PG Diploma: Hello, good morning, sir!
Snehal Tralsawala: Good morning. Good morning. Very good morning to you.
PG Diploma: Yes, sir.
Snehal Tralsawala: So neither I very much, but.
PG Diploma: So we start in 1010, 15 min, actually ask all the participants to join.
Snehal Tralsawala: And, sir, actually, I'm in. I mean, I'm out a session. Actually, I'm.
PG Diploma: I came to my hometown for some management check.
PG Diploma: so I may not be able to continue in the class.
PG Diploma: I request you continue to please, you know, and you know when the.
Snehal Tralsawala: Yes, yes, I saw you correctly.
PG Diploma: Yes, sir.
Snehal Tralsawala: Break. Make a break, may what we'll do during the break that we have to discuss
Snehal Tralsawala: just a chat with oh, keep continuing, and then take 10 min.
PG Diploma: No, we can take as per your as per your convenience. You can take break at whatever time.
Snehal Tralsawala: Maybe during the break we will continue the link on everybody on just come back at.
PG Diploma: Yeah.
Snehal Tralsawala: Like that.
PG Diploma: Yes. Yes. Yeah. Yeah.
Snehal Tralsawala: Okay. Done. Yeah.
PG Diploma: It's yeah, really. I mean, car traveling.
PG Diploma: I know.
Snehal Tralsawala: Are they going back to me, my brother? But yeah, don't worry about it.
PG Diploma: Yes, it is to tell you.
Snehal Tralsawala: Enjoy, enjoy the trip.
PG Diploma: I did.
PG Diploma: Don't decide.
PG Diploma: I'll I'll a straight.
Snehal Tralsawala: Good morning. Can we start now?
Snehal Tralsawala: Good morning, everyone.
Nisarg Patel: Good morning, sir! Good morning.
Dhanasekaran P: Morning, sir!
Snehal Tralsawala: So we'll we'll wait for a few minutes.
Snehal Tralsawala: I think. Let's let's wait for couple of minutes. Okay, then we will start.
Snehal Tralsawala: Okay. So I think. Let's start everyone.
Chetan Bhoyar: Yes, sir.
Snehal Tralsawala: Yeah. So today, today, being a 3 h session.
Snehal Tralsawala: we have 5 points to cover.
Snehal Tralsawala: What? Last time, whatever
Snehal Tralsawala: the root cause analysis, method we went through.
Snehal Tralsawala: We have a 4 more root cause analysis, method to cover one is a brainstorming.
Snehal Tralsawala: And then when it's a causal method.
Snehal Tralsawala: Then there is an incident mapping, and there is event tree.
Snehal Tralsawala: And then on the top of that.
Snehal Tralsawala: I also have one presentation on a basic terminology.
Snehal Tralsawala: basic terminology, meaning that when we talk about safety, then most of us must be familiar, will be like a refresher on what is incident, what is near misses
Snehal Tralsawala: what is dangerous occurrences like that.
Snehal Tralsawala: So I have a presentation on that. So basically brainstorming causal tree
Snehal Tralsawala: incident, mapping and event tree these 4 things we want to cover today and the basic terminology.
Snehal Tralsawala: So for that point of view,
Snehal Tralsawala: you know, it's going to be a very exciting hours
Snehal Tralsawala: as well as your attention is very much requested, because not only
Snehal Tralsawala: from the subject point of view. From the exam point of view, these are good things.
Snehal Tralsawala: but from the practical use of the method also, this is useful
Snehal Tralsawala: to get to the root cause.
Snehal Tralsawala: therefore, your attention, your participation will be greatly appreciated.
Snehal Tralsawala: So with that, let me just start with a
Snehal Tralsawala: 1st one. I'm trying to figure out how to
Snehal Tralsawala: share the screen. Just hold on.
Snehal Tralsawala: Okay, you are able to see these right.
Chaudhari santosh: Yes, sir.
Snehal Tralsawala: Okay, sleep.
Snehal Tralsawala: So the root cause analysis of brainstorming.
Snehal Tralsawala: Now, before I get into the brainstorming, the way it is being discussed
Snehal Tralsawala: general brainstorming method. Can somebody tell me, how do we do the brainstorming at our workplace?
Snehal Tralsawala: Right there? Let's have some interaction in the beginning few minutes of interaction.
Snehal Tralsawala: So when we say we want to have a brainstorming session, how do we do it?
Snehal Tralsawala: Something has happened, and we want to get to the things done.
Snehal Tralsawala: And then, there was some discussion management will say, Okay, let's please do the brainstorming.
Snehal Tralsawala: So how do we do it?
Snehal Tralsawala: Anyone
Snehal Tralsawala: see the brainstorming session, which
Snehal Tralsawala: which is conventionally being heard of, that when we do brainstorming session, in which what happens is that we have a
Snehal Tralsawala: let's say a conference in a conference room. The meetings are taking place.
Snehal Tralsawala: and then let's discuss what can go wrong. I mean, what are the things which can happen? And then, one after another, people will start
Snehal Tralsawala: saying, that this could happen, this can happen. This could be the reason this could be reason.
Snehal Tralsawala: And so it could be a brainstorming session without let's stick down the
Snehal Tralsawala: without listing down what discussed. And then finally, we say, Okay, maybe this is what it is, and then the chair will say, Okay, let's do this.
Snehal Tralsawala: This is a very simple way of brainstorming. We do in our day to day lives in which
Snehal Tralsawala: it we may not categorize it. Brainstorming
Snehal Tralsawala: quote unquote. But we do the brainstorming. And then 2 or 3 people will say, because of this, because of this, because of this. So this is a very typical type of a brainstorming. When you
Snehal Tralsawala: you say, Okay, what are the what could be the possible reasons?
Snehal Tralsawala: Then there could be another brainstorming in which we call it a systematic brainstorming.
Snehal Tralsawala: and we come with a seat with a purpose.
Snehal Tralsawala: Why this accident took place, or how come this month the production is down, or how come the utility consumption is more or less this time.
Snehal Tralsawala: So say, Okay, man, this could be the reason this could be reason, and somebody will start writing it down
Snehal Tralsawala: and then on the board. So that is another kind of brainstorming. We start listing it down. Let's take it down
Snehal Tralsawala: now. I remember sitting in one of the brainstorming sessions where our
Snehal Tralsawala: wherever you know, you need head. A very senior gentleman was sitting in it.
Snehal Tralsawala: And then whoever talks about all right gives an answer.
Snehal Tralsawala: Then, because this plant was actually designed by him, he was a project engineer project manager for the site was 200 acre site, and he was behind the whole thing.
Snehal Tralsawala: and as soon as the
Snehal Tralsawala: or you know, somebody points out that this is the reason. And then the gentleman had an argument which counters that because he felt
Snehal Tralsawala: that it cannot be so.
Snehal Tralsawala: What happens if you have a team of 1020 people sitting in a room.
Snehal Tralsawala: And you start with a brainstorming
Snehal Tralsawala: meaning that you have a problem. And then you say, what? Why, the problem could be.
Snehal Tralsawala: and then you say.
Snehal Tralsawala: somebody will say it could be because of that, and then they will go. The chair will say No, no, it cannot be. Because then how how dare and how? How come you are telling it? Route now? And why not before?
Snehal Tralsawala: So each one, when somebody raises the point gets countered.
Snehal Tralsawala: My 3rd person.
Snehal Tralsawala: then, over the period of time, it gives the impression that even though you are saying that you want to know the the causes. You really don't want to know the causes, because you are eliminating as you go along. Have you seen? Have you any one of like we have 14 of us
Snehal Tralsawala: have anyone of has witnessed this in the past?
Udit: Yes, sir.
Snehal Tralsawala: So yeah, you have an answer, and then answer gets counted immediately, because they oh, no, no, because of these. And how come you're telling it now, and you should have told these, and no, no, this is not the way to do it, so that the team doesn't get motivated to answer the question.
Snehal Tralsawala: Then there are straightforward brainstorming methods
Snehal Tralsawala: in which everybody, everyone is in discipline.
Snehal Tralsawala: That even chair is also
Snehal Tralsawala: chair is also saying that I know what my role is. I'm not supposed to ask everyone why this happened, because the idea is that we need to have a list of ideas on the table.
Snehal Tralsawala: So when the list of ideas are on the table, then it's a matter of
Snehal Tralsawala: listing it down, and then come back and say how it can happen. Why this? Why this? So let's say there are 20 of people in the room, and we asked each one you have to give at least one.
Snehal Tralsawala: So and 2 is also okay. So at the end of the full circle, and nobody is raising any
Snehal Tralsawala: doubt about the question that you're raising. It could be as silly, you know, it could be like, because my pen was not inside my in my pocket that I couldn't write it, or something like some stupid things, you know. So so we allow that person to speak.
Snehal Tralsawala: It could be as simple as that that could be. You know housekeeping was poor, and that's why the accident took place. So if somebody wants to say anything.
Snehal Tralsawala: then he or she can say it.
Snehal Tralsawala: so one person will mention it, and one person will write it down on the board. That is a typical standard brainstorming we think of.
Snehal Tralsawala: And then you list it down. So 20 people are in the room, and there will be 20 ideas at least 20. Then when the 20 is completed, then you say, Okay, anybody else has another idea. So they're okay. So so it kind of creates an environment wherein, everybody is allowed to speak.
Snehal Tralsawala: It requires a lot of discipline. You know the chairperson
Snehal Tralsawala: cannot have a ego, cannot have an ego, and also the chairperson cannot be directly connected to that particular subject, because, if directly connected. Then he have a urge to counter every time.
Snehal Tralsawala: So, assuming that everything is going well, then, on that whiteboard.
Snehal Tralsawala: in the confidence, you'll have a 20 ideas for a given problem
Snehal Tralsawala: and those 20 ideas you listed down.
Snehal Tralsawala: Then you come back to the 1st idea and then discuss over the 1st idea and say, Well, can this be possible? Can this be possible? Can this be possible? Likewise you kind of go into each idea.
Snehal Tralsawala: and then out of 20 ideas, you can scrutinize into maybe 3, 4, 5, 7 of them, which is a more meaning.
Snehal Tralsawala: Then the you know, and then discuss on those 5, 6, 7 like funneling them.
Snehal Tralsawala: But before funneling you will have to have a list of all those, and before listing you need to have an environment in which everybody is allowed to speak what they want to speak, isn't it? Because if the people sitting in the room are not comfortable.
Snehal Tralsawala: then they will not speak right or wrong.
Udit: Yes, sir.
Snehal Tralsawala: So that so that is essential. The most essential part of a
Snehal Tralsawala: typical brainstorming is that everybody should feel at home.
Snehal Tralsawala: Nobody should feel that as soon as so the environment has to be so good that the people will talk about the brainstorming. This is what the typical good brainstorming session mean.
Snehal Tralsawala: Now, what we are going to talk about is one step up
Snehal Tralsawala: beyond the normal brainstorming which our conventional management books tells us
Snehal Tralsawala: we're gonna go one step up, and that is called brainstorming, which is developed by Australia. There was a method from Australia
Snehal Tralsawala: wherein the brainstorming is called brainstorming affinity and quad sort.
Snehal Tralsawala: Quad. QUAD. Quad. You know, you heard about that quad
Snehal Tralsawala: this recently? This quad meetings are taking place when Australia is also there, Australia, America.
Snehal Tralsawala: Japan and India, the 4 4 countries into that quad meeting. You remember you you so quad is basically the word is coming out of Australia.
Snehal Tralsawala: And on the left hand side you see, you play the ideas with this yellow tag. On the left hand side you see the the picture wherein you suddenly stick them down the
Snehal Tralsawala: the ideas on the yellow tag. Now the point is that how come Yellow Tag is required?
Snehal Tralsawala: So that is what we're going to talk about in the next few sessions, I mean next, few slides
Snehal Tralsawala: for the brainstorming important tool can be utilized quickly and silently
Snehal Tralsawala: to help energize in a standard brainstorming.
Snehal Tralsawala: What happens is that somebody will say for example.
Snehal Tralsawala: So when somebody will write it down now, if I have the same idea, then I will not talk about that idea because somebody has already spoken. Isn't it
Snehal Tralsawala: so?
Snehal Tralsawala: And also it can happen that the person who is speaking, he's a manager
Snehal Tralsawala: and electrical short circuit. And I'm saying, No, no, it cannot happen because of electric, because this is the reason, and and so pointing them opposite haggard.
Snehal Tralsawala: So when I'm speaking out loud, though I may not necessarily share
Snehal Tralsawala: something which is opposite to what my one of my 20 members are saying, right or wrong.
Udit: Yes, sir.
Snehal Tralsawala: Right. So there is a element of human behavior comes into picture. The element of psychological behavior comes into picture when we talk about the typical brainstorming.
Snehal Tralsawala: So this particular brainstorming in which I'm carrying it.
Snehal Tralsawala: Yellow tag, blue tag, red tag, green tag is given this like a square thing.
Snehal Tralsawala: So yeah, they care.
Snehal Tralsawala: Likewise, we ask each of the 20 members to write it down.
Snehal Tralsawala: Everyone we ask them
Snehal Tralsawala: or don't give the solution problem, because typically company employee. So the point is that not we don't want action. Problem, what is the problem? What is the cause? Potential cause?
Snehal Tralsawala: Look, make about me somebody like
Snehal Tralsawala: 1, 2, 3, 4, 5, 6, 7, 8, 9, 1011, 1213, 1415, 1617, 1819, 2021, 2223, 2426
Snehal Tralsawala: inputs I had.
Snehal Tralsawala: So what 26 inputs may, both are similar.
Snehal Tralsawala: What you can was called a lagala caro.
Snehal Tralsawala: So the 26 comments that I have to segregate into this 5 different so far, so good.
Dhanasekaran P: So.
Snehal Tralsawala: So we are asking them all. The 20 of them will write at least 5.
Snehal Tralsawala: So 2 people with your volunteer head, or, you know, want to do things into different categories
Snehal Tralsawala: that is called affinity clustering, and by the man
Snehal Tralsawala: meeting could be one of the problem. The other role could be problem communication could be problem
Snehal Tralsawala: likewise, you know. So now I'm going forward and say, meeting role responsibility, likewise
Snehal Tralsawala: identify possible causes.
Snehal Tralsawala: Sorry.
Snehal Tralsawala: So, for example, communication.
Snehal Tralsawala: Wait.
