Root Cause Analysis

...as a result, are the deeper investigation into the reason for the occurrence in the first place. The root cause or causes might be much deeper than outward symptoms reveal, and several layers may have to be pushed aside to reach the "root" cause..

The best action plan of any accident is to find the appropriate solution to stop the same accident happen again in the future. This s preventive action will be most effective if this is being applied to the real cause of accident. To find out the real cause, the root cause analysis must be applied. Root Cause Analysis is structured step by step technique that focuses on finding the real cause of a problem and dealing with rather than merely dealing with its symptoms. It is a process to help stakeholders to understand causes of a problem well enough to achieve permanent resolution of that problem.

The goal of a root Cause Analysis s to find out :
•What happened
•Why it happened
•What can be done to prevent the problem from happening again

A root cause is one of the most basic, or fundamental causes of the situation ( condition) with which we are concerned. Since the situation (condition) is usually affected by many things (physical conditions, human behaviour, behaviour of systems, or processes). Several root causes will usually be found.

THE BENEFIT OF ROOT CAUSE ANALYSIS USAGE

Implementation of root cause analysis will help your company

•The benefits of Root Cause Analysis, as a result, are the deeper investigation into the reason for the occurrence in the first place. The root cause or causes might be much deeper than outward symptoms reveal, and several layers may have to be pushed aside to reach the "root" cause.
•identify barriers and the causes of problems, so that permanent solutions can be found.
•develop a logical approach to problem solving, using data that already exists in most operations.
•identify current and future needs for organizational improvement.
•establish repeatable, step-by-step processes, in which one process can confirm the results of another.

THE DISADVANTAGES OF LIMITATIONS OF ROOT CAUSE ANALYSIS.

This method presupposes a single source of the problem. In reality, the situation may be more complex

General principles of root cause analysis

1.Focus on the basic cause of problem.
2.It must be performed systematically, with conclusions and causes backed up by documented evidence.
3.There may some root cause for any given problem.
4.To be effective the analysis must establish all known causal relationships between the root cause(s) and the defined problem.

General process for performing and documenting an RCA-based Corrective Action
Notice that RCA (in steps 3, 4 and 5) forms the most critical part of successful corrective action, because it directs the corrective action at the root of the problem. That is to say, it is effective solutions we seek, not root causes. Root causes are secondary to the goal of prevention, and are only revealed after we decide which solutions to implement.

1.Define the problem.
2.Gather data/evidence.
3.Ask why and identify the causal relationships associated with the defined problem.
4.Identify which causes if removed or changed will prevent recurrence.
5.Identify effective solutions that prevent recurrence, are within your control, meet your goals and objectives and do not cause other problems.
6.Implement the recommendations.
7.Observe the recommended solutions to ensure effectiveness.

Root cause analysis techniques
1. 5 Whys
2. Failure mode and effects analysis
3. Pareto analysis
4. Fault tree analysis
5. Bayesian inference
6. Ishikawa diagram, / fishbone diagram / cause and effect diagram
7. Cause Mapping
8. Barrier analysis -.
9. Change analysis –
10.Causal factor tree analysis .
11.TapRooT .
12.ARCA; Apollo Root Cause Analysis .
13.RPR Problem Diagnosis –

Reference :
1.Wikipedia.com
2.12manage.com
3.envisionsoftware.com

PS: Picture Taken from pinterest

PROCESS SAFETY

...PROCESS SAFETY is the shortened name for safety at Highly Hazardous Chemicals (HHC) processes. Process Safety generally refers to the prevention of unintentional releases of chemicals, energy, or other potentially dangerous materials (including steam) during the course of refinery processes that can have a serious effect. ..

SCOUPE, FOCUS AND DEFINITION
Process Safety is A discipline that focuses on the prevention of catastrophic accidents, fires, explosions, toxic releases and accidental chemical associated with the use of chemicals and petroleum products.

PROCESS SAFETY is the shortened name for safety at Highly Hazardous Chemicals (HHC) processes. Process Safety generally refers to the prevention of unintentional releases of chemicals, energy, or other potentially dangerous materials (including steam) during the course of refinery processes that can have a serious effect. Process safety involves, for example, the prevention of leaks, spills, equipment malfunction, over-pressures, over-temperatures, corrosion, metal fatigue and other similar conditions.
Chemical Process Safety = Process Safety. It is just another name. While Chemical Safety focus specifically to protection against the toxic effects of chemicals that arise in normal usage.

