Incident Reporting and

Investigation/
Root Cause Analysis
Incident Reporting and Investigation / Root Cause Analysis
Agenda

• Incident Investigation Overview

• Root Cause Analysis
• Purpose
• Steps
• 5 Whys
• Example

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Incident Investigation

• Phase I: Fact Gathering

• Timeline or Chain of Events
• Phase II: Assessment
– Identify Problem (Problem Statement)
– Identify Contributing Causes (Fishbone Diagram, Brainstorming)
– Work down to Root Causes (5-Why Process)
• Phase III: Corrective Actions & Documentation
• Phase IV: Communication of Lessons-Learned
• Phase V: Follow-up

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JLL Incident Reporting and Investigation Requirements

1. All incidents shall be entered into the JLL incident management system within 24 hours
2. Incidents shall be investigated within 5 days and root cause(s) identified
3. Lessons learned shall be completed within 10 days
4. Days away or restricted duty days shall be updated when the employee returns to work
5. Corrective actions shall be tracked to closure in the JLL incident management system
6. Affected employees shall be trained on how to report accidents
7. Those completing incident investigations shall have appropriate experience or training
8. Enforcement authority correspondence shall be uploaded to the incident management system
9. Outcomes and metrics shall be reported to responsible leadership

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What is Root Cause Analysis?

Root Cause Analysis:

Identification and evaluation of the reason for an undesirable condition
or nonconformance; a methodology that leads to the discovery of the
cause(s) of a problem or root cause(s).

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When Do I Need to Conduct an RCA?

Significant EHS Events Requiring an RCA

Injury or work-related illness resulting in more that first aid (aka, Recordable)
Disabling or other Days Away from Work injuries or illnesses
Fatality and/or hospitalization of one or more days

Spill or Release to the Environment of oil or other hazardous materials of a quantity that
requires immediate reporting to a Government Agency

Fire, explosion or similar incident

Receipt of complaint/citation/notice, or Notice of Violation/other written enforcement
Near misses that are medium or high severity, e.g., Violation of JLL Cardinal Rules

NOTE: Conduct an RCA any time a negative event occurs, and your Team needs to understand how it happened.

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RCA – Step 1: Identify Problem Statement

Identifying the problem statement

• Take time to clearly develop your "problem statement", as how
the problem is described can influence the development of the causes
• The problem statement(s) should not attempt to identify the root problem.
For example, if a site loses power during a lightening storm the problem
statement is NOT “lightening caused the site to lose power”, rather the
problem statement is “The site lost power”
• Don’t state the causes of the problem, but simply identify the problem.

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RCA – Step 2: Identify Contributing Causes

Cause & Effect/Fishbone diagram: Use a structured brainstorming session with a team to
develop the possible causes
Look for causes or themes that appear repeatedly

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RCA – Step 3: Identify Root Causes

Identify Root Causes

Apparent Cause vs Root Cause
• An apparent cause is the usually most basic reason that a system fails.
• The root cause is the underlying reason for a failure. This is usually the reason behind the apparent
cause.
• Example: You are driving to work in your new car, and suddenly your car sputters and dies with no
warning or other indications of trouble.
• While waiting for AA to arrive, you determine that your car is out of fuel (apparent cause).
• A mechanic later finds that a defective float on the fuel guage always showed the tank at least one-
quarter full (root cause).

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RCA – Step 3: Identify Root Causes

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RCA – Step 3: Identify Root Causes

Root Cause Analysis Tools

• 5 Why Analysis
• Barrier Analysis
• Causal Factor Tree Analysis
• Cause and Effects Analysis
• Change Analysis
• Failure Mode and Effects Analysis
• Fault Tree Analysis
• Pareto Analysis (80/20)
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RCA – Step 3: Identify Root Causes

Important Conditions for the ‘Whys’

• “Why" is taken to mean "What were the factors that directly resulted in the effect?"
• The real root cause should point toward a process that is not working well or does not exist.
• A key phrase to keep in mind in any 5-Why exercise is "people do not fail, processes do."
• We may observe that causes seem to point towards classical answers such as not enough time, not
enough investments, or not enough manpower. These answers may sometimes be true but in many
cases, they lead to answers that may be out of our control. Therefore, instead of asking the question
why?, ask why did the process fail?