Snehal Tralsawala: Have you made a panch category in Mosco problem to identify earlier? Get this. These are the 5 different
Snehal Tralsawala: causes. Meeting could be the one cause role response could be one cause likewise
Snehal Tralsawala: finished. Academic school list out here.
Snehal Tralsawala: Fear to be slogge.
Snehal Tralsawala: O Bislo! Come, everyone! I had requested to give 5 right fire at the dust.
Snehal Tralsawala: So you come up with this 5 calls, Abhi. Now you tell me
Snehal Tralsawala: we will ask the question. The team leader will ask the question to all the 20 of us.
Snehal Tralsawala: That's then people will vote similarly, Yatho Yellow Text.
Snehal Tralsawala: But may 20 or 20 people will evaluate on these 5 causes and then vote Karenge.
Snehal Tralsawala: So now you can see. Then meeting may patch communication team.
Snehal Tralsawala: So obviously it is clear that now Loga, thinking as a clarity, Rick pitches is one of the main cause, followed by meeting, followed by communication, followed by team and followed by role responsibility. Someone may I?
Snehal Tralsawala: You understand.
Udit: Yes, sir. Yes, sir.
Snehal Tralsawala: You understand? Right? So far, you want.
Snehal Tralsawala: Okay.
Snehal Tralsawala: so this is my main cause. And then I get into the detail main problem. So this is the method which is called brainstorming
Snehal Tralsawala: called affinity and quad. Start. Why affinity? Because you are linking the affinity clustering here and then, so that I can 0 in on
Snehal Tralsawala: individual kapatch cause.
Snehal Tralsawala: 0 enkark.
Snehal Tralsawala: People like sad pitches is the cause which most everyone feels. This could be the reason to your
Snehal Tralsawala: Eladio patch perme, Li Kahe.
Snehal Tralsawala: Yeah.
Snehal Tralsawala: Now, the team has decided that these are the 5 which are the possible causes.
Snehal Tralsawala: Phil, Jackie was called voting online. So this is how the process works.
Snehal Tralsawala: and then it is silent. It is silent, because typical brainstorming
Snehal Tralsawala: Toska. You know the what is the the advantage?
Snehal Tralsawala: A tool eliminates fear, decision, bias due to presence of management. Letter to advocate in May.
Snehal Tralsawala: Go see near Bandabadhai to us
Snehal Tralsawala: and upset Junior. Hey, company employee company worker, Yatho, assistant you know the staff is there.
Snehal Tralsawala: People will immediately make a judgment, good or bad, or this that is the most important aspect of this brainstorming.
Snehal Tralsawala: and then, lastly, that it represent voice of entire team, and then one of you only is going out there and sorting it out, and then deciding on that so many example. There, right now, I'm giving you a real example.
Snehal Tralsawala: A brainstorming at a powder plant, a Kamare.
Snehal Tralsawala: Balia cake plant made.
Snehal Tralsawala: We were producing a synthetic rubble powder.
Snehal Tralsawala: So who's me?
Snehal Tralsawala: The team utilize the process map
Snehal Tralsawala: process, observation, walking the process to identify undesirable effect. Last time, Hamne ud kios per discuss and Huadha
Snehal Tralsawala: so ud product, loss or reason for low yield. So Unka yield Barabanyaradha.
Snehal Tralsawala: and the reason is that product loss, or I have for low yield. Come, Ri, yield, come to whatever loss, or I
Snehal Tralsawala: so gist that I say on the left hand side, you see, tinualagala color may tag. Hey.
Snehal Tralsawala: Hector! Yellow hair.
Snehal Tralsawala: ecto, blue hair or Dusara pinkish type kind, the yellow wall center may, it is actually a process. Flow diagram.
Snehal Tralsawala: reactor, mega reactor mega filter
Snehal Tralsawala: you know likewise. So whatever your flow is that is written in the yellow here.
Snehal Tralsawala: and then on the left hand side, you see the one with the with the green light green. Only stout. 2 gentlemen. One was the paresh. Shah is there, and another is an R, and d
Snehal Tralsawala: it's currently still with the the company in R&D, so
Snehal Tralsawala: Yajo, input higher loga, so 67 inputs, I,
Snehal Tralsawala: Usme is a 52 Johar, which was sorted into 10 different categories. You see. Now, Linkage Essabaya
Snehal Tralsawala: is aggregate.
Snehal Tralsawala: Much so in a real life.
Snehal Tralsawala: Yeah. 67, 67, 52
Snehal Tralsawala: tobacco pan drop me up, Meh
Snehal Tralsawala: Independent, over 10 Independent party here.
Snehal Tralsawala: a Congress party and Bjb. Party that is independent. The 15 h charge
Snehal Tralsawala: that they are independent, and your 52.
Snehal Tralsawala: You see now 12345678910. So 10 losses at vibro screen, then incorrect amount of latex recorded losses during the manual handling likewise. Thus
Snehal Tralsawala: some other way, so far, you understand.
Nisarg Patel: Yes, sir. Yes.
Snehal Tralsawala: Okay, bad. Meju does list out Korea or team member.
Snehal Tralsawala: Don't think that you are Congress party. Don't think you are Bjb party. Think that.
Snehal Tralsawala: And now it was per voting career.
Snehal Tralsawala: So people voted. I know the voting area
Snehal Tralsawala: who mess up say other wording
Snehal Tralsawala: if lost during manual handling. These are losses from cyclone.
Snehal Tralsawala: So Apnahi admin, or Usmesi rating.
Snehal Tralsawala: And then at the end, the team decided that the pitches is the cause main cause, and meeting is the second cause. Similarly, in a technical term.
Snehal Tralsawala: yeah, that's okay. Team 98, Usme, many sorting us.
Snehal Tralsawala: So now I know that number one
Snehal Tralsawala: fill Menu Number one, Leah or Number one, Leah
Snehal Tralsawala: losses during manual handing the losses during manual handing. Maybe brainstorming. Here.
Snehal Tralsawala: let's say, a problem is lossing during manual handling.
Snehal Tralsawala: Everybody will give at least 5 comments, same process. Everybody will have high comments. They will ask 2 people to say, 1, 2, 3, 4, 5, 6, 7, different element may segregate.
Snehal Tralsawala: And then on this voting 3 things came out as a major.
Snehal Tralsawala: You follow the process.
Snehal Tralsawala: Everybody
Snehal Tralsawala: just wanted to confirm, because it's important, you know, similarly, is number 2 here on the top left corner, and then say, what are the causes of lumps in Rbd voting?
Snehal Tralsawala: And then we came up with 3 things which are major.
Snehal Tralsawala: So what we have come is that we've gone from so like likewise from cyclone cyclone media like this, that the 4 things. This is me on the right hand side.
Snehal Tralsawala: and then he's an R&D. Guy, I think so. We were just discussing it over. Live session, child.
Snehal Tralsawala: So this is the advantage of.
Snehal Tralsawala: And look at the board. You see the board there, so that board has to be active.
Snehal Tralsawala: I lost a lot of yellow tech lot of blue tech. So those inventory is required to get the
Snehal Tralsawala: good amount of brainstorming going, you get input from contact worker.
Snehal Tralsawala: So that is the thing and back shaking area. So you know that what are the causes of losses? So these are the 2 causes of losses during many years because of this, this and this results into losses in the many places. So this is typical way of doing the brainstorming
Snehal Tralsawala: before I
Snehal Tralsawala: wait. Huh?
Snehal Tralsawala: Yeah, for the crack.
Nisarg Patel: Yes, sir.
Snehal Tralsawala: So. Yes, yes, setting. If you see the surrounding. This is happened at Upl University. Kaju Conference room. Hannah.
Snehal Tralsawala: Yeah. How many take exercise, Liadha.
Snehal Tralsawala: because what time pay offs, you know.
Snehal Tralsawala: on I mean online Kijagape. There was a hybrid mode.
Snehal Tralsawala: So what we did is that joby look present day off. Mode
Snehal Tralsawala: was up. Cobola. Okay, what is the problem? So we said, many roads are more. Many. Road accidents are taking place in Gujarat because we had to find some common ground
Snehal Tralsawala: to discuss, because one person is from upl, 1, 1 person upl, 2, upl, 3.
Snehal Tralsawala: So how do you create a common ground. So we said that, let's do the
Snehal Tralsawala: you know, let's do a common problem. The common problem was many road accident in Gujarat.
Snehal Tralsawala: And then
Snehal Tralsawala: there was online mode. And there was offline mode. So offline mode. May I told everyone to list down what are the problems? Potential problems which can lead to many road accident in Gujarat.
Snehal Tralsawala: The same thing which we told the online people, also that Abco
Snehal Tralsawala: and I assigned 1% from the offline participation to collect the information from the chat box, and Hareka is a sticker banana guy.
Snehal Tralsawala: So imagine that we had so many of them on the board.
Snehal Tralsawala: And then 2 people I told 2 people to just, you know, categorize karo.
Snehal Tralsawala: So they categorize into different things. For example, on the left top left side, make up
Snehal Tralsawala: traffic rules. Awareness, isn't it?
Snehal Tralsawala: You're able to see this.
Nisarg Patel: Yes, yes.
Snehal Tralsawala: Awareness of traffic rules was one cause.
Snehal Tralsawala: then road condition was another cause.
Snehal Tralsawala: then traffic rules not followed was the 3rd cause over speed was 4th cause.
Snehal Tralsawala: then poor enforcement is a 5th cause, drink and drive. 6th cause, poor vehicle, maintenance, 7th cause driver.
Snehal Tralsawala: What is it? A competence? Was as 8th cause. Illumination was 9th cause, and attitude was a 10th cause.
Snehal Tralsawala: So likewise you will be 2, 3 of us actually segregated into different different categories.
Snehal Tralsawala: We listed down 9 different things. See the
Snehal Tralsawala: the heading traffic rules. So you would look look at on the left hand side, traffic rule, awareness, poor road condition.
Snehal Tralsawala: or all listing connect. But maybe we ask people. So we got an input from the online audience as well as offline audience
Snehal Tralsawala: A, BA, 9 may say, up subco top 3. Bold. 9,
Snehal Tralsawala: top 3, top 3. So you give your opinion.
Snehal Tralsawala: Now I can do both phase.
Snehal Tralsawala: I got dog hay and mujit top number one priority. Then what I will do is your number one.
Snehal Tralsawala: Put a 2, mark
Snehal Tralsawala: number 2 and number 3 market. It's all up to you. It's all up to the the person who is managing it. If you want to say that top and then second, everyone will rate like that.
Snehal Tralsawala: But typically traffic rule awareness, then vehicle number 3. Then everybody gave an input.
Snehal Tralsawala: So we have an idea that joby now causes a audience can input so they will say that traffic number, poor road condition may change number, vehicle over speed, solar, poor road elimination theme likewise. So now you know.
Snehal Tralsawala: concert of colorism.
Nisarg Patel: Poor road conditions.
Bakshi Manish: 16. Vehicle.
Snehal Tralsawala: Vehicle over speed.
Bakshi Manish: Over expenses.
Snehal Tralsawala: And traffic rules not followed. A stop number solar number.
Snehal Tralsawala: followed by traffic rule awareness followed by poor road condition.
Snehal Tralsawala: Right? So, yeah. Then, we said, road accident in city, state.
Snehal Tralsawala: National Highway in Gujarat is happening because of ABC. ABC, take a minute.
Snehal Tralsawala: ABC, ABC. Kansia.
Bakshi Manish: Last element.
Snehal Tralsawala: See a number here. Traffic row, not followed.
Snehal Tralsawala: Traffic rule not followed is Solar Solar Point. Here.
Snehal Tralsawala: sola sola rating the Yaga, followed by traffic rule awareness, so many Ismail area.
Snehal Tralsawala: So after doing entire brainstorm.
Snehal Tralsawala: Now, I know that the team feels the road accident
Snehal Tralsawala: in Gujarat is taking place because of traffic rules not followed
Snehal Tralsawala: poor road conditions. Osme illumination due to scandalgaya and poor enforcement of routes.
Snehal Tralsawala: So I can 0 down.
Snehal Tralsawala: Yeah, technical.
Snehal Tralsawala: Yeah.
Snehal Tralsawala: But this is an outcome of a brainstorming quad method. Is it clear? Everyone.
Bakshi Manish: Yes.
Snehal Tralsawala: This is how to do it.
Snehal Tralsawala: And I am telling you because I have so much of experience with this.
Snehal Tralsawala: then we can get along with everyone and anyone you know.
Snehal Tralsawala: personally, Bowling, and I'll put it down into the tag and put it up there.
Snehal Tralsawala: So it's a yeah. So this is a
Snehal Tralsawala: big Mac.
Snehal Tralsawala: So yeah, brainstorming. Okay, let's move forward to a next
Nisarg Patel: Brainstorming may identify Karsaktung.
Snehal Tralsawala: No, because you will lose people. Man, brainstorming. It's a purely democracy.
Nisarg Patel: Okay. Listen.
Snehal Tralsawala: Yeah, put a democracy here. So, Abco, when you start getting into a Pareto, you will lose the track with the people who are with you.
Nisarg Patel: Yeah, okay, so.
Snehal Tralsawala: Processor process
Snehal Tralsawala: and typical measure actually is so useful that I'm at class. May I at least spare 1 h on going through and and going through the entire gyration.
Snehal Tralsawala: But Abi Online may manage cannah difficulty.
Snehal Tralsawala: If there is a chance of getting together, I'll come back and we can redo this online. Also, it's possible.
Snehal Tralsawala: But we can do this this thing
Snehal Tralsawala: very useful. It's very, very useful.
Snehal Tralsawala: Anybody else has a question.
Snehal Tralsawala: no technology, nothing simple. You talk to people.
Snehal Tralsawala: Oka? Nay, we have to spend time on explaining them problem.
Snehal Tralsawala: And then you cannot have all assistant manager sitting in. You can have all managers sitting in. Because you're not getting the. You're getting a myopic view.
Snehal Tralsawala: You have to get the view from all across the levels break level assistant manager to another level you should be shifting charge. 3rd Level should be company employee. 4th Level should be contact employee. 5th Level should be a a
Snehal Tralsawala: a senior manager likewise, you know, to keep it same level. Majani.
Snehal Tralsawala: You have all that. Then you ask everyone to write it down. Then you do that process. Then, you know, there was cocaro then Akaro
Snehal Tralsawala: Tobijack abco probable cost per job.
Snehal Tralsawala: and then you can tell the mirror output here. It represents what my people think
Snehal Tralsawala: at least you are almost there. You know this is the cause, and we don't have a place to vent it out. So this is like a method by which you can vent it out
Snehal Tralsawala: and feel good about it.
