Root cause analysis handbook : a guide to efficient and effective incident investigation

322 Pages·2008·23.66 MB·English

This new edition provides a detailed, step-by-step process for
learning from experience. It describes an industry-proven method
for investigating, categorizing, and ultimately eliminating causes
of incidents that can have serious safety, health, environmental,
quality, reliability, production, or security impacts.
SPECIAL FEATURES
▲ FREE DOWNLOAD OF BONUS MATERIALS.
▲ Are you trying to improve performance, but fnd that the See instructions on back page to download.
same problems keep getting in the way? ▲ Exclusive Web access to handbook-specifc tools,
▲ Does your organization experience repeat failures? resources and checklists.
▲ When you investigate failures, injuries, customer ▲ Root Cause Map™ (17” by 22”) mailed after download
complaints, or other problems, do you address surface registration.
causes but miss root causes? ▲ More than 120 fgures and tables.
▲ Have you ever performed an investigation and realized that
personnel already “knew” the causes, but no one acted to WHAT’S NEW IN THE THIRD EDITION
prevent the incident? ▲ ENHANCED DETAIL. Step-by-step guidance, forms and
▲ Do you have trouble getting personnel to think long term checklists.
and not just react? ▲ IMPROVED ROOT CAUSE MAP™
— Two additional layers to help you “dig deeper” when
identifying root causes
The ROOT CAUSE ANALYSIS HANDBOOK is a powerful tool for: — Greater focus on quality issues
▲ Understanding why root causes are important, — Ability to easily incorporate YOUR facility-specifc
▲ Identifying and defning inherent problems, procedures and policies into the Root Cause Map™
structure
▲ Collecting data for problem solving,
▲ EXCLUSIVE WEB RESOURCES, PLUS BONUS MATERIALS
▲ Analyzing data for root causes and
IN A FREE DOWNLOAD. Abundant incident investigation
▲ Generating practical recommendations. resources on the exclusive Web site and accompanying
free download. See instructions on back page to download.
▲ SOURCE™ INVESTIGATOR’S TOOLKIT. Integrates forms,
checklists, and guidance referenced in the handbook.
▲ GREATER CONSISTENCY WITH OTHER HUMAN
PERFORMANCE TOOLS. New defnitions of causal
factors improve integration with the concepts of
Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, human performance technology; antecedent, behavior,
Walter E. Hanson, James J. Rooney, and David A. Walker consequence (ABC) analysis; and behavior-based risk
management programs many organizations already use.
About the Authors ABS CONSULTING, an ABS Group Company, has been providing root cause analysis (RCA) services, training,
and software to clients for more than 15 years. ABS Consulting assists organizations in setting up RCA programs, conducting onsite
incident investigations, and delivering RCA training. Through its experience with implementing, teaching, and managing RCA programs,
ABS Consulting has developed an RCA/incident investigation process that really works. More than 5,000 individuals and companies are
using the methods described in this handbook.
Plus Root Cause Map™
(17” x 22”, color)
Rothstein Associates Inc.
Brookfeld, Connecticut USA
www.rothstein.com Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson,
Plus Root Cause Map™ Walter E. Hanson, James J. Rooney, and David A. Walker
(17” x 22”, color)
Root Cause Analysis Handbook A Guide to Effcient and Effective Incident Investigation
Third Edition ABS Consulting Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker
Root Cause
Analysis Handbook
A Guide to Effcient and Effective
Incident Investigation
Third Edition
By
Lee N. Vanden Heuvel, Donald K. Lorenzo,
Laura O. Jackson, Walter E. Hanson,
James J. Rooney and David A. Walker
Rothstein AssociAtes inc., PublisheR
Brookfeld, Connecticut USA
www.rothstein.com
ISBN #1-931332-51-7 (978-1-931332-51-4)
Copyright © 2008
ABSG Consulting Inc.
16855 Northchase Drive
Houston, TX 77060 USA
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the
prior permission of the Publisher.
For permission to reproduce any portion of this handbook, contact the Publisher.
No responsibility is assumed by the Publisher or Author for any injury and/or damage to persons or property
as a matter of product liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions or ideas contained in the material herein.
ISBN #1-931332-51-7 (978-1-931332-51-4)
Library of Congress Control Number: 2008928960
Publisher:
Philip Jan Rothstein, FBCI
Rothstein Associates Inc.
