What’s Going Wrong Here ? Let’s Have a Root Cause Analysis

The Incident:

 I found this interesting video in YouTube and I gave this link below. I thought to share as there are quite a few interesting things to  Learning from QMS and OHSMS perspective.

What Went Wrong ? The Causal Factors

I tried to find what was going wrong here. Quite a few things indeed were missing .

• What I found first is there was no Planning for Product and service Provision. ISO 9001:2015 Clause No. 8.1  before they started the first Lift
• There was no effective Hazard Identification and Risk assessment and Controls as per ISO 45001:2018 Cl No 8.1.2 before they started the first Lift
• After the first Incident, they did not seem to have Performed an Incident investigation  and Root cause Analysis and Did not take Corrective action ISO 9001:2015/ISO 45001:2018-Cl 10.2 .
• Even if the RCA was done after the first accident, and Corrective action was taken , the actions were not effective to prevent a recurrence.

• ISO 45001:2018 Cl No 10.2 c) review existing assessments of OH&S risks and other risks, as appropriate after an accident
• ISO 45001:2018 Cl.No 10.2 d) determine and implement any action needed, including corrective action, in accordance with the hierarchy of controls
• Competence of People ? Look at whether people were competent. ISO 45001:2018 ,7.2 Competence requires  the organization to :
  a) determine the necessary competence of workers that affects or can affect its OH&S performance;
  b) ensure that workers are competent (including the ability to identify hazards) on the basis of appropriate education, training or experience
• Also we need to see whether there was issues with Resources-The Cranes for examples. Suitable resources/Machinery and equipment

Estimated Cost of Incident:

Imagine How much those failures would have Costed them?

• Car Lost: KD 5000 (small Car)
• 1st Crane Lost-KD 20000?
• 2nd Crane Lost KD 20000 ?
• Labour and Other : KD 500?
• Close to KD 45500? (USD 150,000)

Conclusion

• So ISO Standards work.
• We Fail it due to our own limitation or ineffective application or effective implementation. Lack of Knowledge? Behavior? Other factors?
• A well established Management system Saves  Lot !
• A Great Training Saves Lot of Money and resources and prevent operational disruption!

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