Snehal Tralsawala: Okay?
Snehal Tralsawala: So the next method is causal circle.
Snehal Tralsawala: caution, circle. Next method is caution. Circle. One of us asked the question last time that
Snehal Tralsawala: The Causion Circle Palace Amad Liga.
Snehal Tralsawala: the causal circle, displays causal relationship in a complex network of contributing factors.
Snehal Tralsawala: This diagram maps out the problem issue by establishing link among related idea or issues.
Snehal Tralsawala: So pele, Mene, Sabusko, Sabko, yellow tag, medala yellow. Take me back clustering here 5 different scandal.
Snehal Tralsawala: These are the 9 problems. So but let's say that many
Snehal Tralsawala: example. What causes team to succeed?
Snehal Tralsawala: If that is the question
Snehal Tralsawala: in management. I also have an example of technical answer technical question. But just go through this because we are not talking about the
Snehal Tralsawala: the cause. I'm talking the process process case. That was about my journey here.
Snehal Tralsawala: So the problem is what causes team to succeed.
Snehal Tralsawala: But let's say that after going through an entire process.
Snehal Tralsawala: I came up with 9 potential causes.
Snehal Tralsawala: management support, team, synergy, high morale, resource, availability. Likewise. Now scores for me a bias. Me come here.
Snehal Tralsawala: So what is it that I should do now, because in a typical typical Amara Accident investigation report.
Snehal Tralsawala: Hello, Yada Ottana, because it costs a problem, multiple problems are there.
Snehal Tralsawala: But if multiple problems are there causes are there.
Snehal Tralsawala: So this method causal circle is a method by which I can say that. So this is like
Snehal Tralsawala: big command.
Snehal Tralsawala: These you are able to see.
Snehal Tralsawala: Are you able to see this.
Bakshi Manish: Yes, yes.
Udit: Yes, sir.
Snehal Tralsawala: Okay. So, Joe, many no likata. Na.
Snehal Tralsawala: I'm trying to make sense.
Snehal Tralsawala: And they say that I got you
Snehal Tralsawala: management support correlation. Kaha kaha, hey?
Snehal Tralsawala: Sort of complex, like right here.
Snehal Tralsawala: But you understand my logic, simple example, empowerment, hoga, khne, hogar, our management support, empowerment. Honeywallah.
Snehal Tralsawala: Yes, team will be empowered right.
Snehal Tralsawala: So there is an arrow here which connects management support to empowerment the arrow in the direction of empowerment. Look at that, then, other.
Bakshi Manish: Your page is not appear at here.
Snehal Tralsawala: My Weibo number.
Bakshi Manish: Pdf, file is not up here.
Snehal Tralsawala: But that's what I thought.
Snehal Tralsawala: What about now?
Udit: Yes, sir.
Snehal Tralsawala: The German 9 causes. Likata.
Snehal Tralsawala: I get it.
Snehal Tralsawala: O 9, Lagadia.
Snehal Tralsawala: Now I'm asking a question.
Snehal Tralsawala: That management support here.
Snehal Tralsawala: So empowerment hoga team. Other management is supporting.
Snehal Tralsawala: So team empowerment hone. Yes.
Bakshi Manish: Yes.
Snehal Tralsawala: So the arrow is in the direction of empowerment. See the arrow going from management support to empowerment.
Bakshi Manish: See the arrow there.
Snehal Tralsawala: Similarly, management support hoga to good communication, hoga hoga. So there is an arrow from management support to good communication towards.
Bakshi Manish: Company.
Snehal Tralsawala: Discussion, then other management support Hoga to work ethics. Badega Badega
Snehal Tralsawala: similarly, resource availability. Hoga hoga, likewise, management supports a high moral honeywallai moral Aga management can support the both. Then management support team, synergy, Hoga, hoga. Then management supports a
Snehal Tralsawala: problem solving Jose Hoga and management supports it.
Snehal Tralsawala: Team success, hone, vale hone vale to management support. Important here, look at only management support.
Snehal Tralsawala: So Erica, in 0 out, 8 in. 0 out bye bye.
Snehal Tralsawala: Other management support.
Bakshi Manish: You know.
Snehal Tralsawala: Is that in and out.
Snehal Tralsawala: So likewise here, many in, out like how
Snehal Tralsawala: so these exercise I'll have to do to come up with in and out.
Snehal Tralsawala: Kitna in.
Snehal Tralsawala: Okay, let me just come out of this.
Snehal Tralsawala: Okay.
Udit: Yes, sir.
Snehal Tralsawala: In Kitnarahe, out Kitnarahe.
Snehal Tralsawala: They were total. They were total 9.
Snehal Tralsawala: There were total 9.
Snehal Tralsawala: Yes, and then I am saying that Agar in is less than out.
Snehal Tralsawala: Then it is a cause.
Snehal Tralsawala: Yeah. Aren't out, aren't hey? In 0, hey? So in is less than out correct. Mathematically it is correct.
Snehal Tralsawala: So I look at the equation in is less than out than it is cause.
Snehal Tralsawala: and in is more than out, then it is the effect
Snehal Tralsawala: so many. No mese no cause. This may say, yes.
Snehal Tralsawala: Are you with me?
Snehal Tralsawala: And then Machia sanikala?
Snehal Tralsawala: This may. He needs more than out.
Snehal Tralsawala: Yeah. Teams in the image are in head in, out, head.
Snehal Tralsawala: high model, which are in a 3 out work ethics machine chain out here. Problem solving. May 8. In a 8 out, or team. Success may now in a or 0 out here
Snehal Tralsawala: everything leads to deemed success.
Snehal Tralsawala: So Javier formula follow Hota here, so I can tell it is effect formula. Follow Hota, I can tell it is a cause.
Snehal Tralsawala: You're with me.
Bakshi Manish: Yes.
Snehal Tralsawala: So many original. I started with a 9 9 of my potential causes.
Snehal Tralsawala: Here's okay. Many exercise gear or no mess. M. And a Pasco Kozbola or Baqui que Pansco Effectbola.
Snehal Tralsawala: because he had no causes. Tenancy.
Snehal Tralsawala: 9 causes were there but target care team success, 9 plus one
Snehal Tralsawala: operate team success team success team success effect.
Snehal Tralsawala: And I now cost here to cover Id.
Snehal Tralsawala: Do you see my brother here?
Snehal Tralsawala: So yeah, team success being one of the factors, the total factors are 10, yes or no.
Snehal Tralsawala: Hello!
Sushil Kumar Mohapatra: Yes.
Snehal Tralsawala: So thus come in a segregate care.
Snehal Tralsawala: Does miss a passcode calls convert Kia.
Snehal Tralsawala: and do recharco effect convert Kia.
Snehal Tralsawala: which means that originally Jobera Jota.
Snehal Tralsawala: Oh, but that Rsa. Had your cause may have effected.
Snehal Tralsawala: then an original job, a potential cause. A. I've gone to an extent of eliminating another 4
Snehal Tralsawala: and Khalit Majkohiraka.
Snehal Tralsawala: That's the point I wanted to make.
Snehal Tralsawala: So, Abijo, this is an example.
Snehal Tralsawala: is it? Effect on consign. So let's see your team synergy effect
Snehal Tralsawala: your team synergy effect here.
Snehal Tralsawala: Fear, high moral work, ethic, high morale is also effect work. Ethic is also fine.
Snehal Tralsawala: and then problem solving and team success problem solving, do you?
Snehal Tralsawala: So? Originally I started with the premises that 9 I have 9 causes
Snehal Tralsawala: that the one in yellow I eliminated because I said, no, it is not cause, it's an effect.
Snehal Tralsawala: And how did I do it? By doing that exercise?
Snehal Tralsawala: Everybody's clear.
Udit: Yes, sir.
Snehal Tralsawala: Okay. So now let's took another example.
Snehal Tralsawala: Okay to your road accident. Okay, high number of road accidents here.
Snehal Tralsawala: And we just did some interrelation. Kaneka Kia, we tried this.
Snehal Tralsawala: So at the end, this is the picture emerging
Snehal Tralsawala: road accident may, if you remember, there were 5 causes. I'm gonna list out here.
Snehal Tralsawala: What are the causes? Traffic rules not followed. Road facility
Snehal Tralsawala: parking light signage was not there. Poor road condition.
Snehal Tralsawala: fear, a untrained driver, and attitude of welcome.
Snehal Tralsawala: Ask the question, and then at the end. So yeah, in 4 out one, heh?
Snehal Tralsawala: Then, yeah, in 0, yeah out 2 likewise.
Snehal Tralsawala: And then I know the formula more out than in it is caused more in than out. It is effect.
Snehal Tralsawala: So yeah, mere effect.
Snehal Tralsawala: Traffic rules not followed. Yay cause ra ye causera ye cause ra.
Snehal Tralsawala: so the so a traffic rules, not followed is an effect of many other things. It is not a cause by itself, that is concludes
Snehal Tralsawala: you're with me.
Snehal Tralsawala: Otherwise it is actually effect.
Snehal Tralsawala: People are not following traffic rules because that people are untrained. Don't attack rules, attack the untrailed driver, attack the poor road condition, stop jacket automatically, or traffic rules follow. Hoja, yeah.
Snehal Tralsawala: Any questions.
Snehal Tralsawala: any questions.
Snehal Tralsawala: Okay.
Bakshi Manish: Mendoza.
Snehal Tralsawala: So, Abhi, I have this one more example, if I can show you.
Snehal Tralsawala: Hey? Good!
Snehal Tralsawala: This is what I had to tell about. The
Snehal Tralsawala: there is another detailed post detailed is 8 min.
Snehal Tralsawala: So here is a a paper
Snehal Tralsawala: on root cause analysis, framework for tool selection.
Snehal Tralsawala: Do we smell your hair root cause for framework for toolture. Everybody is able to see the English.
Sushil Kumar Mohapatra: Yes.
Snehal Tralsawala: So I got both Sarah Kaneka. So this is a typical something is written.
Snehal Tralsawala: So they like, for example, root, cause, analysis, cause and effect diagram. We discussed about cause and effect diagram like we talked about fishbone diagram.
Snehal Tralsawala: This elaborates the fishbone diagram.
Snehal Tralsawala: Then it talks about interrelationship diagram, which is the same thing as causal, this one interrelationship, diagram.
Snehal Tralsawala: intern relationship, Matlab.
Snehal Tralsawala: So we cannot have a 2 people sitting in the same room.
Snehal Tralsawala: You cannot have a cousin, uncle, and cousin sitting in the same room. When the cause is concerned, you have to segregate those.
Snehal Tralsawala: So interrelationship to neglier causal T. Analysis, Jomne Kia causal Circallabiciana.
Snehal Tralsawala: We hang it.
Snehal Tralsawala: He like here interrelationship, diagram, the crab, or whatever
Snehal Tralsawala: car. There you go. The man.
Bakshi Manish: Yes, yes.
Snehal Tralsawala: Alright! Let'.
Chaudhari santosh: Sir.
Snehal Tralsawala: It Lethare calls Hoi Takakawa. Na, no, ma'am, Ivani, causal analysis.
Snehal Tralsawala: And this is what you have to do.
Snehal Tralsawala: So that's why it's a process. But basically in and out, okay, health, professional availability.
Snehal Tralsawala: Anati and Yasathai, that those questions we have to ask questions other way around.
Snehal Tralsawala: So far as you understand this.
Snehal Tralsawala: So this is like a causal circle.
Snehal Tralsawala: And there is a current tree analysis. What is currently current reality tree?
Snehal Tralsawala: What is that approach? Whatever we went through recently in a reality tree.
Snehal Tralsawala: We went through. YY, and then he said, YY is only one line, but if you have a tree
Snehal Tralsawala: last time we discussed it.
Snehal Tralsawala: If we have a active direct, I don't know. Then it's like almost like a branches.
Snehal Tralsawala: So it becomes like a reality tree. So it's like current reality tree.
Snehal Tralsawala: Here it is so current reality is same thing as reality tree
Snehal Tralsawala: and interrelations. Interrelationship diagram is the same as a same as causal diagram.
Snehal Tralsawala: interrelation diagram is same as caution, diagram.
Snehal Tralsawala: and then fishbone diagram is same as cause and effect diagram.
Snehal Tralsawala: Is it clear? Everyone?
Snehal Tralsawala: So this question, I mean this is available.
Snehal Tralsawala: I will send it to you so you can go through it, make a printout
Snehal Tralsawala: much, or whatever go through it. So you get a understand good understanding of
Snehal Tralsawala: what we are talking about the Kai Root cause of Uppervani.
Snehal Tralsawala: It gives you an idea.
Snehal Tralsawala: So whatever presentation I send you last time upkeepers may open on the guest.
Snehal Tralsawala: Everyone.
Bakshi Manish: Presentation may.
Snehal Tralsawala: Last week
Snehal Tralsawala: last victim in a class in alien.
Bakshi Manish: Yeah.
Snehal Tralsawala: Last time.
Snehal Tralsawala: And what page do you have?
Snehal Tralsawala: So can we take a 5 min, 10 min break now? Because we covered 2 important things.
Snehal Tralsawala: We covered brainstorming. And we covered causal circle.
Snehal Tralsawala: So are we, are we actually 10 more subject incident, mapping event, tree analysis. And then basic terminology.
Snehal Tralsawala: So don't delink it. But toilet.
Snehal Tralsawala: And let's take 5 min. It's okay with everyone.
Bakshi Manish: Yes.
Snehal Tralsawala: Okay? Few minutes. Huh?
Bakshi Manish: Okay.
Bakshi Manish: Awesome.
Bakshi Manish: The speaker. Number.
Snehal Tralsawala: Okay, we can start now.
Bakshi Manish: Hello. Tyler.
Bakshi Manish: Oh, okay.
Snehal Tralsawala: Please everyone mute. Your respective account
Snehal Tralsawala: confirm that you are all present.
Snehal Tralsawala: Hello!
Udit: Yes, sir.
Dhanasekaran P: Yes, sir.
Snehal Tralsawala: Yeah. So let's can we start now just please mute yourself.
Snehal Tralsawala: Background me about me. I got, or
Snehal Tralsawala: good productive session is going on.
Snehal Tralsawala: Let's not so. The next topic is incident mapping incident, mapping.
Snehal Tralsawala: So incident mapping is a different kind of a tool. Conventional tools you have up next.
Snehal Tralsawala: But I have a I'll just go through theory.