The Rothstein Catalog On Service Level Management
4 Arapaho Road
Brookfeld, Connecticut 06804-3104 U.S.A.
203.740.7444
203.740.7401 fax
www.rothstein.com
www.ServiceLevelBooks.com
Thank You for Choosing ABS Consulting’s Root Cause
Analysis Handbook as Your Root Cause Analysis and Incident
Investigation Resource
ABS Consulting srep onnle evah ow dekr on la l tsepy o f or ot uac s e na la sy se na d inic ned t insev tigta ions . sehT e nar g e
orf m ined tiiyf ng uh nam ore sr o r oc opm nne t iaf luser ttah oc ntir ub t e to silpm e ssy t me iaf luser , to id soc irev ng t eh
oir gins o f tac sa tor ihp c inic ned ts yb ip ice ng togte reh a oc lpm xe iahc n o f neve ts torh ug h ir goor us lpa itac ion o f t eh
or ot uac s e na la sy is tnhce iuq se sed irc deb in tih s nah obd o ,k to na la izy ng orhc ni c orp lb sme ta nam y icaf litise . uO r
tnhce iuq se evah neb lpa i de to srep onnle inuj ir se na d taf la itise , ne iv or nnem tla sip lls , sudehc ling issuse , ler iiba lit y
orp lb sme , uq la it y oc nnrec s , na d if nna ic la issuse .
ABS Consulting Investigation Assistance
fI oy u n de leh p insev tigta ing na ica ned t o r orp lb sme ler ta de to ler iiba lit , y uq la it , y orp ud tc ion , suce ir t , y o r if nna sec ,
ABS Consulting nac eb o f sa sistna .ec uO r insev tigta osr nac l dae a t mae o f oy u r srep onnle , ivda s e oy u r t ,mae o r
orp iv ed na inneped ned t na la sy is , neped id ng on oy u r sicep if c nsde .
ABS Consulting Training Services
Bsa de on ou r irepxe ne ,ec ew evah tiar n de toh usna sd o f inid iv ud la s using t eh orp nev tnhce iuq se outlin de in tih s
nah obd o .k An d uaceb s e tseh e tiar ning oc usr se sahpme i ez a ow skr oh p orpa hca to lnrae ing , stuned ts gia n lav ulba e
irepxe ne ec yb tcarp iic ng tahw t yeh lnrae on laer isti c inud st yr lpmaxe se . e W nac neve t hcae a oc usr e ta oy u r icaf lit y
using ow skr oh sp ttah evah neb uc stoim dez to tem t eh nsde o f oy u r oc napm y o r ogr na itaz ion . ehT oc usr se nac
nar g e orf m on e to if ev syad in ud tar ion . ehT of lloiw ng era suiram se o f uj st a oc ulp e o f t eh +57 up lb i c oc usr se
ttah ew t.hcae
tnedicnI toR/noitagitsevnI esuaC sisylanA esruoC( )601 — ehT of uc s o f tih s oc usr e is on oh w to gta reh tad ,a
na la ezy tad a of r uac sla tcaf osr , if ll gspa in tad ,a ted imre n e or ot uac sse , na d irw t e tcef fe i ev ocer nem tad ions using
ABS Consultings’ orp nev SCRUO ™E S( ike ng uO t t eh nU lred iy ng oR ot Cua sse o f nevE ts ) tnhce iuq .e oY u iw ll
lnrae na d lpa y slareve ssy ttame i c tem oh sd , su hc sa uac sla tcaf o r trahc ing , tilem inse , na d uac s e na d tcef fe t er
na la sy is , to unoc rev t eh or ot uac sse o f ssy t me ofrep namr ec orp lb sme . oY u iw ll la so trap iic tap e in slareve ow skr oh sp ,
inlc uid ng on e on t eh us e o f ABS Consultings’ oR ot Cua s e ™paM na d na ot reh in ihw hc oy u iw ll ofrep mr a oc lpm te e
or ot uac s e na la sy is o f a laer isti c orp lb .me oY u iw ll la so lnrae oh w to stur tc u er na tcef fe i ev inic ned t insev tigta ion
o r or ot uac s e na la sy is orp g ,mar ihw hc inlc used ifed ning , lc sa siiyf ng , na d tner id ng tad a on n rae im ssse na d ot reh
inic ned ts ttah n de to eb oper tr .de
gnitneve rP dna gnitagitiM namuH sro rE esruoC( )421 — nI tih s oc usr e oy u iw ll lnrae oh w to imaxe n e uh nam
ore sr to ined ti yf t eh oc nid tions na d ore l- r ilek y situta ions ttah oc ntir ub t de to im stseka . orF m tih s sttra ing op int , oy u
iw ll lnrae to ocer gni ez t eh tur e uac sse o f om st uh nam ore sr , ihw hc era nkaew se sse in t eh nam ga neme t ssy tsme us de
to )1( sed ign uqe inemp t na d orp sec sse , )2( leved o p na d us e orp udec ser na d op liic se , na d )3( sle tce , tiar n , suivrep s ,e
na d oc um nitac e iw t h ow srekr .
