you will need a scenario where a worker becomes injured while performing their job. You will need to describe the job duties in a manner in which a worker will not become injured as an alternative to the injury scenario.
Read chapter 8 in your textbook for details on column placement and what details will be included in each. Yes, you will be writing your own change analysis script as well as a chart.
So the beginning you will need to explain the two scenarios (worker injury one and non-injury one), draw out your analysis chart, fill in each column of what is required to make it an actual change analysis.
Chapter 8
A change of some sort is a major factor in most accidents. Although change is a necessary component of progress, it can also be catastrophic. Change can be planned, anticipated, or desired; it can also be unintentional or unwanted. Change analysis is a technique for analyzing the changes that led up to an accident. It can be combined with other techniques or used independently.
Change analysis can be used both reactively and proactively. When it is used reactively, the investigator looks back at the events that led up to the accident and determines the unintentional or unwanted changes that may have caused it. What was different about how the process was performed this time that caused the accident to happen? When it is used proactively, safety professionals develop scenarios that introduce a planned, anticipated, or desired change into a system and use change analysis techniques to identify potential hazards or accident situations that could arise because of the change. Change analysis can also be used to review processes or to identify the potential effects of changes before implementing a new procedure or process (Stephenson 1991) (Spear 2002). Many safety professionals use a modified change analysis process to comply with the Process Safety Management regulatory requirements for the management of change.
About Change Analysis
The technique of change analysis was first used before World War II (Ferry 1981) and was perfected by Charles Kepner and Benjamin Tregoe for the U.S. Air Force in the 1950s. Bill Johnson also used this technique in the Management Oversight and Risk Tree (MORT) system developed for the Department of Energy. When using it, the investigator compares the sequence of events leading up to an accident with a similar non-accident sequence to find the causes of the accident.
Although change analysis can be used with any accident investigation, it is most useful for accidents that happen while routine tasks are being performed. For first-aid incidents, near misses, and accidents that occur during simple tasks, change analysis may be sufficient on its own to determine what happened; it will provide enough information to determine how to prevent the sequence from developing again.
For more complex accidents, change analysis must be structured and detailed. It is not enough for the investigator to simply ask, “What changed to cause the usual sequence of events to turn into an accident sequence?” Every event that changed, including management systems events, must be analyzed in detail, and frequently other analysis methods must be used in addition to change analysis.
The approach of change analysis is to compare an accident situation or sequence with a similar accident-free situation or sequence. The basic change analysis sequence is illustrated in Exhibit 8.1 and a summary of comparison methods is illustrated in Exhibit 8.2.
Types of Accident-Free Situations
It is critical to find a directly related accident-free situation or sequence to compare with the accident situation. Three types of situations can be used:
Exhibit 8.1
The Same Procedure as It Is Usually Performed
Ideally, the investigator is able to compare the accident sequence with the same procedure as it was performed accident- free—last week, last month, or last year. Since an accident did not occur during that situation, what was different in the sequence this time that may have contributed to the accident.
A Description of the Job as It Is Supposed to Be Performed
Comparing the accident sequence to a written description of how a task is supposed to be performed makes change analysis simple for the investigator. This process is also called Codes, Standards, and Regulations (CSR), Procedure Design Criteria Analysis, or Procedure Adherence Analysis. The investigator compares the accident sequence to the procedure, standard, or regulation and discovers where change has occurred. One problem with comparing the accident sequence to a task description sequence is that the worker involved in the accident might not actually have changed the usual procedure. It is possible that workers have never performed the job as it is described by the standard or procedure. If this is the case, then it was not a change but a difference from the described procedure that caused the accident.
Exhibit 8.2
CHANGE ANALYSIS COMPARISON METHODS
| COMPARE THE ACCIDENT SEQUENCE TO: | |
| 1. An “accident-free” situation |
How the job was performed last week, last month, or last year with no accidents. |
| 2. Plant procedures | How the task was supposed to be performed according to company policy. |
| 3. An “ideal” situation | How the job would be performed under ideal circumstances. |
A Description of the Job as It Should Be Performed
This sounds very much like the comparison in the previous paragraph, but it is subtly different. In this kind of comparison, the investigator compares the accident sequence events not with written standards but with a description of the way the task would be performed under ideal circumstances. With this method, the investigator is not comparing changes but differences between the accident sequence and the ideal sequence, since the task has probably never been performed in the ideal way. If the investigator finds a better way to perform the procedure, it can be recommended as a corrective action.
Making Thorough Comparisons
As you perform change analysis, you must compare all events and conditions involved in the accident with corresponding events and conditions in the accident-free scenario. Ask the following questions about each event: Who was involved? What happened? When did it happen? Where did it happen? How did it happen? Analyze each set of events and conditions and ask what changes may have occurred: Is the time or place different? Are the people involved different? On a managerial level, was it managed, controlled, reviewed, or implemented differently? (DOE 1999.) After you have made a thorough comparison, find the differences between the two sequences. In most situations, they are quite obvious. Finally, determine how that difference caused the accident.
The short example below demonstrates the change analysis approach.
Bob had gone fishing every day for twenty years, and every day he had been able to catch fish for his lunch and dinner. One day, he did not catch any fish, and he wondered why. He compared the unsuccessful day to all of the previous successful days and found that he had used the same fishing hole and the same hook size, and had fished at the same time of day. The only difference was that he had used different bait on the unsuccessful day, so he reasoned that using different bait was the cause of his failure to catch fish.
Accident investigations will never be this easy to analyze, of course, and the analysis does not stop with finding that different bait was the reason for fishing failure. The next steps are to learn why Bob decided to change his bait and why the new bait didn’t seem to attract fish. In change analysis, you must find out all of the changes that occurred and analyze how they affected the outcome.
Change analysis is performed on a four-column worksheet (see Exhibit 8.3).
When performing change analysis, you must find an accident-free sequence to compare to the accident sequence. Although our forklift-and-ladder scenario is a non-recurring task that has no specific written description, there are procedures for using ladders and working in warehouse aisles, and changing light bulbs is similar to installing signs, so that procedure was used as the comparison sequence. Exhibit 8.4 lists only the events in the accident sequence that are different from those in the comparison sequence. After the first three columns are filled in, analyze differences between the accident sequence and the comparison sequence that could be significant to the accident. The fourth column lists several differences that had a significant impact on the accident.
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