THE BACKGROUND
Process Safety was born on the banks of the Brandywine River in the early days of the 19th century at the E. I. du Pont black powder works. Recognizing that even a small incident could precipitate considerable damage and loss of life, du Pont directed the works to be built and operated under very specific safety conditions. Process Safety evolved as industry progressed through the 19th and 20th centuries, but really emerged as a industry-wide discipline following a major industrial accident in Bhopal, India, in which a catastrophic release of methyl isocyanate killed more than 3,000 people

In the twenty years since Bhopal, process safety has gained corporate importance, process safety expertise has extended into the general skill set of chemical and petroleum engineers and operators, and many industry-wide guidelines for process safety have been developed, largely through the efforts of CCPS.
It is important to keep in mind that process safety incidents are “high consequence, low frequency events.” Therefore, it is possible for a plant, and even the entire industry to have declining numbers of incidents for many years, and then have a very serious incident with little or no change in operation. Therefore, any progress in process safety must be viewed over a horizon of many years.
Most companies measure their progress in process safety by defining some kind of threshold for personal injury and property loss, and record process safety incidents exceeding that threshold for internal improvement purposes. While a group of companies belonging to the American Chemistry Council uses a consistent threshold definition, this practice is not uniform through the industry.

The Basics Need to Know about Emergency Preparedness:

First – Read and understand the MSDS of any chemicals, gases, and other energy you are handle about. And find what must be done in the case of emergency regarding to first aids treatments.

Second – know the sound of the emergency alarm, the all-clear signal, and other means of emergency communication from the plant

Three – in case of an off-plant release, you will usually respond by “sheltering-in-place.” To shelter-in-place, close all windows and doors, shut off all heating and air conditioning, and seal other openings to the outside, such as room air conditioner inlets and cracks under external doors.

Four - know how to evacuate if you are told to do so. There may be several alternate routes depending on the direction of the wind. Keep an evacuation kit handy so you don’t have to delay your escape while looking for critical items you have to take with you.

References :
www. Wikipedia.com
www.aiche.org

picture taken from www.thefreijecompany.

Occupational Disease

...The medical record history of those who suspect get the occupational disease is deadly important, so the medical database must be cover this purpose. Beside, a comprehensive diagnose from occupational physicist related to their working environment must be also well considered....

Occupational Disease is a disease (any chronic ailment) resulting from long-term exposure during employment in a particular type of work to conditions or substances that are danger to health.

In general, occupational diseases are related to exposures to physical, chemical or, controversially, psychological hazards; they usually develop over a period of time and often resemble or duplicate diseases occurring in other settings. An occupational disease is typically identified when it is shown that it is more prevalent in a given body of workers than in the general population, or in other worker populations. By comparison, occupational injuries are mostly the immediate result of mechanical factors such as lifting or bending, or failures in safety measures resulting in accidents or fires. In practice, the dividing line is rather arbitrary (eg, established because of administrative convenience): certain types of injury, such as tendonitis resulting from repetitive movements, are counted as "diseases," and certain types of what would normally be considered a disease, such as acute poisoning by chemicals discovered immediately, are counted as "injuries". Occupational hazards that are of a traumatic nature (such as falls by roofers) are not considered to be occupational diseases.

Occupational diseases often develop over many months or years, depending on the intensity and circumstances of exposure. Cancer resulting from inhalation of ASBESTOS fibres, for example, generally takes at least 20 years to develop, and when it does develop it is difficult or impossible to identify the exact cause in the individual patient. Occupational diseases often resemble other medical conditions; for example, LEAD poisoning duplicates the symptoms of several illnesses, and asthma resulting from sensitization to chemicals in the workplace is often falsely attributed to exposures at home. For these reasons, most occupational diseases are often overlooked or misdiagnosed and are undercounted in statistical reports. They are more common than is generally realized.

The medical record history of those who suspect get the occupational disease is deadly important, so the medical database must be cover this purpose. Beside, a comprehensive diagnose from occupational physicist related to their working environment must be also well considered.

