Incident Investigation, Root Cause Analysis, and the Art of Letting Go

This presentation employs examples of research laboratory incidents to introduce the key research safety expectations and a team based root cause analysis incident investigation process.

Several widely publicized and critical accidents in university research laboratories in California, Texas and Massachusetts have shed light on potential safety gaps in research laboratories.  In response, the University of Maryland College Park (UMDCP) research community proactively instituted a set of five Expectations for Conducting Safe Research:  Demonstrate Commitment to Safety, Assess and Plan for Hazards and Risks, Implement Controls, Complete all Safety Trainings, and Strive for Continuous Improvement.

The Research Safety Office within the Department of Environmental Safety, Sustainability and Risk (ESSR) has designed an incident investigation and root cause analysis process predicated on the Expectations for Conducting Safe Research.  Historically, the Office of Research Safety assumed the lead role in incident investigation and root cause analysis which placed the laboratory staff members in a passive role where they were not encouraged to assume ownership of the root cause analysis process and corrective action determination. Our new process is geared to encourage the researchers to actively engage in the incident investigation process and assume the lead role in root cause analysis as well as corrective action determination.