Root Cause Analysis: A Guide to Efficient and Effective Incident Investigation / Edition 3

Root Cause Analysis: A Guide to Efficient and Effective Incident Investigation / Edition 3

by Lee N. Vanden Heuvel, David A. Walker, Walter E. Hanson, ABS Consulting
     
 

ISBN-10: 1931332517

ISBN-13: 9781931332514

Pub. Date: 06/15/2008

Publisher: Rothstein Associates Inc.

The Root Cause Analysis Handbook presents a proven system for investigating, categorizing (and ultimately eliminating) the root causes of incidents with safety, health, environmental, quality, reliability, and production-process impacts. Understanding and applying the processes outlined in this book increases your business ability to recover from and prevent incidents…  See more details below

Overview

The Root Cause Analysis Handbook presents a proven system for investigating, categorizing (and ultimately eliminating) the root causes of incidents with safety, health, environmental, quality, reliability, and production-process impacts. Understanding and applying the processes outlined in this book increases your business ability to recover from and prevent incidents with financial and health/safety implications.

The book outlines ABS Consulting's SOURCE(TM) (Seeking Out the Underlying Causes of Events) root cause analysis (RCA) system, enabling businesses to generate specific, concrete recommendations for preventing incident recurrences. The instructions for performing RCA activities include:

- Initiating an investigation: How to determine whether an incident has occurred, how to classify and categorize the incident, and how to decide whether or not to conduct an in-depth investigation.

- Data gathering: How to collect data related to people, processes, procedures, documents (hard copy & electronic), position, and physical data associated with an incident.

- Data analysis: How to analyze incidents to determine causal factors using tools such as causal factor charts, timelines, and cause and effect trees.

- Developing recommendations: How to document causal factors and root causes identified during the earlier analysis including how to identify what changes (recommendations) may be needed to enhance management systems and reduce risks. - Reporting and trending: How to archive findings and recommendations to allow review and trending of incident patterns after some period of SOURCE(TM) use.

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Product Details

ISBN-13:
9781931332514
Publisher:
Rothstein Associates Inc.
Publication date:
06/15/2008
Edition description:
Enlarged
Pages:
324
Sales rank:
850,982
Product dimensions:
8.25(w) x 11.00(h) x 0.68(d)