Bellow is the list of common Occupational Disease, its trigger and those who have potential risk to :


Musculoskeletal
Carpal tunnel syndrome amongs letter sorting, assembly work, computer work, food processing because of repetition, vibration, awkward postures, cold temperatur
De Quervain's tendinitis amongs Meatpacking, Manufacturing worker caused by Repetition, High force
Cervical strain, amongs Computer work caused by Static posture, repetition
Thoracic outlet syndrome, amongs Assembly worker caused by Static posture, repetition
Static posture, repetition

Respiratory
Interstitial fibrosis, among Mining, construction trades, building maintenance, Mining, foundry work, sandblasting caused by exposure of Asbestos, Silica, Coal
Asthma, among Laboratory worker, Baking, Furniture making, Plastics manufacturing, Hard metals manufacturing, Machine operation, Various occupations caused by Animal products, Wood dust, Isocyanates, Metals (e.g., cobalt), Cutting oils, Irritants (e.g., sulfur dioxide)
Bronchitis, Among Plating worker, Fire fighter, welder because of Moldy Hay, Cutting oils
Hypersensitivity pneumonitis among farmer, Machine operator because of Moldy Hay, Cutting oils
Upper airway irritation, among Office work, Teacher caused by Indoor air pollution (i.e., sick building syndrome)

Neourologic
Chronic encephalopathy, among whose who work at Painting, automobile body repair, Pesticide application, and Bridge work, painting, radiator repair, metal recycling. Caused by Organic Solvents, organophosphate pesticides, and Lead
Peripheral polyneuropathy among those who work at Pesticide application, Fabric coating caused by Organophosphate pesticides, Methyl butyl ketone
Hearing loss, can be happen to many occupations caused by Noise with over TLV

Infectious
Bloodborne infections, among Health care work, prison work caused by HIV, hepatitis B, etc
Airborne infections, among Health care work, prison work caused by Tuberculosis
Infections transmitted fecally or orally, among Health care worker, animal care worker caused by Hepatitis A
Zoonoses, can be happen to Forestry and other outdoor work caused exposured by Lyme disease


Cancer
Lung cancer, can happen to those who work as Construction trades, Welding, plating, Steelworking caused by Asbestor, Chromium, Coal tar, Pitch.
Liver Cancer among Plastics Manufacturing worker caused by exposure of Vynil Chloride
Bladder cancer among Plastics and chemical manufacturing worker because of exposured by Benzidine

Skin
Contact dermatitis, Can happen to Many occupations, Hairdressing, Health care work because of exposured by Organic solvents, Nickel, and Latex

Reproductive
Spontaneous abortion can be happen to those who work at Sterilizing process/ job because of exposured by Ethylene oxide
Sperm abnormalities, among Pesticide manufacturing worker caused by Dibromochloropropane
Birth defects, among Radiographic technicians caused by Ionizing radiation
Developmental abnormalities among Bridge worker, metal recycling worker caused by lead

Cardiovascular
Coronary artery disease, among Working with combustion products, Machine-paced work because of exposured by Carbon monoxide, stress

Gastrointestinal
Hepatitis among Electrical equipment manufacturing and repair caused by Polychlorinated biphenyls

PS : Picture taken from www.risk.state.ut.us

3 Steps of Hazard Management and Control

...The best way to control and manage hazard is mechanical/ technical control...

At my other posting, I wrote that every workplace will always potentially create its risk. This risk then become potential hazard in the future. Then soon become a hazard when it is not properly treated.

Hazard management is the next step after you as safety professional conduct the risk assessment. The best way to control and manage hazard is mechanical/ technical control.

1. Re-engineering/ mechanical control.
2. Administrative control (training, SOP, etc).
3. Use PPE (Personal Protective Equipment) as final choice.

But, there is a better condition that you must consider in this hazard management, so you no need to give extra effort to apply this 3 steps of hazard management and control. It is by including the safety requirement for every process of purchase. Both material and machinery. This will safe your energy much.

PS : Picture taken from : www [dot]forceequipment[dot]com.au

Commitment, a Keyword to Success !

...The commitment will rise policy, responsibility, care, and good teamwork, with less or without conflict. Because every job will be describe clearly. It will invite every body to participate in since the safety is everybody's business...

Every job need a master. But the master can be found or even can be create from internal organization with some very tight effort and screening. Every job need clear target of achievement, tools, and also team or organization structure. But the most important one, whatever job is it, its must be supported well. Support come from superior and decision maker (top management). No doubt that production will always be a first concern of the whole organization to get the best achievement from the target. In some very good company, they also concern the safety management system integrated into their management system. All people in the organization are responsible about safety in each working area. This is a commitment. The commitment will rise policy, responsibility, care, and good teamwork, with less or without conflict. Because every job will be describe clearly. It will invite every body to participate in since the safety is everybody's business. All effort are begin with the commitment and will be ended by good achievement. So, commitment is the beginning process, to get Best Achievement in the last process.

