Investigating Loss Incidents to Determine the Underlying Causes

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• Investigating Loss Incidents to Determine the
  Underlying Causes

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Overall Objective

• To find at least 3 underlying causes for each
  loss incident that is investigated

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Course Overview

• I. Introduction/ Loss Incident Investigation
  Models
• II. Identifying Underlying Causes

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Unit I - Loss Incident Investigation Models

• Lesson I- Introduction
• What is a performance discrepancy?
• What are the rewards and benefits of adopting
  new performance?
• Why are establishing training objectives so
  important?

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Performance Discrepancy

• Supervisors failure to investigate loss
  incidents to determine the underlying causes

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Training

• Training for your supervisors may be needed when
• There is no description of the performance
  discrepancy
• Valuable feedback to management is lost.
• The cost consequences of the performance
  discrepancy is not addressed

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Unit I - Loss Incident Investigation Models

• Lesson I
• Remember-
• -The Heinrich one-cause accident investigation
  model
• -The Multiple causation theory

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Reports Analyzed for Causes
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Lack of Knowledge

• 10 (60) of 600 supervisors were asked to define
  or give an example of an underlying cause.
• None was able to
• All asked, Whats an underlying cause?

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Lack of Knowledge (continued)

• These 60 supervisors were asked to state the
  cause of this loss incident
• An employee used a ladder with a defective foot.
  The ladder shifted and the employee fell to the
  ground.
• Not one supervisor asked for more details
• No supervisor gave an underlying cause.

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Example of Performance Discrepancy

• Incident description
• Employee stepped on a wooden pallet. A wooden
  slat broke and the employees foot went through
  the pallet skinning his ankle.

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Example of Performance Discrepancy (Continued)

• Cause of Loss Incident Employee was careless.
• Corrective Action Told employee not to step on
  pallets.

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Answers Not Found

• Why did employee step on pallet?
• Was the employee trying to reach something that
  is part of his job?
• Does the item he was reaching for need to be
  placed lower?
• Should a permanent step be placed there for
  employee to climb on?
• Why wasnt this considered during design?

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More Answers Not Found

• Was employees action defined in the standard
  operating procedure?
• Was the pallet in the aisleway?
• Is there adequate storage for pallets.
• Who placed the pallet there?

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Still More Answers Not Found

• Do we inspect pallets or wait until they fail
  before we remove them?
• Was this a new pallet?
• Do we need to change the specifications for our
  pallets? Can we???

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And More Answers Not Found

• Was this pallet being taken from service?
• Has pallet failure in the past resulted in
  product damage?
• Did an employee report this faulty pallet?
• Were new pallets on back order?

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Even More Answers Not Found

• Was pallet outside an aisleway?
• If so, why was employee walking there?
• Was being there part of his job?
• How many and how often do employees walk where
  the pallet was?
• Should a permanent walkway be placed where the
  employee was walking?

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Valuable Feedback to Management Lost

• What is process engineerings method of walkway
  placement?
• Equipment placement?
• What is Facilities Engineerings method of
  determining storage size?
• Storage placement?

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More Valuable Feedback to Management Lost

• Does Engineering include loss prevention protocol
  in their Standard Operating Procedures?
• Do line managers have a method for employees to
  report hazards?
• Do line managers have a way to follow up on
  removing reported hazards?
• Did Scheduling make a rush order?

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Even More Valuable Feedback to Management Lost

• Does Quality Control randomly test incoming
  materials for compliance to specifications?
• Does Purchasing keep records of vendor quality?
• Records of vendor on-time deliveries?
• Did Sales promise a customer an unreasonable
  delivery date?

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Expected Results from Performance Improvement
Philip Rivers This was one-half the reduction
with my previous employer

• 25 reduction in the number of loss incidents
  within one year after end of training

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Dollar Savings 6,000,000

• Assuming a 25 decline in the costs of loss
  incidents.

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Expected Losses w.o. Training
Philip Rivers Assuming 3 inflation
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Unit II- Identifying Underlying Causes

• Upper line Ex. Plant Manager
• Process Engineering Ex. P.E. Manager
• Facilities Engineering Ex. F.E. Manager
• Legal Ex. Legal Manager
• Maintenance Ex. Maintenance Manager
• Human Resources Ex. H.R. Manager
• Purchasing- Ex. Purchasing Manager

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Unit II- Identifying Underlying Causes

• Scheduling Ex. Scheduling Supervisor
• Accounting- Ex. Accounting Manager
• Quality Assurance Ex. Q.A. Manager
• Sales and Marketing Ex. S M Manager

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Non-monetary Support Needed

• Have all your first-line supervisors attend.
• Make it clear to the supervisors that you want to
  better serve them.
• Make it clear to the supervisors that you want
  their feedback on causes traceable to your
  department.
• Promptly remove underlying causes identified in
  your department.

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You Want To Better Serve Them
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You Want Their Feedback