Back to Annual Meeting Page		American Public Health Association 133rd Annual Meeting & Exposition December 10-14, 2005 Philadelphia, PA

Abstract #117000

Jordan Barab, U.S. Chemical Safety and Hazard Investigation Board, 2175 K St, Washington, DC 20037, 202-261-7673, jordan.barab@csb.gov

Investigations of workplace “accidents” can take many forms. Often only the direct causes are identified, for example “Worker error, worker opened the wrong valve,” followed by a very narrow recommendation that “Worker should be more careful” or “Worker should be terminated.” In reality, however, there are almost always “root” or underlying causes that, when identified, will result in recommendations that wold have prevented not only that specific incident, but a variety of similar accidents from happening again. The US Chemical Safety and Hazard Investigation Board uses root cause analysis to evaluate the causes of major chemical accidents and develop broad recommendations. The same techniques can be used in smaller incidents, as well. This presentation will use actual case studies of incident investigations that used root cause analysis and contrast these with cases where only the direct cause was evaluated and evaluate which method is more effective for developing recommendations that will best prevent similar incidents in the future.

Learning Objectives:

• Describe the role and importance of root cause analysis in developing strategies to prevent workplace incidents.
• Evaluate the effectiveness of root cause analysis versus identification of immediate causes.
• Discuss how to ensure that root causes are analyzed following workplace incidents.

Keywords: Occupational Safety, Prevention

Related Web page: www.csb.gov

Presenting author's disclosure statement:

I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.