Never miss this magic word, pal!

Mapping Your Environment Through Safety Walktrough Inspection

...Technically, walk through inspection can be applied in to 2 ways. First, by visual methods. Looking for substandard action and substandard condition. And second, by interviewing employees and their supervisor or their other superior regarding the condition...

Every second is different!. The condition must be always controlling and updated.

One of the important activity for safety engineer to listing the unsafe condition in their surrounding is walk through inspection. This kind of inspection must be done by daily basis. The main goal of this activity is to know update condition of each department in the plant. By knowing those potential hazards, this will help the safety engineer to maintain their daily activity and their focus to the most important program first. Especially when you are new in your working environment, the risk assessment must be conducted. The ideal working time for safety engineer is 60 % outdoor activity and the rest for indoor activity (paper work, formal meeting, etc). No doubt, it is important for safety engineer to know the recent condition regarding what happen in their plan.

Technically, walk through inspection can be applied in to 2 ways. First, by visual methods. Looking for substandard action and substandard condition. And second, by interviewing employees and their supervisor or their other superior regarding the condition at their working place. But off course, it should be done in very smart ways, so they won't feel being watched or being intimidated :-). Remember, safety engineer/ officer is not a policeman. Do it correctly, and win a warm friendship plus accurate update safety finding.

Accident is Preventable !

......when the accident happen, they just blame the operator that propose to the 'human error' factor of the accident. No matter how tired, and how big the work pressure they got from the job at a whole day...

...

Everybody want to be happy!. When I was a Safety Engineer at a Multinational Shoes Factory in Sidoarjo, I often heard that some managers are not happy with the safety talk program taken before their worker start to work for about 5 - 10 minutes.

Safety talk is defined as inefficient program since it will take effective working hour of every single employees. Then when the accident happen, they just blame the operator that propose to the 'human error' factor of the accident. No matter how tired, and how big the work pressure they got from the job at a whole day. A safety refreshing program, such as safety talk is effective program to build a main frame of safety for the worker, to become a safety minded person. But this will take a whole of years to maintain their awareness about safety. Think safety, work safely. No body is happy when the accident happen, both company and worker. The production will disturb or even stop because of this accident. So, one more again, let's think safety, and work safely because accident is hurt, but Safety doesn't!

PS : Picture taken from www.i-tec.co.th

Accident is Hurt, But Safety Doesn't !

...when the accident happen, they just blame the operator that propose to the 'human error' factor of the accident. No matter how tired, and how big the work pressure they got from the job at a whole day...

Everybody want to be happy!. When I was a Safety Engineer at a Multinational Shoes Factory in Sidoarjo, I often heard that some managers are not happy with the safety talk program taken before their worker start to work for about 5 - 10 minutes. its proved by the decreasing number of safety talk group every week that we have been agreed at the formal meeting with the managers of production previously. Some of them are still commits but the others are not. They mentioned the reason, its the production time is so limited, while production target is so many.

Well, its not a surprise for me, since I knew that safety talk is defined as inefficient program since it will take effective working hour of every single employees. Then when the accident happen, they just blame the operator that propose to the 'human error' factor of the accident. No matter how tired, and how big the work pressure they got from the job at a whole day.

A safety refreshing program, such as safety talk is an effective program to build a main frame of safety for the worker, to become a safety minded person. But this will take a whole of years to maintain their awareness about safety. Think safety, work safely. No body is happy when the accident happen, both company and worker. The production will disturb or even stop because of this accident. So, one more again, let's think safety, and work safely because accident is hurt, but Safety doesn't!

Job Safety Analysis (JSA)

...The most important parts of this activity is to find and mentioned the safe procedure how to do the job safely...

While a kind of job is required, It must be have been analyzed by competent people (Safety officer, safety inspector, Safety engineer, safety representatives, etc). This purpose of this kind of procedure is to ensure all the risk and hazard are already considered and being eliminated or at least much reduced.

The main activities of this procedure is listing all of working steps that must be taken to perform those kind of job. After the steps already listed, the next process is by analyze all potential risk / hazard that probably found and created in each step. This should be evaluated from human side (ex: physical requirement to perform the job), machine (is it already safe?, always in good condition) and also from environment aspect (material, workplace such as lighting, temperature, etc).