Table of Contents


List of Figures

List of Tables

List of Acronyms

Foreword

Background

The SOURCETM Methodology

Scope of the Handbook

Contents of the Handbook

SECTION 1: BASICS OF INCIDENT INVESTIGATION

1.1 The Need for Incident Investigation

1.1.1 Rational for Taking a Structured Approach to Incident Investigation

1.1.2 Depths of Analysis

1.1.3 Structured Analysis Process

1.2 Selecting Incidents to Investigate

1.3 The Investigation Thought Process

1.3.1 Differences Between Traditional Problem Solving and Structured RCA

1.3.2 The Typical Investigator

1.3.3 A Structured Approach to the Analysis

1.4 RCA Within a Business Context

1.5 The Elements of an Incident

1.6 Causal Factors and Root Causes

1.7 The Goal of the Incident Investigation Process

1.8 Overview of the SOURCETM Methodology

1.9 The SOURCETM Root Cause Analysis Process

1.9.1 Steps That Apply to Acute Incident Analyses

1.9.2 Steps That Apply to Chronic Incident Analysis

1.9.3 Steps That Apply When No Formal Analyses Are Performed

1.9.4 Steps That Apply to All Analyses

1.10 Levels of the Analysis: Root Cause Analysis and Apparent Cause Analysis

1.11 Definitions

1.12 Summary

SECTION 2: INITIATING INVESTIGATIONS

2.1 Initiating the Investigation

2.2 Notification

2.3 Emergency Response Activities

2.4 Immediate Response Activities

2.5 Beginning the Investigation

2.6 Initial Incident Reports and Corrective ActionRequests

2.6.1 Reasons to Generate an IIR or CAR

2.6.2 Typical Information Contained in an IIR or CAR

2.6.3 Using the IIR or CAR in the Incident Investigation Process

2.7 Incident Classification

2.8 Investigation Management Tasks

2.9 Assembling the Team

2.10 Briefing the Team

2.11 Restart Criteria

2.12 Gathering Investigation Resources

2.13 Summary

SECTION 3: GATHERING AND PRESERVING DATA

3.1 Introduction

3.2 General Data-gathering and Preservation Issues

3.2.1 Importance of Data-gathering

3.2.2 Types of Data

3.2.3 Prioritizing Data-gathering Efforts

3.2.3.1 People Data Fragility Issues

3.2.3.2 Electronic Data Fragility Issues

3.2.3.3 Physical/Position Data Fragility Issues

3.2.3.4 Paper Data Fragility Issues

3.3 Gathering Data

3.4 Gathering Data from People

3.4.1 Factors to Assess the Credibility of People Data

3.4.2 Initial Witness Statements

3.4.3 The Interview Process

3.4.3.1 Before the Interviews

3.4.3.2 Beginning the Interview

3.4.3.3 Conducting the Interview

3.4.3.4 Concluding the Interview

3.4.3.5 Follow-up Interviews

3.5 Physical Data

3.5.1 Sources of Physical Data

3.5.2 Types and Nature of Physical Data Analysis Questions

3.5.3 Basic Steps in Failure Analysis

3.5.4 Use of Physical Data Analysis Plans

3.5.5 Chain of Custody for Physical Data

3.5.6 Use of Outside Experts

3.6 Paper Data

3.7 Electronic Data

3.8 Position Data

3.8.1 Unique Aspects of Position Data

3.8.2 Collection of Position Data

3.8.3 Documentation of Photos and Videos

3.8.4 Alternative Sources of Position Data

3.9 Overall Data-collection Plan

3.10 Application to Apparent Cause Analyses and Root Cause Analyses

3.11 Summary

SECTION 4: ANALYZING DATA

4.1 Introduction

4.2 Overview of Primary Techniques

4.3 Cause and Effect Tree Analysis

4.4 Timelines

4.5 Causal Factor Charts

4.6 Using Causal Factor Charts, Timelines, and Cause and Effect Trees Together During

an Investigation

4.7 Application to Apparent Cause Analyses and Root Cause Analyses

4.8 Summary

SECTION 5: IDENTIFYING ROOT CAUSES

5.1 Introduction

5.2 Root Cause Analysis Traps

5.2.1 Trap 1 – Equipment Issues

5.2.2 Trap 2 – Human Performance Issues

5.2.3 Trap 3 – External Event Issues

5.3 Procedure for Identifying Root Causes

5.4 ABS Consulting's Root Cause MapTM

5.5 Observations About the Structure of the Root Cause MapTM

5.6 Using the Root Cause MapTM

5.6.1 The Five Steps

5.6.2 Multiple Coding

5.6.3 Incorporating Organizational Standards, Policies, and Administrative Controls

5.6.4 Using the Root Cause Map™ Guidance During an Investigation

5.6.5 Typical Problems Encountered When Using the Root Cause MapTM

5.6.6 Advantages and Disadvantage of Using the Root Cause MapTM

5.7 Documenting the Root Cause Analysis Process

5.8 Application to Apparent Cause Analyses and Root Cause Analyses

5.9 Summary

SECTION 6: DEVELOPING RECOMMENDATIONS

6.1 Introduction

6.2 Timing of Recommendations

6.3 Levels of Recommendations

6.3.1 Level 1 – Address the Causal Factor

6.3.2 Level 2 – Address the Intermediate Causes of the Specific Problem

6.3.3 Level 3 – Fix Similar Problems

6.3.4 Level 4 – Correct the Process That Creates These Problems

6.4 Types of Recommendations

