Cause analysis manual : incident investigation method & techniques / Fred Forck CPT, Kristen Noakes-Fry ABCI, editor.

Format:

Book

Author/Creator:

Forck, Fred, author.

Contributor:

Noakes-Fry, Kristen, editor.

Language:

English

Subjects (All):

Industrial accidents--Investigation.

Industrial accidents.

Physical Description:

1 online resource (406 pages)

Edition:

1st ed.

Place of Publication:

Brookfield, Connecticut : Rothstein Publishing, 2016.

Summary:

A failure or accident brings your business to a sudden halt. How did it happen? What's at the root of the problem? What keeps it from happening again? Good detective work is needed -- but how do you go about it? In this new book, industry pioneer Fred Forck's seven-step cause analysis methodology guides you to the root of the incident, enabling you to act effectively to avoid loss of time, money, productivity, and quality.

Contents:

Cover

Title

Copyright

Table of Contents

Acknowledgments

Preface

Foreword by Ben Whitmer

Foreword by John D. Schnack

Foreword by Mark Reidmeyer

Introduction: Getting Started with Cause Analysis

0.1 Defining Cause Analysis

0.1.1 Purpose

0.1.2 Method

0.2 Successful and Unsuccessful Results

0.2.1 Success (Positive Results)

0.2.2 Failure (Negative Results)

0.3 Human Behavior

0.3.1 Behavior Model 1

0.3.2 Behavior Model 2

0.3.3 Behavior Model 3

0.3.4 Behavior Model 4

0.4 Accountability

0.4.1 Personal and Organizational Accountability

0.5 Investigator Attitude (Mindset)

0.6 Investigation Steps

0.6.1 Job Task Analysis

0.6.2 The Seven-Step Methodology

Step 1: Scope the Problem

1.1 Problem Statement

1.1.1 Problem Statement Examples

1.2 Problem Description

1.2.1 Problem Description Examples

1.3 Difference Mapping

1.3.1 Difference Mapping Examples

1.4 Extent of Condition Review

1.4.1 Extent of Condition Review Examples

Step 2: Investigate the Factors

2.1 Evidence Preservation

2.1.1 Preserve and Control Evidence

2.1.2 Collect Physical Evidence

2.1.3 Collect Documentary Evidence

2.1.4 Collect Human Evidence

2.2 Witness Recollection Statement

2.3 Interviewing

2.3.1 Lines of Inquiry: Question Generators

2.3.2 Question Generator: Individual Mindset

2.3.3 Question Generator: Personal and Organizational Accountability

2.3.4 Question Generator: Management Control Elements

2.4 Pareto Analysis

2.4.1 Pareto Chart Template

2.4.2 Pareto Analysis Examples

Step 3: Reconstruct the Story

3.1 Fault Tree Analysis

3.1.1 Fault Tree Example

3.2 Task Analysis

3.2.1 Task Analysis Example

3.3 Critical Activity Charting(Critical Incident Technique)

3.3.1 Critical Activity Chart Example.

3.4 Actions and Factors Charting

3.4.1 Actions and Factors Chart Example

3.4.2 Notes

Step 4: Establish Contributing Factors

4.1 Contributing Factor Test

4.2 "Five" WHYs

4.2.1 "Five" WHYs Example

4.2.2 Exxon-Valdez Oil Spill Example

4.2.3 Tokai-Mura Criticality Incident Example

4.2.4 Reactor Trip Example

4.3 Cause and Effect Trees

4.3.1 Cause and Effect Tree Examples

4.4 Difference Analysis (a.k.a. Change Analysis)

4.4.1 Broken Back Example

4.4.2 Falling Objects Example

4.4.3 Breaker Trip Example

4.5 Defense Analysis (a.k.a. Barrier Analysis)

4.5.1 Breaker Fire Example

4.6 Structure Tree Diagrams

4.6.1 Fishbone (Ishikawa) Diagram

4.6.1.1 Forearm Fracture Example

4.6.1.2 Poor Safety Culture Example

4.6.2 Defense-in-Depth Analysis

4.6.3 MORT Analysis

4.6.3.1 MORT Maintenance Example

4.6.4 Production/Protection Strategy Analysis

4.6.5 Safety Culture Analysis

Step 5: Validate Underlying Factors

5.1 Support/Refute Methodology

5.1.1 Truck Will Not Start Example

5.1.2 Crane Incident Example

5.2 WHY Factor Staircase

5.2.1 Lost Time Away Injury Example

5.2.2 Criticality Incident Example

5.2.3 Broken Back Example

5.3 Root Cause Test

5.4 Cause Evaluation Matrix

5.4.1 Dump Truck Example

5.5 Extent of Cause Review

5.5.1 Example 1: Flood Protection Strategy Inadequate

5.5.2 Example 2: Leak Due To Stress Corrosion Cracking

5.5.3 Example 3: Rental Car Flat Tire

5.5.4 Example 4: Waste Not Labeled as Required

Step 6: Plan Corrective Actions

6.1 Action Plan

6.1.1 Change Management

6.1.2 S.M.A.R.T.E.R

6.1.2.1 Safety Precedence Sequence (Hierarchy of Corrective Action Effectiveness)

6.1.3 Barriers and Aids Analysis (Pros and Cons)

6.1.4 Solution Selection Tree

6.1.5 Solution Selection Matrix

6.1.6 Contingency Plan.

6.1.7 Lessons To Be Learned Communication Plan

6.1.8 Institutionalization/Active Coaching Plan

6.2 Effectiveness Review

6.2.1 Performance Indicator Development

Step 7: Report Learnings

7.1 Preparing to Create Your Report

7.2 Report Template

7.2.1 Sample Incident Analysis Report Template

7.3 Grade Cards/Scoresheets

7.3.1 Root Cause Analysis - Sample Organizational Learning Scoresheet

Appendix A: Creating Working Definitions

Appendix B: Common Factor Analysis

Glossary

Index

Credits

About the Author.

Notes:

Description based on print version record.

Includes index.

ISBN:

9781944480103

1944480102

OCLC:

1020699603