The most important parts of this activity is to find and mentioned the safe procedure how to do the job safely. Because a safe procedure and improvement recommendation will be found to support the achievement of safe work environment. Hopefully the sub standard condition will not found and creating loss and accident in the future.

Note:

Picture taken from : www[dot]osha[dot]gov

Job Safety Observation (JSO)

... Any findings from this step will be reported to the HR Department and also department head to consider some alternatives that can be done to eliminate the gap(s)...

As we know that every machine should be equipped with the safe procedure and all the operator have been trained and already familiar with those procedure, we also need to conduct the evaluation about how good is those procedure and training effect to safety attitude of employees?, how good the training can be understood, and will it create other difficulties to the operator?.

A formal evaluation named Job Safety Observation (JSO) is the next step to answer the questions above. In this observation a safety officer will observe whether there is any gaps between purpose of the safety program (Procedures and Training) with the facts.

Any findings from this step will be reported to the HR Department and also department head to consider some alternatives that can be done to eliminate the gap(s).

In other word JSO is the next step after training and JSA already conducted.

Note:

Picture taken from: www.pulsar-optical.co.uk

Top 6 Common Accident Causes

...Some people will be easily try to find something or someone to be blamed than doing Investigation to looking for the root cause of the accident....

Many factors can contribute to cause an accident. Some people will be easily try to find something or someone to be blamed than doing Investigation to looking for the root cause of the accident. Root cause analysis is being so important to find the primary cause of accident so the same type of accident will be prevented in the future. Please check the bellow common accident causes, and be honest to yourself whether you are included in this list, means you are in the high risk to get the accident.

•Taking Shortcuts: People thing that doing job faster is genius, efficient and can make everybody happy. But ,..wait a minute,..do you forget the more important one than just getting faster? Your Safety!. It’s different, getting smart with silly. Smart if you can finish your job on time or faster but SAFE. Silly if you then sent to hospital or getting injury because of your ‘brilliant ‘idea to modify your working procedure. That’s not shortcut, it is a silly thing.

•Over Confident: being confident is good. But do not over. Overconfident is far from good. "It'll never happen to me" is an attitude that can lead you to an accident.

•Doing Job with Incomplete Instructions: Instruction makes you always in the right track. The instruction makes you do the job correctly. Whenever you miss the instruction, don’t be shy to ask your superior. The complete and clear instruction will guaranty that responsible is not given to you.

•Bad Housekeeping: Bad housekeeping creates many hazards of all types. A house keeping is a simple indicator whether your safety and productivity is good or bad.

•Ignoring Safety Procedures: Safety Procedure ensure you to finish your job safely. It is important for the company if you can do the job faster and in high quality. But more important for the company to ensure that you will come to work tomorrow because you are safe today!

•Mental Distractions From Work: having problem with your boss, while have problem at your home in the same time can break your focus. Difficulties to manage your (multi) tasking will generate the potential hazard for your mental. Leave your home problem at home, stay focus on the job you are doing.

PS :
Picture taken from :blog.oregonlive[dot]com

RISK ASSESSMENT

...From first risk which have been identified, it is surely will be compared with the acceptance criteria that have been considered,...

DEFINITION OF RISK ASSESSMENT
Risk assessment is a whole process that include risk identification, risk analysis and risk evaluation (AS/NZS 4360:2004), in simple word Risk Assessment is systematic method to determine wether a risk which resulted from an activity can be tolerated or not.

WHEN RISK ASSESSMENT NEED TO BE APPLIED?
Risk assessment used to be conduct when we will :
1. Compose a HSE manual,
2. Compose risk assesment manual,
3. or as follow up of recomendation from an accident investigation,
4. or as part of recomendation from an Safety Audit Process,
5. or for Demolishion Plant/ Facilities purpose,
6. For HSE Program compose purpose. So it is not applied at the beginning project only.

From first risk which have been identified, it is surely will be compared with the acceptance criteria that have been considered, if the risk is already under the tolerable criteria then those activity can be done but if still above of acceptance criteria, then an risk reduction/ prevention plan need to be done in order to make sure those activity can be accepted in tolerable criteria.

The most important thing of this risk assessment is the urgency of a guide regarding residual risk that can be accepted. Each company or organization off course will have different acceptance level. This is the art of risk assessment even though use the same criteria, but the result can be different if conducted by different team. So, a good risk assessment need to be conducted by skilled and experienced team.
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