operations started the new
engine. At 2:25PM, operations saw lube oil
spraying out of a dresser coupling on the oil
system.the oil contacted the bare exhaust piping
and ignited.
 Exercise 2
lube oil fire (continued)
The fire was immediately extinguished with a hand
held extinguisher in the area.
The investigation indicated that the dresser coupling
had been on the original equipment. The new
engine had a piping arrangement that was a little
shorter than the original engine. Consequently, a
proper seal was not obtained when the piping was
connected. This was not noticed by the mechanics
who were being pushed to complete the job.
 Lube oil fire
Lube oil fire

AND

Lube oil leaked from

Oil contacted hot
Dresser coupling
Exhaust piping

AND NORMAL
CONDITION

Old coupling did

Mechanics did Not fit new engine and proper
Not notice Seal not obtained

New engine slightly

No testing done prior to Different-not a "change
Turnover to operations In kind"

Management of change
process did not discover
problem, or no MOC
process

OR

Production given Mechanics not required to

greater emphasis than complete testing prior
proper installation and To turnover
testing