ABS Consulting Web-based Services
nI ida tion to t eh guinad ec orp iv ded in tih s nah obd o k na d in ou r oc usr se , ABS Consulting orp iv sed or ot uac s e na la sy is
ser ousecr on ou r be W sit .e t-pU otad- e lc ira if tac ions na d guinad ec sab de on kcabdef orf m ussre o f tih s nah obd o ,k
sa lew l sa slpma e orp gsmar na d oper tr s , era la l iava llba e ta :
sec ruoseRkobdnaHACR/moc.gnitlusnocsba. w
ABS Consulting ROOT CAUSE ANALYSIS HANDBOOK iii
Contact Us for Information and Assistance
fI oy u ow ul d li ek a oc yp o f ou r tiar ning tac la og o r om er inof tamr ion oba ut oh w ew nac sa sist oy u , oc nttca ABS
Consulting.
• By phone at 1-800-769-1199
• By fax at 1-281-673-2931
• By e-mail at
What’s New in the 2008 Edition of the
Root Cause Analysis Handbook
The 2008 edition of the Root Cause Analysis Handbook inc o r p o r a t e s ma n y up d a t e s an d ne w fe a t u r e s . AB S
s ’gnitlusnoC ™ECRUOS tnedicni noitagitsevni ygolodohtem seunitnoc ot evlove desab no eht ecneirepxe fo SBA
gnitlusnoC lenosrep gnisu eht ,euqinhcet noitavresbo fo sremotsuc gnisu eht slot ew ,edivorp dna kcabdef morf
ruo .sremotsuc ehT segnahc detaroprocni otni siht noitide ekam eht esu fo eht ™ECRUOS ygolodohtem neve erom
tneicif fe dna .evitcef fe
• More detail. ehT tsom elbisiv egnahc si taht eht kobdnah sah hcum erom liated no woh ot mrofrep na
.sisylana tI sedulcni deliated ,spets ,stsilkcehc dna smrof desu ot mrofrep na .sisylana sihT dluohs wola
sresu ot erom ylevitcef fe etaroprocni eht ygolodohtem dna ylpa ti ot a yteirav fo .snoitautis
• Changes to the Root Cause Map™. ehT toR esuaC ™paM sah degnahc . yltnacifingis roF :elpmaxe
– Two layers have been added. The two sections on Administrative/Management Systems related
ot ,sdradnatS ,seiciloP dna evitartsinimdA slortnoC )sCA PS( evah neb devom f fo fo eht niam toR
esuaC ™paM dna era won desu gniwolof noitacifitnedi fo a raen tor .esuac sihT dluohs egaruocne
sresu ot gid reped ni gnidnif gniylrednu .sesuac
– It has been refined to more specifically address management of change. B e c a u s e
tnemeganam fo egnahc si netfo a rotubirtnoc ot ,stnedicni eht spets devlovni ni siht secorp evah
neb ylacificeps deserda no eht toR esuaC .™paM
– There is additional focus on quality issues. Th e l a t e s t v e r s i o n o f t h e R o o t C a u s e M a p ™
in c o r p o r a t e s cha n g e s aim e d at ad r e s s i n g is u e s fre q u e n t l y enc o u n t e r e d dur i n g the ana l y s i s o f
tcudorp gnirutcafunam dna remotsuc snoitaler .seusi nI ,noitida eht desiver kobdnah secalp a
retaerg sisahpme no gnitceted dna gnitceroc namuh dna tnempiuqe ecnamrofrep .seusi sA a ,tluser
ytilauq seitivitca taht sucof no siht tcepsa fo snoitarepo era won ylacificeps deserda no eht toR
esuaC .™paM
– It incorporates facility-specific procedures and policies. cificeps-ytilicaF serudecorp dna
