Site Name / Location : Gensuite Case Number:

Date and Time:

Injury Type/Body Part : Employee Years of GE Experience:
Recordability Rationale: 5 days away from work DAFW: YES
Management System Failure: No Incident Location: GE

Description:

Shift
Overtime work - No
Normal or unusual task - Normal
Personnel involved Fbio dos Santos
INSERT PHOTO:
Equipment and process involved Stylet Starret Add additional photos on
Environmental conditions Not aplicable
Accident description must be in sequence from beginning to end of the event second page if needed.
Employee was cutting plastic trunk using retractable knife when performing the
cutting motion, the retractable knife slipped sharply, reaching its forefinger of his left hand,
which was positioned above the piece, holding it.
Root Causes (include Causal Analysis Results): Lessons Learned

Inadequate tool for the finishing activity; Lessons learned 1

Gloves without suficient protection for the risk of cuttings with retractable knife;
Unsafety hand positioning during the activity; Lessons learned 2
HOP Considerations: Key Local Factors (Error Enablers) /
Active Errors (Triggers) / Risk-Important Steps Latent System Weaknesses (LSW)

Corrective Action (including HOP Error Enablers & LSW actons) Responsible Person ATS ID Target/Closure Date
 Strength of Defenses Matrix
Personal
Type Engineered Admin Oversight Cultural
Defenses Defenses Defenses Protective Defenses
Purpose Equipment
Eliminate Ex: eliminate need for permit
confined space entry,
substitute les hazardous
Ex: SRA with Critical Steps.
No single error
vulnerability at critical
Ex: Supervisor verify daily
checklist inspection to
confirm critical controls
Not Applicable Ex: effective employee
EXPECTATION to stop
unsafe work; consistent
(substitute)
Strength of Defenses
material, task redesign to steps operating correctly management style
eliminate hazard reinforcing H&S

Prevent
Matrix required for all
Ex: machine guard, local Ex: limit on maximum Ex: Permit to Work before Not Applicable Ex: Chronic unease and
exhaust ventilation, or exposure time to hazard, proceed with high risk task questioning attitude
interlock equipment-specific LOTO emphasized by leadership
procedure, or permit to and employees
work, training on SRA

Catch
RECORDABLE and A / B
Ex: process over-pressure or
high temperature sensors with
Ex: peer check at critical
step
Ex: supervisor approval
prior to high risk task
Ex: Faceshield for splash
protection, cut resistant
Ex: stop when unsure

cases.
emergency shutdown gloves
procedures

Detect Ex: continuous air monitor to

hazardous gas
Ex: pre-job checklist
inspection
Ex: supervisor audits to
verify use of established
procedures. Add to
Ex: Personal dosimeter for
ionizing radiation
Ex: active use of Concern
Reports

supervisor scorecard.

Mitigate Ex: blast barriers, noise baffles Ex: training on response to

unexpected conditions,
CSE emergency rescue
Ex: supervisory verification
that only necessary and
qualified personnel
Ex: Vibration attenuation
gloves
Ex: Value system, priorities

arrangement allowed where HRO to be

performed

Purpose what you want to achieve in terms of hazard defense and error management
Type how you want to achieve it; determines reliability of defenses. All defenses have value
but up / left in matrix are stronger/more reliable
Describe your selected corrective actions in the appropriate cells.
Adapted from Muschara Error Management Consulting, LLC
IT IS NOT NECESSARY to have an entry in every cell 2
 Strength of Defenses Matrix
Personal
Type Engineered Admin Oversight Cultural
Defenses Defenses Protective Defenses
Purpose Defenses
Equipment
Eliminate Not Applicable

(substitute)
Strength of Defenses
Prevent Matrix required for all
Not Applicable

Catch
RECORDABLE and A / B
cases.
Detect

Mitigate

Purpose what you want to achieve in terms of hazard defense and error management
Type how you want to achieve it; determines reliability of defenses. All defenses have value
but up / left in matrix are stronger/more reliable
Describe your selected corrective actions in the appropriate cells.
IT IS NOT NECESSARY to have an entry in every cell 3
Root Cause Contributing Factors
Required for
Administrative
Contributors
Missed Critical
Steps
Ergo
Contributors LEVEL A / B

RCA Tool must be used

for A / B cases. Other Resulting

RCA tools are injury or

illness

permitted in addition
to fishbone.