Snehal Tralsawala: And then we had done. One incident. Mapping for a 1 accident is a 3rd
Snehal Tralsawala: Athar in Surat, near Surat accident had taken place.
Snehal Tralsawala: so as per the public demand, I had done the incident mapping of ether incident.
Snehal Tralsawala: So so what is incident? Mapping. It is a tool
Snehal Tralsawala: used to determine action and conditions that existed along the path leading up
Snehal Tralsawala: to and concluding the result of incident
Snehal Tralsawala: and benefits are that forces the team to define the problem clearly incorporates
Snehal Tralsawala: the action and conditions set into the analysis theory. Here drawbacks are must have a right people and information available.
Snehal Tralsawala: You know, it's like a computer. You have a wrong people, wrong data, wrong output. So that's true with actually all the methods.
Snehal Tralsawala: But more so in case of incident, mapping must have enough time available.
Snehal Tralsawala: It combines a 5 y and process mapping process. Mapping is nothing. But.
Snehal Tralsawala: you know, like process mapping yellow. I had shown 1 1 graph one photograph
Snehal Tralsawala: in which yellow was the process mapping
Snehal Tralsawala: it. It tells you that yellow line I had shown you in that. That photograph is process mapping.
Snehal Tralsawala: So the people.
Bakshi Manish: I see the other code.
Snehal Tralsawala: Are I mute? Kariya, sir?
Bakshi Manish: Is, that.
Snehal Tralsawala: Mute Kardana.
Snehal Tralsawala: So I think, before I show you the theory, important for me to show you the
Snehal Tralsawala: examples of linkage. Bhadegha.
Snehal Tralsawala: See, now, here is a case.
Snehal Tralsawala: So we start from left to right, and we say that
Snehal Tralsawala: no car accident over 2 car total costing $33,000.
Snehal Tralsawala: Did he cry, Yapko!
Snehal Tralsawala: To left, to right key problem to eat your problem here, Oske, upper safety goal impact.
Snehal Tralsawala: the safety goal, be impactful because this may
Snehal Tralsawala: or financial goal, the impact Whoa.
Snehal Tralsawala: so there are financial losses. And then accident.
Snehal Tralsawala: So I start with the safety goal getting impacted.
Snehal Tralsawala: So why safety call got impacted because insufficient system to
Snehal Tralsawala: system support, to protect the occupant.
Snehal Tralsawala: Then why that happened so car ran into each other.
Snehal Tralsawala: And why? That happened? Because Driver failed to stop at the red light. And why that happened? Because excessive speeding for condition.
Snehal Tralsawala: So it is like a 5. I
Snehal Tralsawala: if I simply follow this track
Snehal Tralsawala: so almost like a 5. I yes or no.
Snehal Tralsawala: Oh, hi! Sabko!
Udit: Yes, sir.
Snehal Tralsawala: Okay, because your screen sharing is paused as avatar diagram. Everyone.
Udit: No, sir. Diagram nearby.
Snehal Tralsawala: That is the proper equipment.
Snehal Tralsawala: Oh, okay.
Snehal Tralsawala: so I'll be there. Care.
Snehal Tralsawala: Here is a typical practical way of implementing incident mapping.
Snehal Tralsawala: You start from left to right, left me, Kadik Rahi.
Snehal Tralsawala: 2 car total costing $33,000. No car catcher in Hogar.
Snehal Tralsawala: So remember, this is like Aezo incident mapping here.
Snehal Tralsawala: If 5 I behalf, I usme Jura y.
Snehal Tralsawala: So 2 car total is there? Was there a safety call impacted? Yes, so there is a call. There is a box on safety call and financial call impacted. Yes, because $33,000 a loss over here. So safety goal impacted. Why, it happened.
Snehal Tralsawala: Insufficient safety system to protect occupied. Why that happened? Because car ran into each other. Why car ran into each other so there could be multiple reasons. But one of the reason the driver failed to stop at Red Light. Why it happened because of excessive
Snehal Tralsawala: speed for condition.
Snehal Tralsawala: And then there are 2 causes for car running to each of the Hector driver failed to stop, and then ice was on the road.
Snehal Tralsawala: and then vice I why, ice was on the road, so likewise it's almost like a 5. I method
Snehal Tralsawala: you follow me.
Snehal Tralsawala: Thaly white Mokshi, Pakani, Abby simple. Only follow the white boxes.
Snehal Tralsawala: Then we'll another. We'll deal with white board white box. They're looking like a 5. I method
Snehal Tralsawala: a recordo volo.
Udit: Yes, sir.
Snehal Tralsawala: Okay? So it's a 5. I method. Right?
Snehal Tralsawala: Abi Hank, okay, insufficient safety system to protect dagger hay, huska proof.
Snehal Tralsawala: insufficient safety system. Individual transported to hospital by ambulance
Snehal Tralsawala: car, ran into each other. Ruska proof! What is the proof?
Snehal Tralsawala: Mene Bolneko? Bold Kaprovke?
Snehal Tralsawala: Anyone.
Udit: Injury. Surge of accidents. A year ago.
Snehal Tralsawala: No car. Ig, duce me
Snehal Tralsawala: collide! Who are the Otambe police? Are the police 3rd party bulldog in a car accident? Who are.
Udit: Yes, sir.
Snehal Tralsawala: Writing me there I want.
Snehal Tralsawala: So we're looking for the proof. When when we make a statement incident, mapping Hamlok theory or name, angry proof. Name, angry method, hey? We are asking proof.
Snehal Tralsawala: And that's why this method is used for major incident.
Snehal Tralsawala: accident, investigation. They ask all the proof.
Snehal Tralsawala: So uptake of Fishborne diagram wearing under under some bad karte
Snehal Tralsawala: and yes, no carte. And then we trust each other.
Snehal Tralsawala: Okay, now we're getting a different league wherein the officials will come in and do the investigation
Snehal Tralsawala: to approve money.
Snehal Tralsawala: So on the right hand side top your consacular.
Snehal Tralsawala: your local letterhead, or your local, there is a proof.
Snehal Tralsawala: So Car ran into each other. What is the proof?
Snehal Tralsawala: Polisca reporta, then how come
Snehal Tralsawala: Another insufficient safety system to protect document? How come it happened, because then Driver failed to stop at that light.
Snehal Tralsawala: The Wall eyewitness was interviewed, and eyewitness told this the interview scandal
Snehal Tralsawala: to interview my eyewitness. Sabola. So Jobi, Ajo, Bish, and all these people who come in. They also interview our local people. Yes.
Snehal Tralsawala: they make a report.
Snehal Tralsawala: and in which they interview the eyewitness, and not only interview. According to me, this happened. This did not happen.
Snehal Tralsawala: so the role of shipping charge becomes very crucial. The Joby section in charge here
Snehal Tralsawala: or section. Ninja Nagaro accident. Badani, who via section, is still there, so he's his eyewitness will make a make a so he'll make a report on that
Snehal Tralsawala: Dominee Bologge.
Snehal Tralsawala: One of the causes ice on the road
Snehal Tralsawala: to AI son Kor Rodka. Proof.
Udit: Photo of Excellency.
Snehal Tralsawala: We cannot write something at random.
Snehal Tralsawala: so with that, so 5 I may. I came to a look at the A top right side me a. IA.
Snehal Tralsawala: E. To men.
Snehal Tralsawala: How come excessive speeding has taken place? Top right, bottom, top, bottom. Sorry left top may excessive speed for the condition. How the why that happened? Because
Snehal Tralsawala: drove driver drove fast to be at home before the start of the race, you know.
Snehal Tralsawala: Okay, Sir Malgampada, what is the proof of that. The proof of that is the driver statement, driverness, Ebola.
Snehal Tralsawala: Georgia, Limetta.
Snehal Tralsawala: So I'm not assuming anything. I'm just saying that I when I took an interview
Snehal Tralsawala: driver told me this. This has happened so driver statement become a proof.
Snehal Tralsawala: Similarly, Nascar race starting in 20 min, I look at the television scheme as scheduled
Snehal Tralsawala: similarly big fan on Jr.
Snehal Tralsawala: Big fan of Jr. Madelebosco driving Wotimga Big Fan Time.
Snehal Tralsawala: the driver wearing 88 head.
Snehal Tralsawala: So these are the visible signs by which I can tell that he was really a
Snehal Tralsawala: a big fan. There was a television schedule which tells that it start in 20 min. Likewise, you know.
Snehal Tralsawala: Okay, to be me.
Snehal Tralsawala: So yeah, yeah, before I close this color coding hack
Snehal Tralsawala: color coding me agar, meh, yellow evidence, Bolenge.
Snehal Tralsawala: And if I'm using the red, then I reach a condition so condition concept huh?
Snehal Tralsawala: Ice on the robust condition. Slippery condition. Tha?
Snehal Tralsawala: So if there is a condition like thing, then I can put into red. Other evidence is here.
Snehal Tralsawala: or a significant. So it starts with the 1st one. The major point number of things, I explained.
Snehal Tralsawala: and I also have a I know it's what are complicated,
Snehal Tralsawala: But I have another example also that you should be able to
Snehal Tralsawala: follow this, so don't worry about it. Okay, if you don't understand. So far as you know.
Snehal Tralsawala: 35. I had clearly decry.
Snehal Tralsawala: Then some proofs are required, proof is required, and then action. There is a difference between action and condition.
Snehal Tralsawala: Condition, a create lake here it was there.
Snehal Tralsawala: slippery condition or condition, slippery condition. It happened to be there. So there's a differentiation between action and condition. Probably you have any egg.
Snehal Tralsawala: A cogator care. I came up with the root, causes the root causes a mania star Dalaw. You see this
Snehal Tralsawala: start the crash, of course.
Snehal Tralsawala: Hello!
Nisarg Patel: Yes, sir. Yes, sir. Yes, sir.
Snehal Tralsawala: So I'm going down. I came up with a multiple causes which are the root causes
Snehal Tralsawala: Jaha root kozaya. When a star, Mara and I also got a proof for that.
Snehal Tralsawala: So that is about 8.
Snehal Tralsawala: What about? So there's another another one on that.
Snehal Tralsawala: You're able to see this.
Udit: Yes, sir.
Snehal Tralsawala: So icing on the road. This is a bee here, this is a B,
Snehal Tralsawala: and then why sing? I sing on the road, Utah.
Snehal Tralsawala: so we have a soda. There was a recently snowfall who had happened
Snehal Tralsawala: the snowfall Huatya proof. Okay, I can check the weather report weather report recently snowfall huat. And then another point is that
Snehal Tralsawala: flow truck has not been to intersection yet.
Snehal Tralsawala: A Us. Mayor hang on.
Snehal Tralsawala: Okay.
Snehal Tralsawala: ice, Manjayga.
Snehal Tralsawala: So snow snow is less risky then ice
Snehal Tralsawala: noko hatatete, piljack, a truck kpiche.
Snehal Tralsawala: Oh, me, too, a Metoo naktajay.
Snehal Tralsawala: So the there is a there is a mechanical truck
Snehal Tralsawala: which has got a lot of salt in the back, and then it spreads the salt on the road.
Snehal Tralsawala: So whatever there is a melting has taken place that that ice is there ice gets melted to water by use of that
Snehal Tralsawala: sorted so that they're saying, Blow truck, float up.
Snehal Tralsawala: He's saying that the floor truck has not been at the intersection. So why? It was icy, because the the so sodium chloride truck cost did not come. Why did not come? Because it was busy busy at other location.
Snehal Tralsawala: So point is not the content. But point is how we, how we follow these.
Snehal Tralsawala: And how do you know that product has not come because there's a photograph that has not come.
Snehal Tralsawala: And how do you know that they are busy at the intersection? Because we know that the other intersection have higher accident rates the one they normally go there.
Snehal Tralsawala: So this is how you kind of go through the incident. Mapping
Snehal Tralsawala: go one step at a time, and at each point you collect the collect the evidences.
Snehal Tralsawala: Let me just open up this one also.
Snehal Tralsawala: Okay, so you're hot.
Snehal Tralsawala: So so the driver got distracted.
Snehal Tralsawala: Driver got distracted. Who told you
Snehal Tralsawala: to a driver, Guy? We took an interview of a driver, and he told us the drivers were distracted.
Snehal Tralsawala: so the evidence becomes the diverse account.
Snehal Tralsawala: Then Driver said, Let me just say
Snehal Tralsawala: Driver chose to drive, even though there was a slippery road he chose to drive.
Snehal Tralsawala: Why he chose to drive because of scope
Snehal Tralsawala: ran out of beer. He ran out of beer. This I sent out of beer. Then he said, another another example is
Snehal Tralsawala: that. Why, Driver was distracted because window not entirely defrosted because of atmosphere, was such that there is a you know, ice in the area and defrost Naitha.
Snehal Tralsawala: And then why Driver chose to drive? Because he ran out of beer, and wife was not at home. So now we stuck your proof head window, not not entirely defrost.
Snehal Tralsawala: because Driver stated that Defrosted not working correctly. So his car. His account also came into picture. So his interview was taken Driver, in which he said that he was distracted, and he said why it was distracted. He also gave a reason that it's because
Snehal Tralsawala: the the you know correct not correctly, I mean, no.
Snehal Tralsawala: Ochali Radha. The defroster was not working. Okay.
Snehal Tralsawala: so you're saying, not only it's a 5, I
Snehal Tralsawala: or YY method, but you also attaching the witnesses. Yeah, to some sort of a proof
Snehal Tralsawala: that this is what has happened.
Snehal Tralsawala: Okay, so this is what I wanted to say here, and we will be.
Snehal Tralsawala: Let me just show you the real life example.
Snehal Tralsawala: Thank you.
Snehal Tralsawala: So how many of you actually are aware of Ngt report
Snehal Tralsawala: how many of you are aware of Ngt report.
Snehal Tralsawala: You're able to see this. Everyone.
Udit: Yes, sir.
Snehal Tralsawala: So this is called Ngt. National green tabinal
Snehal Tralsawala: to put Barahat saota,
Snehal Tralsawala: So Ngd comes into picture, and then they prepare a report on the accident.
Snehal Tralsawala: So in this particular instance, I had taken a ngt report of a company in Surat.
Snehal Tralsawala: She says, Ngt. Western zhong pune.
Snehal Tralsawala: It said news item appearing in Indian Express, dated 30, 11, 2,023,
Snehal Tralsawala: title fire at Chemical plant in Sura, 24 workers injured
Snehal Tralsawala: if we do it on the behalf.
