Environmental Engineering Reference
In-Depth Information
the. details. of. root. cause. information. with. similar. facilities. where. signiicant. or.
long-standing.problems.may.also.exist.
PhAse v: FolloW-uP
Follow-up.includes.determining.if.corrective.actions.have.been.effective.in.resolv-
ing. problems.. First,. the. corrective. actions. should. be. tracked. to. ensure. that. they.
have. been. properly. implemented. and. are. functioning. as. intended.. Second,. a. peri-
odically.structured.review.of.the.corrective.action.tracking.system,.normal.process.
and.change.control.system,.and.occurrence.tracking.system.should.be.conducted.to.
ensure.that.past.corrective.actions.have.been.effectively.handled..The.recurrence.of.
the.same.or.similar.events.must.be.identiied.and.analyzed..If.an.occurrence.recurs,.
the.original.occurrence.should.be.reevaluated.to.determine.why.corrective.actions.
were. not. effective.. Also,. the. new. occurrence. should. be. investigated. using. change.
analysis..The.process.change.control.system.should.be.evaluated.to.determine.what.
improvements.are.needed.to.keep.up.with.changing.conditions..Early.indications.of.
deteriorating.conditions.can.be.obtained.from.tracking.and.trend.analyses.of.occur-
rence.information.
summAry
Determining. facts. related. to. any. accident. is. the. key. to. an. accurate. and. effective.
analysis..Remember.to
•. Begin.deining.facts.early.in.the.collection.of.evidence.
•. Develop.an.accident.chronology.(e.g.,.events.and.causal.factors.chart).while.
collecting.evidence.
•.
Set.aside.preconceived.notions.and.speculation.
•.
Allow.discovery.of.facts.to.guide.the.investigative.process.
•.
Consider.all.information.for.relevance.and.possible.causation.
•.
Continually.review.facts.to.verify.accuracy.and.relevance.
•.
Retain.all.information.gathered,.even.that.which.is.removed.from.the.acci-
dent.chronology.
•.
Establish.a.clear.description.of.the.accident.
Select.the.one.(most).direct.cause.and.the.root.(basic).cause.(the.one.for.which.
corrective. action. will. prevent. recurrence. and. have. the. greatest,. most. widespread.
effect)..In.cause.selection,.focus.on.programmatic.and.system.deiciencies.and.avoid.
simple.excuses.such.as.blaming.the.employee..Note.that.the.root.(basic).cause.must.
be. an. explanation. (the. why). of. the. direct. cause,. not. a. repeat. of. the. direct. cause..
In addition,.a.cause.description.is.not.just.a.repeat.of.the.category.code.description;.
it is. a. description. speciic. to. the. occurrence.. Also,. up. to. three. (contributing. or.
indirect).causes.may.be.selected..Describe.the.corrective.actions.selected.to.prevent.
recurrence,.including.the.reason.why.they.were.selected,.and.how.they.will.prevent.
recurrence..Collect.additional.information.as.necessary.