6.4.1 Eliminate the Hazard

6.4.2 Make the System Inherently Safer or More Reliable

6.4.3 Prevent Occurrence of the Incident

6.4.4 Detect and Mitigate the Loss

6.4.5 Implementing Multiple Types of Recommendations

6.5 Suggested Format for Recommendations

6.6 Special Recommendation Issues

6.7 Management Responsibilities

6.8 Examples of Reasons to Reject Recommendations

6.9 Assessing Benefit/Cost Ratios

6.9.1 Estimating the Benefits of Implementing a Recommendation

6.9.2 Estimating the Costs of Implementing a Recommendation

6.9.3 Benefit/Cost Ratios

6.10 Assessing Recommendation Effectiveness

6.11 Application to Apparent Cause Analyses and Root Cause Analyses

6.12 Summary

SECTION 7: COMPLETING THE INVESTIGATION

7.1 Introduction

7.2 Writing Investigation Reports

7.2.1 Typical Items to Be Included in an Investigation Report

7.2.2 Tips for Writing Reports

7.3 Communicating Investigation Results

7.3.1 Decide to Whom the Results Should Be Communicated

7.3.2 Decide How to Distribute the Report

7.3.3 Document the Communication

7.4 Resolving Recommendations and Communicating Resolutions

7.4.1 Tracking Recommendations

7.4.2 Report Resolution Phase and Closure of Files

7.5 Addressing Final Issues

7.5.1 Enter Trending Data

7.5.2 Evaluate the Investigation Process

7.6 Application to Apparent Cause Analyses and Root Cause Analyses

7.7 Summary

SECTION 8: SELECTING INCIDENTS FOR ANALYSIS

8.1 Introduction

8.2 Why Be Careful When Selecting Incidents for Investigation?

8.3 Some General Guidance

8.3.1 Incidents to Investigate (High Potential Learning Value)

8.3.2 Incidents to Trend (Low to Moderate Potential Learning Value)

8.3.3 No Investigation (Low Potential Learning Value)

8.4 Performing the Investigation

8.4.1 Incidents to Investigate Immediately (Acute Incidents)

8.4.2 Incidents to Trend (Potentially Chronic Incidents)

8.5 Near Misses

8.5.1 Factors to Consider When Defining Near Misses

8.5.2 Reasons Why Near Misses Should Be Investigated

8.5.3 Barriers to Getting Near Misses Reported

8.5.4 Overcoming the Barriers

8.6 Acute Analysis Versus Chronic Analysis

8.7 Identifying Chronic Incidents That Should Be Analyzed

8.7.1 Using Pareto Analysis for Environmental, Health, and Safety Incidents

8.7.1.1 Examples of Pareto Analysis

8.7.1.2 Weaknesses of Pareto Analysis

8.7.2 Chronic Analysis of Reliability Problems

8.7.2.1 Prioritizing the RCA Efforts

8.7.2.2 Repeating the Process

8.7.3 Chronic Analysis for Quality Incidents

8.7.3.1 Prioritizing the RCA Efforts

8.7.3.2 Repeating the Process

8.7.4 Other Data Analysis Tools

8.8 Summary

SECTION 9: DATA AND RESULTS TRENDING

9.1 Introduction

9.2 Benefits of a Trending Program

9.3 Determining the Data to Collect

9.3.1 Deciding What Data to Collect

9.3.2 Defining the Data to Collect

9.3.3 Other Data-collection Guidance

9.4 Data Analysis

9.4.1 Interpreting Data Trends

9.5 Application to Apparent Cause Analyses and Root Cause Analyses

9.6 Summary

SECTION 10: PROGRAM DEVELOPMENT

10.1 Introduction

10.2 Program Implementation Process

10.2.1 Design the Program

10.2.2 Develop the Program

10.2.3 Implement the Program

10.2.4 Monitor the Program's Performance

10.2.5 Improve the Program

10.3 Key Considerations

10.3.1 Legal Considerations and Guidelines

10.3.2 Media Considerations

10.3.3 Some Regulatory Requirements and Industry Standards

10.3.4 Training

10.4 Management Influence on the Program

10.5 Common Investigation Problems and Solutions

10.5.1 There Is No Business Driver to Change

10.5.2 There Is No Organizational Champion for the Program

10.5.3 The Organization Never Leaves the Reactive Mode

10.5.4 The Organization Must Find an Individual to Blame

10.5.5 Personnel Are Unwilling to Critique Management Systems

10.5.6 Reward Implementation of Recommendations

10.5.7 The Organization Tries to Investigate Everything

10.5.8 The Organization Only Performs Incident Investigations on Large Incidents

10.5.9 Recommendations Are Never Implemented

10.6 Summary

SECTION 11: CONTENTS OF THE COMPANION CD AND DOWNLOADABLE RESOURCES

11.1 Introduction

11.2 Resources Available on the Companion CD and at www.absconsulting.com

11.2.1 SOURCETM Investigator's Toolkit

11.2.2 Updates and Modifications to the Root Cause Map™ Guidance

11.2.3 Examples Specific to Handbook Sections

11.3 Download Instructions

APPENDIX A: GLOSSARY

APPENDIX B: CAUSE AND EFFECT TREE

APPENDIX C: TIMELINE DETAILS

APPENDIX D: CAUSAL FACTOR CHARTING DETAILS

APPENDIX E: ROOT CAUSE MAPTM GUIDANCE

APPENDIX F: SOURCETM INVESTIGATOR'S TOOLKIT

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