Snehal Tralsawala: Welcome.
Snehal Tralsawala: So it is talking about Jojo is accident of Surat. Major accident. Goa
Snehal Tralsawala: detail. See 187 pages. You see, 187 pages right side
Snehal Tralsawala: so 187. Page report is prepared by Ngt.
Snehal Tralsawala: On an accident.
Snehal Tralsawala: So any major accident which takes place
Snehal Tralsawala: there will be Ngt. Report on it.
Snehal Tralsawala: Let me just go through this. Okay.
Snehal Tralsawala: how many of you are seeing? Ngt report for the 1st time.
Sushil Kumar Mohapatra: This is my 1st 10, sir.
Snehal Tralsawala: Okay, how many, many others are also. So we'll just go slow. Right?
Udit: Yes, sir.
Snehal Tralsawala: So this says, letter paid of joint director, industrial Safety and Health Office, Surat region
Snehal Tralsawala: regarding sending investigation report related to incident of fire Accident.
Snehal Tralsawala: company, ether Industries Limited, situated in Sachin Gidc.
Snehal Tralsawala: In pursuit of the above subject and reference to State committee formed by you regarding accident of the blast incident in the factory ether Industry Company happened at the early morning hour of 2911, 2023 asked to submit the joint report. So what have they? They create a committee committee goes there and does the report
Snehal Tralsawala: in the process?
Snehal Tralsawala: The photograph taken.
Snehal Tralsawala: so so many people are involved. Police inspector Sachin is involved. Chief fire Officer Surat is involved. Then Gpcb is involved.
Snehal Tralsawala: Then, yeah, this is also involved.
Snehal Tralsawala: And then you go into the detail.
Snehal Tralsawala: So there is a committee report goes into detail.
Snehal Tralsawala: It says Akasmatni banana, only we got got it kind of a it goes into
Snehal Tralsawala: with Padak so and so.
Snehal Tralsawala: This is what happened then. Itala, Phenol, Banawani, get detail into what they do.
Snehal Tralsawala: And then then, on the 29, th 11, 2,023. Here.
Snehal Tralsawala: here, it says.
Snehal Tralsawala: he said, 29, 2,022. So he basically gets into detail of what happened. And then they are going further investigation.
Snehal Tralsawala: All good.
Snehal Tralsawala: So this is the report prepared by green tribunal, and then it gets into gets into detail.
Snehal Tralsawala: Then how many people root up?
Snehal Tralsawala: So this one person, this he died, he died.
Snehal Tralsawala: he died. He died. The 5 people died.
Snehal Tralsawala: Okay, there are. There are 10 people who died.
Snehal Tralsawala: and then of the injured people are how many?
Snehal Tralsawala: So 24. Yohamdi cry.
Snehal Tralsawala: So 24 are injured that list out everything.
Snehal Tralsawala: Then then the steps taken.
Snehal Tralsawala: I think what I want to show you report now? Is it the English version? Oh, that was a Gujarati English version. There's more understandable, I think.
Snehal Tralsawala: He talks about the technically what happened. Solvent mixture produce vapor cloud on the leakage. Moreover, the explosive range of thf was 2 to 12% volume is 1.1 to 7.1, which means the solvent.
Snehal Tralsawala: It reaches the explosive range of the mixture. So how it happened according to them, but how? The point question is how they will come to know they are the 3rd party.
Snehal Tralsawala: because they are listing down. What is the probable cause?
Snehal Tralsawala: This is the number of people died. It was earlier, was in Gujarati now is English
Snehal Tralsawala: steps taken by different departments.
Snehal Tralsawala: Major Fire happened. It's just. It's a lot of some of our reputation is also there.
Snehal Tralsawala: But I want to show you something.
Snehal Tralsawala: See? Now, here.
Snehal Tralsawala: this is like 34 sarnamo. So and so, Chellauchu
Snehal Tralsawala: Halma Karkanana, factory manager, Tariq Nibahu. So they interviewed who.
Bakshi Manish: Factory, manager.
Snehal Tralsawala: They interviewed factory manager.
Snehal Tralsawala: and they interviewed, and then, according to him, what happened? They just told so, he said, project manager.
Snehal Tralsawala: So they so they went all the way to factory manager. Right?
Snehal Tralsawala: And then he's finding he will say, My, this is my medical qualification.
Snehal Tralsawala: Telephone career may plant. So all this what he has to say he will say in his statement.
Snehal Tralsawala: a cosmetic
Snehal Tralsawala: Maruman
Snehal Tralsawala: 15 kl solvent recovery tank solvent recovery tank, ma, I will transfer pump. So basically they can, they take an interview of people
Snehal Tralsawala: and what each thinks.
Snehal Tralsawala: oh, like a bad day. So many. I showed you the factory manager right now I'll tell you some somebody else.
Snehal Tralsawala: Yogi, Vidal, Kumar, Sanso, Daria Limited production chemist. So down the interval production chemist night shipma.
Snehal Tralsawala: so he's interviewing key people.
Snehal Tralsawala: And then let's take it down. What happened
Snehal Tralsawala: here is a this is Shram Yogi Kalpesh Dinesh Bhaivanand.
Snehal Tralsawala: He's a che Lazadora's team distillation control system. Dcs operator.
Snehal Tralsawala: So here you interview. This is operator.
Snehal Tralsawala: factory manager, production chemist. This is operator everybody they interviewed. They got their feedback. What happened?
Snehal Tralsawala: Oh, and then they came up with the
Snehal Tralsawala: that's the right statement.
Snehal Tralsawala: See?
Snehal Tralsawala: So point is that interviewing is a very good technique. It's 1 of the techniques which we learn. I tell you, because you know, we have to know how to how to interview what to interview. The people will may say right thing may say wrong things.
Snehal Tralsawala: So anyway, this is what I think.
Snehal Tralsawala: they should give you some flavor of how much detail they get into.
Snehal Tralsawala: Yes.
Bakshi Manish: But the question is that.
Snehal Tralsawala: What? What is it that they use?
Snehal Tralsawala: What is it that they must be using it to come up with the probable cause? So what I did here.
Snehal Tralsawala: You're able to see this now.
Nisarg Patel: Yes, sir.
Snehal Tralsawala: So what I took is a fire explosion car Ngt report I took.
Snehal Tralsawala: So what happens here is the separation is taking place. Organic mass.
Snehal Tralsawala: See, the separation is taking place, organic mass and aqueous mass. Then it goes to recovery from recovery. It goes to
Snehal Tralsawala: storage tank 0 2 0 St. 0 2 2, which is 15 K,
Snehal Tralsawala: and from there it gets pumped to thf, tank.
Snehal Tralsawala: Okay?
Snehal Tralsawala: And then there is a pump.
Snehal Tralsawala: So the one in the circle Jokala circle might allow. Go ahead, Cala circle, Major Lahua.
Snehal Tralsawala: So there was a leakage. There was a leakage from the pump
Snehal Tralsawala: out of St. 0 2, 2, 3, 800 liter leakage containing 60, 65% Thm and 25 to 30% toluye.
Snehal Tralsawala: So how come the leakage took place is another question, but what happened is as per the report.
Snehal Tralsawala: This line leaked also.
Snehal Tralsawala: When the accident took place, explosion took place.
Snehal Tralsawala: Thf. Tech 25 Kl. Cajo, immediately connecting valve was leak damaged
Snehal Tralsawala: to damage due to explosion because explosion happened here in this area.
Snehal Tralsawala: But since the Thf. Tank was nearby
Snehal Tralsawala: it got there a vial also, and then a pump also.
Snehal Tralsawala: and then the 3rd one is the Neely Ss distillation reactor. So high surrounding temperature in the area leading to high pressure in 0 to 0 rt, 55. So it started here.
Snehal Tralsawala: It went up there to the Upa thf tank. And then it came to assess distill distillation reactor.
Snehal Tralsawala: So this is what I collected from the entire National Green Tribunal report. Because how do you? You know you take that as a base.
Snehal Tralsawala: And then it says that, yeah, if you recover image, our Gator last batch taken 2412, 2,02312,200 liter
Snehal Tralsawala: thf plus was taken in. And then this particular tank, yeah, say, 0 2 0 tk, 1, 1 0 was taken, thrown away by 8 meters.
Snehal Tralsawala: So the accident the way they described is that faster?
Snehal Tralsawala: It happened in the in the pump section of 0 2 0 st. 0 2 2. Then it went to Thf. Tank, which is in our kalaju surrounding here. Then it came to this. So there was a major
Snehal Tralsawala: major explosion took place.
Snehal Tralsawala: This is a preliminary information using these, how can I convert these into incident mapping?
Snehal Tralsawala: Do I have a something for you?
Snehal Tralsawala: You are able to see.
Bakshi Manish: Yes, let's see.
Snehal Tralsawala: So start start with the left hand side.
Snehal Tralsawala: Remember the theory. Now, I told you
Snehal Tralsawala: that joby accident, Hua, Oscar, safety goal got impacted.
Snehal Tralsawala: Yes, 11 people died.
Snehal Tralsawala: Look at the top left section.
Snehal Tralsawala: So 11 people died, and then financial gold impacted. Yes, rupees. 5.5 crore in compensation plus plant got destroyed they have to pay 5. How did I get this 5.5 crore.
Bakshi Manish: Losses in government.
Snehal Tralsawala: Claiming. But what is the what is the proof? I mean? So the Ngd report.
Bakshi Manish: And detailed.
Snehal Tralsawala: So ngt. Report is telling me that Iran people died. Ngd. Report is telling me that 5.5 crore compensation taken place, so I cannot pick the number from the air. I need some documentary evidence. You are with me.
Bakshi Manish: Yes, yes.
Snehal Tralsawala: Then site fire explosion took place.
Snehal Tralsawala: So 1st thing happened is that Tank farm fire took place.
Snehal Tralsawala: So how do I know? Tank Firefight took place.
Snehal Tralsawala: There was a videography
Snehal Tralsawala: there will be after after destruction. Kajobi photo hoga day after videographic. So I know the tank farm fire took place.
Snehal Tralsawala: so why tank from fire took place.
Snehal Tralsawala: So then I said, the Tfh. 25 kl.
Snehal Tralsawala: Thf League tua.
Snehal Tralsawala: How did I know photo and report concern? Report?
Snehal Tralsawala: Ngt report?
Snehal Tralsawala: Hello.
Bakshi Manish: Yes. Yeah.
Snehal Tralsawala: Okay. Now, I said, what is that? Now I want to do? 5, I on this.
Snehal Tralsawala: So why, that 12 Klthk thf leaked
Snehal Tralsawala: because tank bottom valve was damaged. You, you remember seeing the
Snehal Tralsawala: seeing the earlier diagram I put together, the tank bottom valve was damaged. How do I know that it was damaged because blind was put in place.
Snehal Tralsawala: Then tank bottom valve leakage which led to vapor cloud explosion.
Snehal Tralsawala: Okay. So now I come to plant number one fire plant, one number one fire took place. How do I know? Because of the videography and recording was there?
Snehal Tralsawala: So what happened there? The reactor, 0 2 0 rt. 55 exploded.
Snehal Tralsawala: How do I confirm this by photograph and by report?
Snehal Tralsawala: Why it happened was pressurization.
Snehal Tralsawala: Why it was precipitization, because high local temperature was there.
Snehal Tralsawala: This only proof can find is that local temperature, Jadatha.
Snehal Tralsawala: So high local temperature. Why? It happened because environment temperatures are that.
Snehal Tralsawala: See? 1st incident happened. Tank, bottom wall leakage damaged, but because of it the temperature was outside high, and that led to explosion so height and that because of vapor, cloud explosion vapor cloud that was surrounding me. Temperature because of it. Pressure has declined because of this. So this is like
Snehal Tralsawala: this way or that way.
Snehal Tralsawala: And then
Snehal Tralsawala: why this to take? Then I come to this 15 kl. 0, 2 0 st. 22 blown. How do I confirm that by photon, by report? Why that happened because we have per cloud explosion.
Snehal Tralsawala: So for the all, the 3
Snehal Tralsawala: paper cloud was a common cause.
Snehal Tralsawala: And then vapor Cloud, why happen? Because 3,800 liter leaked.
Snehal Tralsawala: Why it leaked the total vapor. It leaked leaked the Hua. But the explosion be hua! Why it happened? Because toluene vapor, density high and thf vapor density high. How do I know it is high?
Snehal Tralsawala: I know it through literature it is high. How do I know? 1,300 liter got leaked.
Snehal Tralsawala: I know it through Dcs Ally trends everywhere. Wherever I'm putting.
Snehal Tralsawala: I'm connecting the dots.
Snehal Tralsawala: I'm connecting some proofs and putting onto the mapping.
Snehal Tralsawala: So this is the incident. Mapping.
Snehal Tralsawala: you understand? Now all.
Udit: Yes, sir.
Snehal Tralsawala: Many Engetika report, Leah.
Snehal Tralsawala: Many things I can write down in the even. The witnesses may also say something so authenticated. Report is the report my baseline.
Snehal Tralsawala: then only you can say that it is a fact, otherwise it's not a hearsay both.
Snehal Tralsawala: So these incident mapping is more about precision.
Snehal Tralsawala: more about using at the high level incident mapping.
Snehal Tralsawala: So this covers a incident mapping.
Snehal Tralsawala: Now let me go to the theory.
Snehal Tralsawala: It's a manabular type of theory, ma'am.
Snehal Tralsawala: The Theodicia Batara.
Snehal Tralsawala: So I skip the theory for most part.
Snehal Tralsawala: So that what I'm cap for technology, but we'll still go through this.
Snehal Tralsawala: So now you have a background. Right? You have 3,
Snehal Tralsawala: 2, 2 examples with you. Take example. Your do. Car calculation, example. Hei.
Snehal Tralsawala: And with that I'll tell you.
Snehal Tralsawala: Then, incident mapping combines use of 5 in process. Mapping
Snehal Tralsawala: causes are rarely part of continuous chain. Asking why pi Y often produces a linear chain. Action needs to coexist with the condition
Snehal Tralsawala: in order for incident to occur.
Snehal Tralsawala: for pale case may slippery tha. Oh, that was a condition.
Snehal Tralsawala: or mayor, or Afk Hartmani. Your environment was such that it happened.
Snehal Tralsawala: Temperature, that is the condition.
Snehal Tralsawala: So we start with the impacted goal.
