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

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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: 6/15/2008
  • Edition description: Enlarged
  • Edition number: 3
  • Pages: 324
  • Sales rank: 361,296
  • Product dimensions: 8.25 (w) x 11.00 (h) x 0.68 (d)

Meet the Author

Mr. Lee N. Vanden Heuvel is the Manager of Incident Investigation/Root Cause Analysis Services and the Manager of Training Services for ABS Consulting. He has more than 23 years of experience in plant operations and analysis. Mr. Vanden Heuvel has assisted organizations in many different industries with the development and implementation of incident investigation and root cause analysis (RCA) programs. He has also led and participated in investigations in many types of industries, including chemical, refining, healthcare, manufacturing, drilling, machining, pharmaceuticals, waste disposal, nuclear power, and food processing. He is a coauthor of Guidelines for the Investigation of Chemical Process Incidents, Second Edition and Risk Based Process Safety (both published by the American Institute of Chemical Engineers’ Center for Chemical Process Safety) and Reliability Management (published by Rothstein Associates).

Mr. Vanden Heuvel was previously the project manager and lead analyst for a large

quantitative risk assessment program at the Oak Ridge National Laboratory. He also worked for 8 years at a nuclear power plant in operations, engineering support, and training. His current responsibilities are in the areas of RCAs, incident investigations, human factors, procedures, safety analyses, and economic/decision analyses. He is the prime developer of ABS Consulting’s Root Cause Analysis and Incident Investigation course and has taught RCA techniques to thousands of students.

Donald Lorenzo is the Director of Training Services for ABS Consulting. He has more than 28 years of experience in hazard analysis and risk assessment. He was previously a development engineer forUnion Carbide Corporation. He is the author of A Manager’s Guide to Reducing Human Errors and A Manager’s Guide to Quantitative Risk Assessment (published by the Chemical Manufacturers Association, now known as the American Chemistry Council) and a coauthor of Guidelines for Hazard Evaluation Procedures, Second Edition with Worked Examples; Risk Based Process Safety; and Human Factors Methods for Improving Performance in the Process Industries (published by the American Institute of Chemical Engineers’ Center for Chemical Process Safety). Mr. Lorenzo specializes in safety and environmental applications of ABS Consulting’s SOURCETM methodology. He is a registered Professional Engineer in the state of Tennessee and a Certified Technical Trainer.

Walter Hanson is a Project Manager and Risk/Reliability Engineer for ABS Consulting. He has more than 22 years of experience in developing, implementing, and managing loss prevention management systems, including mishap investigation, system safety, policy and procedure, training systems, performance measurement, and human factors. At ABS Consulting he works on various risk management projects for the United States Coast Guard (Coast Guard) and other transportation and maritime clients. Before joining ABS Consulting, Mr. Hanson had 13 years of safety management experience as a ommissioned officer of the Coast Guard. He completed nearly 25 years of ommissioned service and attained the rank of captain. Mr. Hanson was a primary developer of ABS Consulting’s Marine Root Cause Analysis Technique (MaRCAT). He is the lead nstructor for ABS Consulting’s Maritime Root Cause Analysis course.

Laura Jackson is a Risk/Reliability Engineer for ABS Consulting. Since joining the organization, Ms. Jackson has been involved in evaluating the risks associated with corporate and governmental operations through the development and application of a number of methodologies, including relative risk ranking, risk matrices, enterprise risk management (ERM), project risk management, root cause analysis, and hazard and operability (HAZOP) analysis. She has served on teams that investigated incidents at a variety of commercial facilities, and she has performed comprehensive hazard assessments, including security risk, for the United States Coast Guard and the Department of Homeland Security. She also co-instructs for ABS Consulting and develops instructor-led and Web-based materials relating to root cause analysis/incident investigation, ERM, and transportation risk. Ms. Jackson, a nuclear engineer, previously worked in the nuclear power industry where she provided technical resolutions for nuclear safeguard and security issues and supported the regulatory interface for an emergency operations facility.

James Rooney is a Senior Risk/Reliability Engineer and the Manager of Webinar Training Services for ABS Consulting. He has more than 25 years of experience in quality engineering, reliability engineering, risk assessment, and process safety management. He is a Fellow of the American Society for Quality (ASQ). Mr. Rooney is an ASQ-certified HACCP auditor, Certified Quality Auditor, Certified Quality Engineer, Certified Quality Improvement Associate, Certified Quality Manager, and Certified Reliability Engineer. He is also a registered Professional Engineer in the state of Tennessee. Mr. Rooney teaches courses on quality engineering, qualitative and quantitative hazard/reliability analysis, management system development/auditing, and incident investigation/root cause analysis. He specializes in quality and medical applications of the SOURCE(tm) technique.

David Walker has been working in the risk management, process safety, loss prevention, incident investigation/root cause analysis, system reliability, and asset integrity management fields for the past 18 years. He is currently the Vice President of Public Sector for ABS Consulting. He is also an instructor for (1) ABS Consulting Training Services, (2) professional societies such as the American Society of Mechanical Engineers and the American Institute of Chemical Engineers’ Center for Chemical Process Safety, and (3) specialized centers at universities such as the Maintenance and Reliability Center at the University of Tennessee and the Center for Competitive Change at the University of Dayton. Mr. Walker specializes in using innovative applications of risk and reliability technology and cultural change to help government agencies and major corporations with significant loss exposures make the best use of their limited resources to achieve their organizational performance goals.

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Table of Contents

List of Figures

List of Tables

List of Acronyms



The SOURCETM Methodology

Scope of the Handbook

Contents of the Handbook


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


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


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 People Data Fragility Issues Electronic Data Fragility Issues Physical/Position Data Fragility Issues 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 Before the Interviews Beginning the Interview Conducting the Interview Concluding the Interview 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


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


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


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


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


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 Examples of Pareto Analysis Weaknesses of Pareto Analysis

8.7.2 Chronic Analysis of Reliability Problems Prioritizing the RCA Efforts Repeating the Process

8.7.3 Chronic Analysis for Quality Incidents Prioritizing the RCA Efforts Repeating the Process

8.7.4 Other Data Analysis Tools

8.8 Summary


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


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


11.1 Introduction

11.2 Resources Available on the Companion CD and at

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






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