February 11, 2010 | Barb Carr

Root Cause Analysis Tip: Understanding Human Engineering Investigations after a Fatality

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See the Video of the Incident Investigation here: http://www2.worksafebc.com/media/fss/garbageTruck/slideshow.htm

The Workers’ Compensation Board of British Columbia do a great job of sharing lessons learned after an investigation. Watch the video in this link to learn where Controls NI, Plant/Unit Differences, Arrangement/Placement, and Fatigue Root Causes come into the picture during a fatality investigation. Do you think this was the first time the wrong switch has been selected?

We introduce these root causes in our TapRooT® Root Cause Analysis Courses, however seeing the impact of muscle memory and an almost reflex like movement in this fatality really adds strength to why these Root Causes are part of our analysis process. To help people get a better understanding of a person’s ability to feel, see, hear, smell, and move in his/her environment, I added hands on exercises in our Stopping Human Error course last year, which will be taught again in San Antonio this October at the Pre-Summit. For those students who took the course last year and asked for additional behavior changing techniques, this request was heard and will be added in this year.

So looking at the fatality above and after reviewing the video what could have been done when the two trucks were introduced to the workforce:

1. Inexpensive fix: Turn the toggle switches to match the movement of the container ( Up, Down, Out, In); even with muscle memory from driving one truck or another, the person would get feedback when the switch did not move and the label would not need to be the only indicator.

2. Little more expensive fix: Put more space in between the switches which according to Fitt’s Law will improve speed and accuracy trade off.

Remember to use SMARTER, Corrective Action Helper®, and Root Cause Dictionary to help develop achievable and sustainable corrective actions.

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