Snehal Tralsawala: left hand side pajo, move backward in time, pulling all action and conditions that were presented. Each state supply evidence where you have it and identify places where it may be needed.
Snehal Tralsawala: What are the evidences?
Snehal Tralsawala: Do you see by evidence crackers, Emma.
Snehal Tralsawala: Evidence is what we I told is that some reports are there. Some proofs? Are there. Those are the report. Okay? Then use why? Why? And brainstorming to develop an action and condition. Don't debate over action and conditions. They are simple facts. If you find a team member debating.
Snehal Tralsawala: then it's probably over actions and condition that should be the next step.
Snehal Tralsawala: End of the branches are action and condition that had to exist at the same time, in order in order to allow the incident to take place.
Snehal Tralsawala: This is the theory, and 2 examples I shared with you.
Snehal Tralsawala: Product difficult here. But if you ask the questions I'll be able to answer.
Snehal Tralsawala: Clarify your doubts if you have any doubts.
Snehal Tralsawala: So that completes our incident mapping.
Snehal Tralsawala: And
Snehal Tralsawala: okay, are you able to see event tree analysis.
Nisarg Patel: Yes, sir. Yes.
Snehal Tralsawala: So. Event, tree analysis. How many are familiar with event analysis?
Snehal Tralsawala: See? Being familiar is one thing, and being knowledgeable is another thing. You know I'm not saying you are
Snehal Tralsawala: this morning. I just wanted to understand how much you, how, how how depth, you know.
Snehal Tralsawala: But anyway, we'll proceed.
Snehal Tralsawala: So, event free. So we talked about fault tree analysis. And now we are talking about event tree analysis.
Snehal Tralsawala: So you can take a simple picture of these if you want, I'm sure presentation will also come
Snehal Tralsawala: on your way.
Snehal Tralsawala: But keeping the undesirable event in the center.
Snehal Tralsawala: keeping the undesirable event in the center.
Snehal Tralsawala: Which explosion hog. Yeah, something has happened which leads to consequences.
Snehal Tralsawala: In the case of ether accident took place. Leakage took place.
Snehal Tralsawala: but usek yahuwa. There was a major fire explosion, vapor, cloud explosion.
Snehal Tralsawala: So on the right hand side is the consequences.
Snehal Tralsawala: and on the left hand side are the causes.
Snehal Tralsawala: So what could be the cause?
Snehal Tralsawala: So, you know they've not into gone into a specific cause. But why that? Why that particular pipeline leaked?
Snehal Tralsawala: That is the question. And how come it leaked? Because you're not supposed to leak.
Snehal Tralsawala: So that is another. That is the point, and then bad me, we get into the causes, but
Snehal Tralsawala: keeping the undesirable effect in center left side is called preventing.
Snehal Tralsawala: and right side is called mitigating.
Snehal Tralsawala: If you have a right side, which means that we are in the process of mitigating it.
Snehal Tralsawala: Then it is called event tree analysis. If it is trying to find out what caused it.
Snehal Tralsawala: then it is becoming a fault. Tree analysis, basic difference.
Snehal Tralsawala: Okay, another way of saying that is a bow tie technique. It's a simple bow tie technique.
Snehal Tralsawala: initial, undesirable effect.
Snehal Tralsawala: And if I'm focusing on event tree analysis, mitigating measures, hydroscope problem
Snehal Tralsawala: problem to Hua Heber, Osca consequences.
Snehal Tralsawala: So then, it is called mitigating measures. And then what are the preventive measures? So from here
Snehal Tralsawala: I come to
Snehal Tralsawala: Yay, or yes like say me here, except that I'm saying that during the consequences, what are the mitigative measures I have.
Snehal Tralsawala: and what are the preventive measures. I have mitigative measure.
Snehal Tralsawala: Okay, anything which helps reduce the aggravation.
Snehal Tralsawala: You know. Dialogue.
Snehal Tralsawala: We are going to die in Khalijara Mari. So that is also mitigation.
Snehal Tralsawala: Yeah, though you know it could have been worse. That and it didn't happen because of that is medicative measures and preventive measures is
Snehal Tralsawala: that Saakiat has this show accident? Who won it?
Snehal Tralsawala: Okay, so that is a
Snehal Tralsawala: 3rd way of looking at this this 1st slide, because I thought that practically saying the same thing.
Snehal Tralsawala: But 3rd way of looking at this the reviews has taken place. Accident has taken place.
Snehal Tralsawala: and what are the things which I have which comes in between release and consequences.
Snehal Tralsawala: Palaba pre I play sass consequences motu nathai.
Snehal Tralsawala: Are you able to understand this?
Udit: Yes, sir.
Snehal Tralsawala: So now I am talking about mitigating measures. m. 1, m. 2, m. 3.
Snehal Tralsawala: So what are my mitigating measures? So multiple detection system, chair, shutdown chair, active protection, chair, passive protection chair.
Snehal Tralsawala: What is active protection.
Snehal Tralsawala: active protection, something which does not let it. Active production is more about, does not let it happen.
Snehal Tralsawala: But the smoke detector alarm is there everything is. They will come into the active detection.
Snehal Tralsawala: escape, evacuation, and rescue. So all this plan is there. So between the event and consequences.
Snehal Tralsawala: I have my soldiers, m. 1 m. 2, m. 3, and on the left hand side, what are the preventive measures I have the soldiers which helps ensure that it doesn't happen. That is called my layout is proper. My construction standards are proper, my inspections are proper, instrumentation is correct. The interlocks are correct. I'm getting it checked. Critical are getting checked on a monthly basis. Likewise all those.
Snehal Tralsawala: So now I'm focusing on the release to consequences. Right hand side.
Snehal Tralsawala: So this is a so how do I construct the event? Tree?
Snehal Tralsawala: But these are the steps. I'll come back to Event tree.
Snehal Tralsawala: So here is a scenario of a higher has taken place, initiating event being fire
Snehal Tralsawala: and the last event possible. Outcome. What are the possible outcomes?
Snehal Tralsawala: Okay, auto botto damage time, Kato, moderate damage type of minimal damage type.
Snehal Tralsawala: It's a success.
Snehal Tralsawala: So it is a failure.
Snehal Tralsawala: So, fire you. You may. I may have a fire suppression system.
Snehal Tralsawala: I may have a fire alarm system with sending signal to department. So fire suppression system actuates when it actuates. In our case what happens, the fire suppression system is typically opens a bulb chair, the bulb 2 Ti, and then automatically auto deluge will start. When that happens. Then
Snehal Tralsawala: I'm reducing the damages. But it doesn't happen.
Snehal Tralsawala: Then it will go to the alarm system. If alarm system activates, then damage will be there. But less than the the more damage, so there will be some success.
Snehal Tralsawala: And then in in a some, some European countries, fire alarm system is directly connected with the fire department. So this is like a
Snehal Tralsawala: another way of looking at the event. Tree analysis.
Snehal Tralsawala: Now I go further, deeper into event analysis.
Snehal Tralsawala: I go further detail.
Snehal Tralsawala: So here you see in the 1st row accident, event, and then outcome
Snehal Tralsawala: between accident, even an outcome. How many barriers are shown? 4 barriers are shown.
Snehal Tralsawala: b, 1 b, 2 B. 3 B. 4. It is the same barrier which I've shown here.
Snehal Tralsawala: I'm saying, mitigation. Yeah, I'm saying mitigation m. 1, m. 2, M. 3, M. 4. Here, I'm saying, barrier b, 1 b, 2 b, 3 b, 1 b, 2 b, 3.
Snehal Tralsawala: So accident honeke badme.
Snehal Tralsawala: If the b 1 triggers b 1,
Snehal Tralsawala: and then, if I come to the B 2, then
Snehal Tralsawala: be Agarubi to trigger Huat of Haidae, Naito Luksane. Likewise
Snehal Tralsawala: I can go to the all the 4 mitigation, I mean barriers.
Snehal Tralsawala: and then each one will have these different outcomes.
Snehal Tralsawala: Now, I go into further detail.
Snehal Tralsawala: So, okay, this could be a theoretical question. You may be asking the exam.
Snehal Tralsawala: That what are the branches?
Snehal Tralsawala: In event? 3. What are the end? Nodes.
Snehal Tralsawala: What is the branch? Probability? And what is the chance, node. And what is the pathway?
Snehal Tralsawala: So just by looking at this diagram you can tell that the branches Kisko Bolenge.
Snehal Tralsawala: probability is Co. Bowling,
Snehal Tralsawala: Then end node is coupling likewise. Okay, this is clear.
Snehal Tralsawala: Can we do that? For now
Snehal Tralsawala: everyone.
Udit: Yes, sir.
Snehal Tralsawala: Okay from the same slide. I make a made a 4 slide for one slide
Snehal Tralsawala: so that people will have a different understanding.
Snehal Tralsawala: Now let's look at this one.
Snehal Tralsawala: So the fire has conveyor. Belka fire. Whoa! Left left side pay center of the page.
Snehal Tralsawala: conveyor, belt, fire. Here, conveyor, belt is fire is on fire.
Snehal Tralsawala: How frequently it happens! 2 times in a year it happens
Snehal Tralsawala: so. What are the chances that heat sensor will detect it?
Snehal Tralsawala: Heat, sensor, see between between fire and consequences. I have a barrier, one barrier to barrier. 3.
Snehal Tralsawala: I have a mitigation, one. Mitigation, 2. Mitigation. 3. What is the 1st barrier, heat sensor?
Snehal Tralsawala: What is the second barrier? One.
Snehal Tralsawala: And what is the 3? rd Barrier? Barrier, water spray?
Snehal Tralsawala: The 3 barriers are there
Snehal Tralsawala: so Hareq barrier, Kitana? What are the chances? That is the question. So the conveyor belt is on fire. Then heat sensor, detect. What is this probability?
Snehal Tralsawala: The combat capability?
Snehal Tralsawala: Who will give me the probability? Figures.
Nisarg Patel: Sensor, Casey, quality.
Snehal Tralsawala: Ha quality the supplier will give
Snehal Tralsawala: supplier will give supplier will give his 1st thing. It is 95% correct or 90% correct.
Snehal Tralsawala: But then one experience will also come into play.
Snehal Tralsawala: So there are 90% chances that Jesse Firehua hit sensor pocket lega.
Snehal Tralsawala: so that 90% becomes the probability.
Snehal Tralsawala: So then 90% pass a Matlab K 10% failure.
Snehal Tralsawala: Yes, because probability is a combination of
Snehal Tralsawala: success and failure. If I'm saying that 90% is passing, which means that 10% is not passing, not failure. So chances of failure becomes point 1.
Snehal Tralsawala: Then I go one step up that heat sensor, chalo hogya.
Snehal Tralsawala: Then what is the probability of all will operate?
Snehal Tralsawala: So there is the 80% probability that Val will operate, which means that there are 20% chances that Val will not operate
Snehal Tralsawala: correct.
Snehal Tralsawala: See, the success in success line is shown in green and failure line is shown in red dotted red.
Snehal Tralsawala: and then.
Snehal Tralsawala: 3, rd one is water spray. What is the probability that it is its success? 70% and 30%.
Snehal Tralsawala: So agar, Mojay, if I want to find out what is the probability of success, then I can say 2 is the probability multiply by 0 point 9.8 point 7 is 1.0 0 8
Snehal Tralsawala: divided per 4th year.
Snehal Tralsawala: So out of 2 times it is happening per year, one time.
Snehal Tralsawala: Mira success red board the Chahu Nevala.
Snehal Tralsawala: But then, if I look at the negative aspect of it
Snehal Tralsawala: almost one time, it is not going to be successful.
Snehal Tralsawala: Osca, it will show the research.
Snehal Tralsawala: So the yeah, for example, you had 2.2 higher point 3 6 and point 4 3 2 2.
Snehal Tralsawala: So this is how to look at it. Now. Another way of looking at it is the same thing.
Snehal Tralsawala: Fire happened then fire detected, so that is a. m. 1. Fire alarm locks, M. 2. Sprinkler works, m. 3 m. 1 m. 2, m. 3.
Snehal Tralsawala: See if I am. Everything is
Snehal Tralsawala: everything worked, then limited damage, but nothing worked. Then there will be extensive damage on the
Snehal Tralsawala: right bottom. So this is the same thing. I'm talking in 4 different 5 different things. Same thing. I'm just telling you like a fire. Hua! There could be mineral damage could be severity, damage, severe damage, and it all depends on event. One triggering.
Snehal Tralsawala: So the event, one figure in Kachanskit Nahona. So this is the. This is analysis is called event tree analysis.
Snehal Tralsawala: Okay? So that completes a event tree.
Snehal Tralsawala: Let's take a break for 5 min.
Snehal Tralsawala: Bio break and then come back with the
Snehal Tralsawala: question on basic terminology. So I'll just let me just set the stage for you.
Snehal Tralsawala: Okay, so bad. Give me 5 min, huh? And 1220 will start. You relax in the meantime.
Snehal Tralsawala: and we'll cover this topic
Snehal Tralsawala: and then keep your questions ready if you have any immediately after safety terminology, session.
Snehal Tralsawala: We will have a discussion on what we learned today.
Snehal Tralsawala: Thank you.
Snehal Tralsawala: Okay, everyone.
Snehal Tralsawala: You're all out here.
Snehal Tralsawala: Hello.
Udit: Yes, sir.
Snehal Tralsawala: Okay, can we start now?
Snehal Tralsawala: If you are ready, we can start.
Sushil Kumar Mohapatra: Okay, sir.
Chaudhari santosh: Yes, sir.
Snehal Tralsawala: Yeah.
Snehal Tralsawala: So so we covered almost all the root cause analysis tools now.
Snehal Tralsawala: And we are getting into our next segment.
Snehal Tralsawala: which is about the method of accident investigation.
Snehal Tralsawala: so that will cover in the next session.
Snehal Tralsawala: But to getting ready for it. And I know you are all professionals and everything, and you know the
Snehal Tralsawala: the safety terminology. But still it's a good course to good good subject to go through one more time.
Snehal Tralsawala: So this presentation is put together.
Snehal Tralsawala: wherein we will cover all these basic definitions.
Snehal Tralsawala: Incident, accident near miss, oversight, dangerous occurrence, error, mistake, injury, unsafe condition, unsafe act, hazard risk.
Snehal Tralsawala: non-conformance, corrective action, correct correction, action, corrective action and preventive action.
Snehal Tralsawala: I know it's piece of cake, I'm sure, for you.
