Root Cause Analysis Using Fishbone Diagram: Safety Procedures

This document outlines the safety procedures for conducting a root cause analysis (RCA) using a fishbone diagram, also known as an Ishikawa diagram. The goal is to identify potential hazards, prevent future incidents, and improve overall workplace safety. This process involves a systematic approach to determine the underlying causes of an incident or potential hazard, allowing for the implementation of effective corrective actions.

1. Preparation and Planning

1. Define the Problem Statement: Clearly and concisely define the incident or potential hazard that needs to be analyzed. This statement will form the 'head' of the fishbone.

2. Assemble a Diverse Team: Include individuals with different perspectives and expertise related to the incident or process. This ensures a comprehensive analysis.

3. Gather Information: Collect all relevant data related to the incident, including witness statements, equipment maintenance records, environmental conditions, and any other pertinent information.

2. Constructing the Fishbone Diagram

1. Draw the 'Backbone': Draw a horizontal arrow pointing to the right. This represents the main process or issue being investigated.

2. Identify Major Categories: Determine the main categories that could have contributed to the problem. Common categories include:

• Manpower: Human factors, training, experience, and competence.

• Methods: Procedures, work instructions, and processes.

• Machines: Equipment, tools, and technology.

• Materials: Raw materials, components, and supplies.

• Measurement: Data collection, analysis, and accuracy.

• Environment: Workplace conditions, temperature, lighting, and external factors.

3. Add 'Bones' for Each Category: Draw angled lines (bones) extending from the backbone for each category. Label each bone with the corresponding category.

4. Brainstorm Potential Causes: For each category, brainstorm potential causes that could have contributed to the problem. Ask 'why' repeatedly to drill down to the root causes.

5. Add Sub-Branches: For each potential cause, add sub-branches to explore contributing factors or more specific details. Continue to ask 'why' to uncover deeper layers of causation.

3. Analysis and Hazard Identification

1. Review the Diagram: Systematically review the completed fishbone diagram to identify all potential causes and contributing factors.

2. Identify Hazards: Determine which potential causes represent actual or potential hazards that could lead to future incidents or injuries.

3. Assess Risk: Evaluate the likelihood and severity of each identified hazard to prioritize corrective actions. Risk assessment methodologies (e.g., risk matrix) can be used.

4. Developing and Implementing Corrective Actions

1. Prioritize Actions: Focus on addressing the root causes that pose the greatest risk and have the highest potential for preventing future incidents.

2. Develop Action Plans: Create detailed action plans for each corrective action, including specific tasks, responsible parties, timelines, and required resources.

3. Implement Controls: Implement appropriate control measures to eliminate or mitigate the identified hazards. These may include:

• Engineering controls (e.g., machine guarding, ventilation)

• Administrative controls (e.g., safe work procedures, training)

• Personal protective equipment (PPE) (e.g., gloves, safety boots, eye protection)

4. Communicate Changes: Ensure that all employees are informed about the identified hazards, the implemented corrective actions, and any changes to work procedures.

5. Monitoring and Evaluation

1. Monitor Implementation: Track the progress of the action plans to ensure that corrective actions are implemented as scheduled.

2. Evaluate Effectiveness: After implementation, evaluate the effectiveness of the corrective actions in reducing or eliminating the identified hazards. This may involve:

• Incident data analysis

• Workplace inspections

• Employee feedback

3. Adjust as Needed: If the corrective actions are not effective, revise the action plans and implement additional controls as necessary.

6. Documentation and Record Keeping

1. Document the RCA Process: Maintain detailed records of the entire RCA process, including the problem statement, fishbone diagram, identified causes, corrective actions, and evaluation results.

2. Retain Records: Keep the records readily accessible for future reference, audits, and continuous improvement efforts.

7. Training and Competency

1. Provide Training: Ensure that all employees involved in the RCA process are properly trained in the use of the fishbone diagram and other RCA techniques.

2. Verify Understanding: After a suitable interval, workers should be briefed to ensure they understand the rules applicable to their work. [1]

2. Promote a Safety Culture: Foster a workplace culture where employees are encouraged to report incidents and potential hazards without fear of reprisal.

Compliance with health and safety rules should be considered a condition of employment. Rules must be explained to new workers when they start work or if they are transferred or retrained. [1]

Accident Prevention

Use protective clothing and safety equipment. Always use approved safety equipment such as: gloves, safety boots, safety hard hats/ goggles and ear protection when necessary. [2]

Safety powered by SALUS