Root Cause Analysis and 5 Whys – Under OSHA

For every human being sickness is common. During our Grandfathers period, they used to consult Ayurvedha and Siddha Doctors were available in their areas. The Doctors study the pulse and give medicines. Even injections were considered rare. The Doctors know the family background attend treat the patients. After sometime the allopathy doctors occupied the positions gradually. Doctors prescribe medicines after a checkup.

Nowadays, the allopathy doctors are specialised in a particular field. The patients visit by appointment. It is almost a business relationship. Therefore they suggest to take blood test and scanning etc to understand the problem. Though the cost of the test may be more, they study the result and decide the treatment (study the ROOT CAUSE)

Knowing how to properly a root cause analysis is imperative when handling a safety incident.

It is not just OSHA that encourages the use of during an incident investigation, but  also the EPA under their Risk Management Program. Concerning the Root Cause Analysis During an incident investigation, an employer must determine which factors  contribute to the incident and both OSHA and the EPA encourage employers to go beyond the minimum investigation required and conduct a root cause analysis . Root cause analysis allows an employer to discover the underlying or systematic, rather than the generalised or the immediate, causes of an incident .

Correcting only immediate cause of an incident may eliminate a symptom of a problem but not the problem itself.-

Source

While this is not an official order to conduct a root cause analysis and it may not result in an OSHA fine for not complying it can potentially result on a violation of OSHA General duty clause:

a) Each employer-

1) Shall furnish to each of his employees employment and a place employment which are free from recognized hazards that are causing or are likely to cause death or serious physical  harm to employees. That is because the occurrence of a safety incident is a clear indication of a work place  hazard and a failure to abate this hazard potentially means your company is no longer employees with a work place with recognized hazards, as a full proper root cause investigation would have uncovered the direct cause of this hazard.

So OSHA does not require it , they may cite you over not investigating properly. Any one with an understanding of OSHA rules and regulations and interpretations  will understanding  this is often the case as OSHA will always err on the site of caution for employee protection

5 Why method as a Root Cause Analysis Method for work place incidents.

The 5 Why technique can also be a method for determining root causes of work place incidents. What would 5 Why's like in the context of a work place  incident  investigation? Here is the application of 5 Why's to an example  mentioned in an fact sheets.

The Problem :

A worker slips and falls and suffers an injury.

1st Why: There was a puddle of oil on the plant floor.

2nd Why : Oil spilled from a compressor.

3rd Why: An oil leak from the  compressor was not detected.

4th Why: The compressor was not inspected on a regular basis and repaired ( if required)

5th Why: The compressor was not in the maintenance system.

This is the 3rd in series of Root cause analysis. In theory it takes five Why's to get the  root cause, but in practice  there will be Cases where you may use more or fewer than five " Why's ".

This 5 why method training will explain the basics of how to conduct a root cause analysis using the 5 why method. Adding a 5 why method to your Company's incident investigation to best identify hazards in the work place along with empowering your employees in owning their safety.

Finally according to the Washington State Department of Labor and Industries. These are the benefits of asking 5 Why's.

* Simplicity : Easy to use and requires no advanced mathematics or tools.

*Effectiveness: Helps to quickly separate symptoms from causes and identify the root cause .

*Comprehensiveness: Helps to determine relationships between various problem causes.

*Flexibility: Works well alone and when combined with other methods.

Fact finding sheet.

Define the problem

What is happening

*Engaging: Fosters team work.

*Inexpensive: A guided team- focused exercise with no additional costs.

How to solve a problem

CASE 1. A patient approach his family Doctor for his fever. Doctor study the pulse and regular check up and confirm that it is a general fever and prescribe tablets for 3 days.

CASE 2 A patient approach his family Doctor telling some type of ailment. Doctor make a checkup and prescribe some medicine for 3 days and to report for a review checkup. When the patient arrives for the review, since the ailment is not totally cured, he suggest for blood test etc. The reveals that the patient is having a typical problem and to be referred to a specialist. Accordingly as per his direction, the patient moves to the specialist.

A PRACTICAL EXAMPLE

A foundry installed an Induction Furnace with a capacity of 8 Tonnes and the supplier has specified for 12 months warranty. The Induction Furnace mainly operate with Copper Flat duly insulated by which the heat will be passed on to the Furnace. The Furnace requires proper maintenance. After 20 heats, a powder coating has to be carried out.

The Induction Furnace has to be in good function for a period of 9 months. In the last heat, the Copper melted and got mixed with the iron parts in the furnace. The purchaser and the seller developed a litigation.

ROOT CAUSE

Since the furnace given good result for the 9 months, the supplier says that there was no technical mistake. The buyer says that the product was well within the warranty period he is eligible for replacement

The supplier studied the log book and come to understand that the buyer carried out the heats even after the 20 heats (neglecting for powder coating maintenance). The permissible capacity allowed was 8 Tonnes, whereas due to commitment and short of time, the buyer loaded the furnace with 10 tons of iron materials. Due to the higher capacity and maintenance lapse, the copper portion got melted and mixed with the iron parts in the furnace.

Hence the buyer cannot claim for replacement. He suggests for a compromise formula for a smooth business relationship. If the buyer ready to pay the cost of the Copper flats, the supplier prepared to bear the labour.

CONCLUSION

The experts decision can also be reviewed and possible to get second opinion. Here the results and the medical records are crucial to take decision. Due to technological improvement, the records can be scanned and forward to highly specialised person at any corner of the world. The same system is applicable for the ROOT CAUSE ANALYSIS in any industry and safety sectors as well .

By V. Narasimhan & A.K. Srikantan, Safety Consultants and Partners, Enyes Associates, Chennai and Coimbatore