Snehal Tralsawala: But yes, still, we'll go through it. Okay? So
Snehal Tralsawala: so accident causation, what is accident, causation, and accident occurrences?
Snehal Tralsawala: Anybody can tell me that.
Snehal Tralsawala: What is the difference between accident, causation, and accident occurrence.
Snehal Tralsawala: It says that accident do not occur. They are caused any accident, any accident which takes place.
Snehal Tralsawala: It is caused by our own past actions.
Snehal Tralsawala: and so it simply doesn't occur. So when you have this one question.
Snehal Tralsawala: 1 1 of the question I had asked we had asked in the paper differentiate between causation and occurrence.
Snehal Tralsawala: And so, you know, quite a few people did not get it right.
Snehal Tralsawala: because there is nothing like accident occurrence.
Snehal Tralsawala: Okay, you are
Snehal Tralsawala: You are. If you are not a safety professional.
Snehal Tralsawala: and you you are allowed to say what you want to say.
Snehal Tralsawala: but once we are into it, there is no world like accident occurrence, because there is no such thing
Snehal Tralsawala: as accident occurred, it only accidents are caused.
Snehal Tralsawala: So basic difference is that so word causation points out that our responsibility to find out cause and preventive measures to remove real reason, causing the accident.
Snehal Tralsawala: A word occurrence points out occurring by chance or fate.
Snehal Tralsawala: He's ended
Snehal Tralsawala: Hogia accident, Hogia. So when we say accident, Hogia at our level when we say it, it doesn't suit, but somebody newer newcomer or somebody will come in and say Accident, Hogia, so that is acceptable.
Snehal Tralsawala: But in our dictionary there is no such thing as accident occurrence.
Snehal Tralsawala: Is it clear? Everyone.
Snehal Tralsawala: because unless we say accident caused, how will you go to the root cause analysis? So for basic premises is that accident has been caused
Snehal Tralsawala: and not occurred by fluke
Snehal Tralsawala: you all with me.
Udit: Yes, sir.
Nisarg Patel: And also, when we say, accident, occurrence.
Snehal Tralsawala: It also means that the person who is speaking is not owning up.
Snehal Tralsawala: So the another angle of when you say, differentiate the causation and occurrence of accident.
Snehal Tralsawala: So causation is about accepting the fact that this caused.
Snehal Tralsawala: But as soon as I say occurrence, then I means that I'm not owning up the responsibility part is also missing when I'm saying accident has occurred.
Snehal Tralsawala: So there are 2, 3, 4 angles to causation versus occurrences.
Snehal Tralsawala: So incident is unintended, unplanned event that could or does result in unintended harm to people
Snehal Tralsawala: and or damage to property. So incident deals with the damages
Snehal Tralsawala: that could, does not result in unintended harm to people, damage to property, accident.
Snehal Tralsawala: incident that do harm or damage, or as potential to do so. They are often called lost time incidents, and in unintended, unplanned event which has the
Snehal Tralsawala: potential to cause or even Jerry.
Snehal Tralsawala: that also may fall, come into the accident.
Snehal Tralsawala: If I look at incident, dissected. That incident could be no loss or resulting in a loss
Snehal Tralsawala: when it results in the loss, then accident for sure
Snehal Tralsawala: and when it goes into the lost time. Accident then called incident accident lost time incident.
Snehal Tralsawala: and then no loss.
Snehal Tralsawala: I can say no loss. Incident near misses.
Snehal Tralsawala: so there are some theories, people say near misses incident or near miss is actually
Snehal Tralsawala: whether it can be considered an incident because no harm is done. But incidents near me should be put into the
Snehal Tralsawala: incident.
Snehal Tralsawala: As advance we go
Snehal Tralsawala: more and more advanced, we go into process safety, and then there are lagging indicator and leading indicators are there? Then the question will come
Snehal Tralsawala: whether near Miss can be put into lagging indicator, or it can be put into leading indicator.
Snehal Tralsawala: so it should be put into lagging indicator, because it actually happened, but not bold.
Snehal Tralsawala: went from the second floor Upar Sekira, and then
Snehal Tralsawala: it fell. Just before I was about to walk there
Snehal Tralsawala: so near. The incident already has taken place, so
Snehal Tralsawala: that should be taken as a lagging indicator rather than leading indicator.
Snehal Tralsawala: and then you go into the root cause of that, and that becomes the lagging indicator.
Snehal Tralsawala: So that's the because near me. The point is not. That point is that it should 1st of all get captured, and whether you consider them as a leading indicator or lagging, it's a company policy.
Snehal Tralsawala: There is no straight line on where it fits in. But if you management feels that, let's put it into a
Snehal Tralsawala: leading indicator, that's also fine. So far as it gets captured, it is more important. All the near misses captured
Snehal Tralsawala: is important. And I've written a very good article on near miss.
Snehal Tralsawala: for process safety as well as these, and I'm I'm I'm hoping that it should be.
Snehal Tralsawala: Whatever the safety magazine that comes out of upl incident upl University.
Snehal Tralsawala: So good article on near miss. I return for process how to actually identify.
Snehal Tralsawala: Oh, the New Year misses so many of them, and so chaotic.
Snehal Tralsawala: Yeah, so lot can be said only on near Miss. But just move on.
Snehal Tralsawala: If see if I have a time, I'll show share with you the incident I mean the the article I wrote on that also
Snehal Tralsawala: so near, miss that could have caused harm or damage did not near miss an unplanned event that did not result in injury. Near smaller in size, easier to deal with
Snehal Tralsawala: cheaper learning tool than learning from the actual loss.
Snehal Tralsawala: The event is called near Miss. If the event is unplanned, undesired, if the event is a result of contact with the substance of source of energy. If the event could have caused harm to people.
Snehal Tralsawala: but did not.
Snehal Tralsawala: So all those can be so this is all in the airbs.
Snehal Tralsawala: So you guys are more into field. You know better about what is important is that definition, oversight.
Snehal Tralsawala: oversight is it means overlooking, or something, error or supervision.
Snehal Tralsawala: When there are more electrical switches side by side, looking identical. An operator may operate wrong, stitch by oversight.
Snehal Tralsawala: sweet. Sorry when there are Dusara Lagadia. Something else happened, but that is an oversight, dangerous occurrences.
Snehal Tralsawala: As per section 88, a of Factory Act rule 1, 0 3
Snehal Tralsawala: following occurrences are prescribed, the dangerous there are reportable in form number 2120, 21,
Snehal Tralsawala: and 21 a.
Snehal Tralsawala: When there is something called busting of steam plant under pressure, collapse or failure of lifting appliances.
Snehal Tralsawala: Fire explosion, escape of molten Metal. Hot liquor Gas explosion of Pressure. Vessel collapse of subsidi surface right
Snehal Tralsawala: subsidence of a structure here to go.
Snehal Tralsawala: So that is all called dangerous occurrences.
Snehal Tralsawala: Reportable accident as per factory is that when there is a factory.
Snehal Tralsawala: when in effect, an accident occurs
Snehal Tralsawala: from the day of the accident. 48 h.
Snehal Tralsawala: or Naya, I thought. It is reportable, then death is definitely reportable, and then, which causes and bodily injury, by reason
Snehal Tralsawala: of which the person injured is prevented.
Snehal Tralsawala: which causes an bodily injury by reason of what which the person injured is prevented
Snehal Tralsawala: immediately following the accident of which
Snehal Tralsawala: is of such nature as maybe describe in this behalf the manager of actors, and
Snehal Tralsawala: shall send notice, I'm sure, but the difference between our reportable and Uk Hsc. Reportable
Snehal Tralsawala: see us UU. Khsc report Manuke accident. Hua.
Snehal Tralsawala: so it will give one more day.
Snehal Tralsawala: And then, said Kalsevo, 48 h, Chalu Hoga
Snehal Tralsawala: so effectively 3 days it's given, I mean the Uk. Just gives 3 days before it can be converted into reportable accident
Snehal Tralsawala: in our case is like 48 h for the time it starts 48 h can. Then there is go report. Can
Snehal Tralsawala: I told you about reportable, dangerous occurrence oversight, and we spend good time on near Miss
Snehal Tralsawala: A. Committed
Snehal Tralsawala: just a minute. Huh?
Snehal Tralsawala: The cries of call
Snehal Tralsawala: everyone! You are able to see this.
Udit: Yes, sir.
Chaudhari santosh: Yes, sir.
Snehal Tralsawala: So they go. Theory is one part.
Snehal Tralsawala: but the importance of near misses I have written down
Snehal Tralsawala: this was sent for our this this safe Excel Cajona Magazine.
Snehal Tralsawala: So they've written down on the 7th auspiciously of Navarati. I'm happy that I'm given chance to author an article promoting process safety.
Snehal Tralsawala: I feel immense sense of gratitude.
Snehal Tralsawala: Often during my spell as a full-time employee organization for our Banakarte. Huh!
Snehal Tralsawala: Consultant relationship in past I found that importance of near miss reporting. A greater good or a few understand its importance, and many do not.
Snehal Tralsawala: Simple desire is not good enough and prevailing. Hsn. Culture may be deciding factor
Snehal Tralsawala: of what near Miss get reported.
Snehal Tralsawala: So what is near Miss near miss is an incident that did not result in injury or property damage
Snehal Tralsawala: would have if it had not addressed in timely manner
Snehal Tralsawala: in the classification fires as having serious injury and fatality
Snehal Tralsawala: potential. If the realistic worst outcome is the life threatening
Snehal Tralsawala: a simple video and following link may give you understanding what the Dms is like. Name is usually
Snehal Tralsawala: one of the following, and then a process safety
Snehal Tralsawala: for us. Then then here is the example. See? Because near me still here.
Snehal Tralsawala: Oh, Hamlog, we are tuned to understand. Near Miss.
Snehal Tralsawala: near me is only general safety can. Near me is Kojada. Focus Rotahi.
Snehal Tralsawala: So as per the Henry accident incident ratio 300 that you all know. Right? 3 300 to 30 to one.
Snehal Tralsawala: but go into process, safety process safety. Then there should be insufficient operating discipline near miss, including. So yeah, general safety. I'm not a strong head
Snehal Tralsawala: process. Safety cards on here, Mrs. Hay, voicemail loss of containment for process, safety event. When I say there will be many of the procedures not followed. PIN id diagram, not updated lack of maintenance, all that will come.
Snehal Tralsawala: So this is what. So what are the benefits of reporting near misses.
Snehal Tralsawala: reducing risk, preventive accident, identifying hazards.
Snehal Tralsawala: raising awareness about hazard, ensuring safer working environment, improving safety culture, making better decisions, adapting to the segment, adapting
Snehal Tralsawala: quickly and making necessary changes to exiting policies involving workforce, reinforcing worker self-esteem, collecting valuable information.
Snehal Tralsawala: avoiding complacency, avoiding identity, identification of so many advantage? What are the internal what are the internal impediments
Snehal Tralsawala: under prevailing hefty and self-culture, safety, culture, management, commitment, trust between staff and management, communication from worker and staff is not finding a way to top
Snehal Tralsawala: obviously lack of participation of vertical in consultation.
Snehal Tralsawala: What are the legal requirements?
Snehal Tralsawala: So there is a no, as such legal. I will listed down few of them. Okay, Hamari Factories Act make which legal requirement
Snehal Tralsawala: near Miss Report Carnega. But if I look at Ilo
Snehal Tralsawala: International Label, Organized conventions, they are the mother of all the rules which communicate the need of certain level of regulations.
Snehal Tralsawala: Is Ilo Convention, C, 155, 1981 article 19 reads that there shall be arrangement at level of undertaking under which worker reports fortnightly to his immediate supervisor any situation which he has seen, justification to believe that immediate danger to the life.
Snehal Tralsawala: So IA local requirement here
Snehal Tralsawala: that it has to be done.
Snehal Tralsawala: Then 45,001 weekend that will be near Miska Bataya over here that you all know Osha
Snehal Tralsawala: Osha is reporting near me supporting this promote Kara, and they've got a format here, so you'll see a format also in which you are supposed to report the
Snehal Tralsawala: let me see whether I'm able to open this.
Snehal Tralsawala: See, there is an the Oshaka document here near Miss reporting, and then, more than that.
Snehal Tralsawala: then Aiche Ccps center of chemical process. Safety has laid down guideline for process, safety, metric for leading and lagging it in the link below. If I just press this.
Snehal Tralsawala: it tells me chemical process safety for leading and lagging indicator, it gives you idea of what should be but definitely near me should be in it, and legal standard. There are no legal requirement or reporting near me in Osha or British, such as your Indian factories act.
Snehal Tralsawala: So conclusion is that I share here by my views of what near miss is specifically what may be example of near miss benefits of their reporting legal standard vital that management get information about near misses on time to improve.
Snehal Tralsawala: We just need to desire to improve our workplace and should be good initiative.
Snehal Tralsawala: So yeah, many of these had returned.
Snehal Tralsawala: and send it for safe safety. Excel around a month that we will see when it surfaces.
Snehal Tralsawala: Okay? So when we do the I mean. Yes.
Snehal Tralsawala: So when we go out for an audit.
Snehal Tralsawala: and invariably we find that near misses reporting, and we keep giving the guidances for how it can be improved, you know. So that is as far as the discount. Then error. I told you different type of errors.
Snehal Tralsawala: So reporting will be discussed.
Snehal Tralsawala: Error is a different type of human error, design, error, planning, production, and maintenance. Error.
Snehal Tralsawala: mistake is a act of wrong opinion.
Snehal Tralsawala: Judgment about things, then injury is injury, subcomalume chota injury, then nonconformity, what is nonconformity?
Snehal Tralsawala: So we all know. Okay, confirm it in fulfillment of requirement, action, action.
Snehal Tralsawala: correction, action is action to eliminate the non-conformance immediately that becomes correction action.
Snehal Tralsawala: and then take immediate action, and then corrective action is action to eliminate the cause.
Snehal Tralsawala: What we are going through root cause analysis is about corrective action
Snehal Tralsawala: and about preventive action correct? What is the difference between corrective and preventive action?
Snehal Tralsawala: Agar may kutcha corrective action, letter action to eliminate the cause.
Snehal Tralsawala: But if the accident took place in one unit and I'm in in complete, I'm implementing that
Snehal Tralsawala: action item in the another unit, my accident, neigh. Who I that will, I'll call a preventive action.
Snehal Tralsawala: So that's a
Snehal Tralsawala: pre-corrective and preventive. Some example is given which you already know unsafe condition. I'm sure you know what is unsafe condition, what is unsafe act
Snehal Tralsawala: kuma lume like, for example, unsafe condition, hey? Right top right side may take care.
