RCA Case Study - Industrial Accident

´ Scenario: "Maintenance worker severely injured while repairing conveyor system"

Initial Facts:

´ Worker bypassed safety interlock

´ Machine started unexpectedly

´ No lockout/tagout procedure followed

´ Inadequate supervision

Investigation Findings:

´ Multiple system failures identified

´ Organizational and cultural issues

´ Training deficiencies

´ Equipment design flaws

Group Activity - RCA Diagram

´ Task: Create a Cause and Effect Diagram for the conveyor accident

´ Categories to Consider:

´ People: Training, competence, supervision

´ Methods: Procedures, work permits, communication

´ Machines: Design, maintenance, safety features

´ Environment: Lighting, noise, workspace

´ Management: Policies, resources, safety culture