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RCA – Step 3: Identify Root Causes

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C
RCA – Step 3: Identify Root Causes

Single-Track vs. Multiple-Track RCAs

• Many RCA “forms” or processes rely on a single-track, or one straight line of single
contributing causes responsible for each why (e.g., Domino Effect)
• Simpler, but rarely captures real-life scenarios
• Run the risk of missing an important root cause
• A better process to use is multi-track, accommodating multiple contributing causes
responsible for each why

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RCA – Step 3: Identify Root Causes

Single-Track

Problem: Car sputters and dies

Why 1 Why 2 Why 3 Why 4 Why 5 Root Cause Recurrence Prevention

No fuel getting to Car is out of fuel Defective float on the Defective float on Replace (warranty repair)
engine fuel gauge the fuel gauge defective float

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RCA – Step 3: Identify Root Causes
Multiple-Track
Problem: Scaffolding Collapsed
Why 1 Why 2 Why 3
Gust of wind Scaffold was not It was considered scaffold
blew scaffold mechanically tied off anchors could damage
over to a listed building newly refurbished building
façade
An incomplete risk
assessment was developed
but not reviewed as part of
management of change
process
Local permissions to gain
consent for façade drilling
would take weeks and were
not considered early
enough in project
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Why 4
They would have to drill into façade
and so width of scaffold base was
increased by scaffold company,
although this design modification was
clearly inappropriate
Modification to scaffold design done
as per verbal instruction between
principal contractor site supervisor &
their subcontractor scaffolder only
Principal contractor supervisor
instructed changes to the scaffold
(Contrary to his specialist suppliers
design).
Lack of detailed planning by ??? and
Principal contractor, principal
designer (it was known that a
scaffold was needed and that the
building was listed)
Why 5 Root Cause Recurrence Prevention
The design drawings Lack of understanding Training of JLL supplier
were not verified by a and verification of CDM Project Manager and JLL
competent person and roles and Facility manager on CDM
shared with the responsibilities regulations. Put a system in
principal designer or place to review JLL contractors
client (including principal designer)
training on CDM
This change was not Lack of communication Enhance communication
communicated to the and lack of inspection through site orientation /
principal designer nor program induction, cross party
identified through spot meetings and introduction of
checks through client spot check process by client.
(JLL)
Overstepped Delegation of authority Clear lines of communication
boundaries of authority not clearly defined and and defined DOA established
checked between all parties at
commencement of project
Lack of client Lack of supervision and Enhanced management of
supervision of Principal vendor performance contractors and contractor
contractor management selection
Poor planning and Lack of planning Improved pre-construction
communication safety planning
17
RCA – Step 3: Identify Root Causes

When should you stop asking why?

• Beyond the control of your organization or the company

• Sufficient safeguards in place to ensure prevention of recurrence

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Example RCA

A warehouse employee has had

enough and decides to leave early

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Example RCA

Rather than going the correct

route, he decides to take a short
cut through the warehouse.

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Example RCA

The forklift driver is under

pressure to get finished before the
end of shift and is driving faster
than permitted because the
limiter has been disabled.

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Example RCA

The warehouse operative

appears in front of the forklift

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Example RCA

The forklift driver brakes hard

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Example RCA

The forklift skids on oil on the floor

which has been leaking from the
forklift during the last few days.

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Example RCA

The unsecured load is thrown

forward, striking the warehouse
operative. He receives a broken leg
and multiple bruises.

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Example RCA

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Example RCA

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References

• Incident Reporting and Investigation global standard (link)

• 5 Why Root Cause Analysis Template (link)
• Incident Investigation and Reporting courses are available in the JLL
Learning Management System

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