Machine Environmental Personal Contributors

Contributors (Must Include Active or Latent Errors)

HOP: Highlight Active Errors & LSW in Purple

4
GE Energy Management Guidance
Establish the facts, trace the root causes, Eliminate insignificant causes, Identify realistic actions

Accident Description: Root Causes:

(A detailed chronological sequence of events)
Questions you should ask yourself
Why did this event happen?
Accident must be precisely described, including:
What happened before, during & after
What was the EE doing there?
Date and time Does this task/process need to take place?
Location Was pre use inspection done?
Shift Is this the best way to do it? Have we looked at other ways? (different
Overtime work tool, lift assist, process flow redesign, job rotation)
Was the right tool used for the job?
Normal or unusual task
Is maintenance(PM) done and sufficient?
Personnel involved
Was training given and sufficient?
Equipment and process involved
Was this injury reported on time? If not why?
Environmental conditions Has this happened before?
What did the EE have to say during the investigation?
Accident description must be in sequence from beginning to Is this a quality or sourcing issue?
end of the event Was EE in a rush? If so why?
Is this an ergo related injury or illness?

HOP Guidance:
Refer to slides 6-7 for HOP
Guidance.
Corrective action
Each root cause / contributing factor must be followed by its own corrective action, detailed on Slide 1 and uploaded in ATS.

The corrective actions must be reflected in the JSA/SRA update if applicable.

If ergo related, the ergo team and the injured employee must be involved in the corrective action.
If there are any similar applications where these corrective actions can be applied, add to Slide 1 under Corrective Actions.
*** Think of Engineered solutions, training ,administrative solutions, PPE.. In this order***
5
Applying HOP to Incident Review HOP Incident
Review Questions
Questions for Incident Investigations
1. Were there critical steps identified in the procedures / processes?

2. Did the employee recognize those steps and take appropriate actions? Did the employees understand
and/or acknowledge the critical steps? If yes, what actions did he/she take?

3. Were there risk important actions identified in the procedures / processes? Change procedure to work
instruction or have both. Some people call them procedures some work instructions.

4. Did the employee recognize those steps and take appropriate actions? Did the employee understand the
steps and mitigate any/all risks during the task?

5. Describe the multiple levels of defense (controls, barriers, safeguards) in place at critical & risk important
steps in the process.

6. Were there conflicting goals, directives, procedures from the Supervisor, contractor, work leader, EHS,
etc.?

7. Put yourself in the person who made the errors place. Why did what he/she chose to do make sense to
them at the time and under the existing circumstances? (Do everything possible to eliminate hindsight
bias).
a. How did the site world look to them?
b. How did the situation unfold around them?
c. What cues did they receive and when (i.e. see, hear, touch, or feel)?
d. What were they paying attention to?
e. What factors / error traps influenced their decision making?
f. Were they going with the flow of what was happening around them? 6
Applying HOP to Incident Review HOP Incident
Review Questions
Employee Questionnaire / Discussion
Please rank the following factors on a scale of 1 to 10 with 10 being the most impactful and 1 the least, in
playing a part in your injury.

1. The lack/shortage of supervision/direction ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

2. Working extended hours/overtime ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

3. Limited availability of the correct tools/equipment ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

4. Having a sense/perception of being hurried/rushed to meet a schedule or
customer request ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

5. Procedures not available and/or not adequate ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

6. My knowledge and understanding of the task ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

7. My physical & mental fitness and awareness/alertness ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

8. My work group's beliefs/attitudes towards safety ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

9. Communication between team and other trades, business, companies, etc. ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

10. Other (Please list) ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )

7