Snehal Tralsawala: A Lord have a Lord definitely.
Snehal Tralsawala: What is hazard?
Snehal Tralsawala: What is risk? You know what is hazard, what is risk
Snehal Tralsawala: and what is the risk? Is a probability. Times has, I mean severity.
Snehal Tralsawala: Hazard is any event.
Snehal Tralsawala: hazard methods of how chemical that is called hazard, and then risk is a probability of occurrence and severity of consequence. You all know that I did not get into the Mh. You already know, as per defined under Rule 2. G.
Snehal Tralsawala: Isolated storage and industrial activity of hazardous chemical equal to within it.
Snehal Tralsawala: So we covered incident accident near me. So oversight, dangerous occurrence all this we covered.
Snehal Tralsawala: So now we get into the type of accidents. Now I'm getting into a different segment.
Snehal Tralsawala: So type of accident. This could be a typical question in the exam.
Snehal Tralsawala: what are the different types of accident which takes place, so there are. Accident can be based on severity.
Snehal Tralsawala: Thai nathi ABC. So based on severity.
Snehal Tralsawala: In one case you have a
Snehal Tralsawala: injury, has not taken place. In other case, the major injury. The photograph shows that.
Snehal Tralsawala: And second case, okay, there could be injury as well as property damage.
Snehal Tralsawala: There could be injury and property damage.
Snehal Tralsawala: See, for example, in a car accident.
Snehal Tralsawala: in some instance you have injury and no property damage.
Snehal Tralsawala: and then in some other cases
Snehal Tralsawala: you have a property damage, but no injury.
Snehal Tralsawala: And in another case no property damage and not injured.
Snehal Tralsawala: So chat a level.
Snehal Tralsawala: Okay? So therefore, actually, this is a okay.
Snehal Tralsawala: feel like here and be
Snehal Tralsawala: so major and minor, and no property damage.
Snehal Tralsawala: And then, based on the causation
Snehal Tralsawala: based on the causation crack, I type an accident have so psychological, physiological, and physical
Snehal Tralsawala: psychologically, is like such as inexperienced, not motivated.
Snehal Tralsawala: So a quota decision, then, that is a physiological cause.
Snehal Tralsawala: Sorry psychological cause. Physiological is about age, sex, body build.
Snehal Tralsawala: Okay, a current.
Snehal Tralsawala: How, whether it is possible or not.
Snehal Tralsawala: so that poor hearing could be caused, that is, physiological and physical, could mean heavy workload, long working hours, no rest, unhealthy work, environment working at height.
Snehal Tralsawala: All this comes into the physical.
Snehal Tralsawala: The 4th one is a mechanical, identical chemical radiation cause.
Snehal Tralsawala: such as unguarded machine, defective equipment, noise, vibration.
Snehal Tralsawala: You know, this could be the cause high noise area. If it is there, it can lead to cause, or you may have, a static. Electricity will fall into it. Some radiation is taking place in a
Snehal Tralsawala: in a machine that is affecting, that is becoming the cause, then it becomes into this 4th category. And 5th category is environment. Where in bogaramish, you know, like my like Bogar mihoy.
Snehal Tralsawala: so what is going to happen is, yeah, internally.
Snehal Tralsawala: you'll not feel comfortable on the top of it. Some sweater. My full sleeve shirt is there.
Snehal Tralsawala: and that is letting me get into the accident.
Snehal Tralsawala: or some too much of rain, is there? I'm supposed to, you know. Too much of wind is there, and I'm getting involved into the
Snehal Tralsawala: an accident took place because of that.
Snehal Tralsawala: Lightning has taken place. There are. There are cases when people are
Snehal Tralsawala: people died because of the lightning itself.
Snehal Tralsawala: and that becomes the environment cause. So there are 5 causes, are there.
Snehal Tralsawala: So I told you, type of accident, ma, 2 different categories
Snehal Tralsawala: based on severity based on causation.
Snehal Tralsawala: Okay to everyone.
Snehal Tralsawala: I'm luck done with my subject for today.
Snehal Tralsawala: and the floor is open for discussion.
Snehal Tralsawala: I'm going to shut off the stop sharing and open for discussion
Snehal Tralsawala: since we covered good amount of things today. Huh?
Snehal Tralsawala: Everyone.
Snehal Tralsawala: So 10 min is for question, answer.
Snehal Tralsawala: Any discussions, any inputs.
Bakshi Manish: Sir Manisha.
Snehal Tralsawala: Yeah. Yeah. Money.
Bakshi Manish: Sir, for selection of the right tool for carrying out things we had discussed so many tools. But what happened? Actually, you know, so many people are at the site.
Bakshi Manish: those who are not aware. With these tools.
Bakshi Manish: and in the category one and 2 investigation they have to carry down 4 and 5, not 1, 2, 3, carry down by the trained people.
Bakshi Manish: but 4 and 5. Category isn't being carried out by the shop floor level people
Bakshi Manish: means executive level up to the executive level.
Bakshi Manish: so which is the best way for them, so that they can easily understand and implement.
Snehal Tralsawala: No, it comes with the experience, actually.
Snehal Tralsawala: everything. This comes with the experience. But I showed you that incident mapping right
Snehal Tralsawala: now. Incident mapping. You cannot apply to day to day, accident.
Bakshi Manish: Hmm.
Snehal Tralsawala: Incident. Mapping is something which is something big has happened.
Snehal Tralsawala: and you want to go to the bottom of it. Then you want to apply the incident mapping.
Snehal Tralsawala: Similarly, because high end we talk about. Then you look at the faulty analysis.
Snehal Tralsawala: faulty analysis, also, high end, high end, major major importance to you.
Bakshi Manish: Right.
Snehal Tralsawala: Like faulty analysis can be done for the major. Incidents like with a the gopal.
Bakshi Manish: You want to go into the Bhopal tragedy, then you follow faulty analysis. What actually happened.
Snehal Tralsawala: Because the complications are so many, and combination and permutation is so many, then you won't look at faulty analysis. Event tree is not about
Snehal Tralsawala: root cause.
Snehal Tralsawala: Event tree is about understanding the consequences. How you reduce the consequences.
Snehal Tralsawala: So incident. Mapping is clear. Fault tree is clear. That doesn't mean I cannot apply fault tree locally, but I should have a good reason to do faulty analysis.
Snehal Tralsawala: caution, tree circle is caution. Analysis is circle is used. When you have too many causes, you derive.
Bakshi Manish: Yeah.
Snehal Tralsawala: Then then you say, Okay, so many are there now? How many I I actually work on? Because I don't have time to work on, and invariably, when in the report, you will have so many of the
Snehal Tralsawala: causes you come up with.
Snehal Tralsawala: So for your internal satisfaction, it is good idea to when you have more than 5, for example, 5 causes. Are there, then, good idea to do a causal on that.
Bakshi Manish: Okay.
Snehal Tralsawala: And see whether they are talking to each other.
Bakshi Manish: Right? Right? Right? That's a basic actually.
Snehal Tralsawala: It is basic. Then you can reduce, then at least, management will also think that you've gone one step up
Snehal Tralsawala: and you try to make sense out of these 5 causes that you put it so. Which
Snehal Tralsawala: tech first.st So you so for your for your own clarity.
Bakshi Manish: Yes, yes.
Snehal Tralsawala: More and more of the caution.
Bakshi Manish: And right over a period they will become expert. Then we can utilize that technique.
Snehal Tralsawala: Correct. Then the 5 I everyone is using it. But don't limit 5, I to 5. I.
Bakshi Manish: No, it's a wi-fi.
Snehal Tralsawala: So it's a YY, so 5 y should be actually name should be changed to YY,
Snehal Tralsawala: so wi-fi is a good method.
Snehal Tralsawala: But why, why may then? But if you look at the brainstorming
Snehal Tralsawala: brainstorming is pretty decent in that. It gets the view of all different spectrum.
Snehal Tralsawala: Hmm! I
Snehal Tralsawala: of any complicated problem. I want to start with the I have so much of faith in the brainstorming method.
Snehal Tralsawala: so brainstorming is one of the 1st thing to do, and which which we know very less of.
Snehal Tralsawala: we get hung into the YY, but YY may be the brainstorming. Yeah, Tahina.
Bakshi Manish: But brainstorming. Everybody can contribute either work or labor behavior. He can contribute.
Snehal Tralsawala: So, Agar, if you ask me, I want to use brainstorming as much as possible.
Snehal Tralsawala: and you kind of everyone in the room, and all enjoyed.
Snehal Tralsawala: So this is how to look at it. Sort of complicated here, I mean. Simple formula is that you? You know the answer almost know the answer, do the why.
Snehal Tralsawala: if you don't know the answer.
Bakshi Manish: If you almost know the answer. But it's go validate. Can I have to go through bye, baby?
Snehal Tralsawala: But if you don't know the answer, don't use YY go into the fishbone diagram or faulty analysis.
Snehal Tralsawala: So top jacket, coach, Nick Lega, you know.
Bakshi Manish: Yeah.
Snehal Tralsawala: So this is, there is one presentation. 5, page on 5 5. Slide presentation is on selection criteria.
Snehal Tralsawala: But motivity here.
Bakshi Manish: No, but you rightly said, Sir, if you know the reason, then you can do the.
Snehal Tralsawala: Or maybe you don't.
Snehal Tralsawala: Don't force fit it.
Bakshi Manish: No, no.
Snehal Tralsawala: Don't force pit it.
Snehal Tralsawala: Then it's good idea to do yy. And then again, don't get into the rhythm of knowing the solution.
Bakshi Manish: Yeah.
Snehal Tralsawala: Because we are only talking about action.
Snehal Tralsawala: So you should have a 2 separate sessions. One is on cause, other, one is on the, on the solution.
Bakshi Manish: Yes.
Bakshi Manish: yeah. 1st lecture. I've never done.
Snehal Tralsawala: We're pretty much done with this
Snehal Tralsawala: This thing is normally, I wish I could have done more practical on this brainstorming.
Snehal Tralsawala: but because of the this online circumstances it's difficult to do otherwise. We'll we'll see an error
Snehal Tralsawala: share one article which I sent you.
Snehal Tralsawala: I mean, I showed you.
Snehal Tralsawala: It's kind of gives outline on the
Snehal Tralsawala: underutilized or I. Cautious cautual circle is getting utilized, underutilized.
Snehal Tralsawala: According to me, it should be more and more used in the industry.
Snehal Tralsawala: So thank you. At least, somebody is asking. Manishi is asking question. Anybody else has a question.
Snehal Tralsawala: Accident. Investigation can be accident. Investigation.
Bakshi Manish: Hmm.
Snehal Tralsawala: We'll go. We'll get. Now get into the different apkaju method. We will look at the Uk general method, and then we'll get into interview, interview
Snehal Tralsawala: all those things we'll discuss, you know.
Bakshi Manish: Victim should sit, and we have to interview with the key persons.
Snehal Tralsawala: Both technique can be used.
Snehal Tralsawala: The interview should be done as early as possible. That is the thing.
Bakshi Manish: Yeah.
Snehal Tralsawala: Late Goge.
Snehal Tralsawala: So normally people will have some some mind game, maybe also at play.
Snehal Tralsawala: So it is like, what is the right time to take an interview is important, but it should be done as early as possible. That is the thing.
Snehal Tralsawala: location. It should be location of the interview.
Snehal Tralsawala: Malaba. The people should feel comfortable with you.
Snehal Tralsawala: If you are interviewing someone he doesn't know you, whatever. He will not talk with you, he or she will not talk with you.
Bakshi Manish: All right.
Snehal Tralsawala: So you have to provide a setting so that they are
Snehal Tralsawala: comfortable, comfortable in talking to you. Maybe get his one of his good good friend sit with him with you, or will the Hr. Guy sit with you? He's comfortable with the Whatsapp Whatsapp inquiry can I have? Or that is part of the preparation to the interview.
Snehal Tralsawala: or so that he's able to talk to you better.
Bakshi Manish: Right, right.
Snehal Tralsawala: Because that is like like you showed you saw now, ultimately.
Bakshi Manish: It's part of our Ghetto.
Snehal Tralsawala: And then there is a a console I'll share with you offshore. Main incident. What happened?
Snehal Tralsawala: Can? I'm a famous name, Oscar.
Bakshi Manish: 5. 11.
Bakshi Manish: Hyper. Alpha. Vault.
Snehal Tralsawala: I. Cypher, Alpha Piper, Alpha, the Piper Alpha Makeover workplace itself got abolished.
Bakshi Manish: After the fact that Piper Alpha was in the middle of the sea.
Snehal Tralsawala: And we have interviewed you don't have any proof.
Bakshi Manish: Nobody was there.
Snehal Tralsawala: Everything is in water.
Snehal Tralsawala: You, every. You have to rely on the videos, and you have to rely on the interviews to make sense, and how they did it is, you know. You will find time. We'll talk about how actually they put the pieces together. One of the best investigating.
Bakshi Manish: Yes, yes, after one or one and half.
Snehal Tralsawala: Got it, got it? Got it?
Snehal Tralsawala: So that investigation. Now we're getting into the method of investigating.
Snehal Tralsawala: Yeah, Jack. And I saw that Jack and I saw that because it's amazing, you know.
Bakshi Manish: Hipass.
Snehal Tralsawala: Correct, correct. And then 1,500 people. It's got team to come up with an answer. They were looking at the footages, footages.
Bakshi Manish: They were evaluating, putting those pieces together.
Bakshi Manish: No one wants it.
Snehal Tralsawala: That is an art, you know. Investigation that is an art.
Bakshi Manish: Right.
Snehal Tralsawala: To Cassie interview, can. I will talk about that? We'll also talk about
Snehal Tralsawala: you know. What is the method?
Snehal Tralsawala: What are the checkpoints at each one that we'll discuss. And some case study be language
Snehal Tralsawala: like Piper Alpha. You're already aware that we'll take something else, you know.
Bakshi Manish: It's a very interesting case study. Actually, sir.
Snehal Tralsawala: Anybody else.
Snehal Tralsawala: Abjara, follow up presentation.
Snehal Tralsawala: And I say, Yeah, you know.
Snehal Tralsawala: start looking at reading it, looking at it.
Bakshi Manish: Yes.
Snehal Tralsawala: Take care!
Bakshi Manish: Okay, thank you. So.
Snehal Tralsawala: Yeah, thank you very much. Yeah.