seicilop nac eb detaroprocni otni eht esu fo eht toR esuaC ™paM yb gnida taht noitamrofni ot eht
gnidoc fo hcae tor esuac ta eht tor esuac .level
• New definitions. nI eht roir p ,no i t i d e ew den i f e d lasu a c srot c a f sa namu h sror r e dna tne m p i u q e .ser u l i a f sA
ew deunitnoc ot krow htiw lanoitan dna lanoitanretni ,snoitazinag ro ew deretnuocne seitlucif fid ni gniylpa
eht sno i t i n i f e d fo ror r e dna .er u l i a f nA rorr e ta eno tna l p ro yti l i c a f saw ylt c e f r e p elb a t p e c c a ta reh t o n a des a b
no gni t a r e p o sci t s i r e t c a r a h c dna .st n e m e r i u q e r e W eva h det p o d a eht esu fo eni l - t n o r f len n o s r e p ecn a m r o f r e p
s p a g d n a t n e m p i u eq c e n a m r o f r e p s p a g o t e c a l p e r n a m u h s r o r r e d n a t n e m p i u q e . s e r u l i a f es e h T w e n s n o i t i n i f e d
ecrof eht resu ot ylacificeps enifed htob eht lautca dna derised roivaheb fo eht elpoep dna tnempiuqe rof
yna lasuac . rotcaf esehT snoitinifed etargetni reteb htiw eht stpecnoc fo namuh ecnamrofrep ;ygolonhcet
,tnedecetna , roivaheb ecneuqesnoc )CBA( ;sisylana dna desab- roivaheb ksir tnemeganam smargorp taht
ynam snoitazinag ro era ydaerla .gnisu esehT segnahc dluohs egaruocne sresu ot erom ylesicerp enifed eht
ecnamrofrep spag tneserp ni rieht .noitazinag ro
• Online resources. SBA gni t l u s n o C sev e i l e b ni gni d i v o r p eht sre s u fo sti ™EC R U O S ygo l o d o h t e m hti w eht
tseb slot ot yolped eht hcaorpa ni rieht .seitilicaf o T taht ,dne SBA gnitlusnoC si gnidivorp na ecnadnuba
fo tnedicni noitagitsevni secruoser no ruo be W .etis ehT toR esuaC ™paM ecnadiug taht saw ylremrof
dedulcni ni eht oR ot Cua s e Anla sy is naH obd ok si won elbaliava no ruo be W etis htiw na noitacilpa taht
swola sresu ot yldipar seca ecnadiug no gnisu eht toR esuaC ™paM sa lew sa gniseca suoremun
elp m a x e .se s y l a n a ehT ecn a d i u g lli t s sni a t n o c na noi t a n a l p x e fo eht ,ed o n ,se l p m a x e dna .sno i t a d n e m m o c e r
decnahnE gnicnerefer-sorc ot rehto sedon sah osla neb dedivorp ot wola sresu ot erom yltnetsisnoc edoc
tor .sesuac ehT enilno ecnadiug liw eb detadpu desab no kcabdef morf sresu fo eht toR esuaC .™paM
dneS su ruoy selpmaxe dna ew liw etaroprocni meht otni eht enilno .ecnadiug
ABS Consulting ROOT CAUSE ANALYSIS HANDBOOK v
• seR ou ec r C.D nI noitida ot eht secruoser elbaliava no eht ,be W SBA gnitlusnoC si gnidivorp hcum fo
the same information on a resource CD that accompanies this handbook. This should allow users without
ydaer seca ot eht be W ot esu hcum fo eht ecnadiug deniatnoc no eht be W .etis
• SCRUO ™E nI sev tigta osr’ oT olik t . ehT ™ECRUOS s rotagitsevnI ’ tiklo T sah syawla neb elbaliava rof
sresu ot daolnwod morf eht SBA gnitlusnoC be W .etis sihT noitida ot eht kobdnah setargetni eht ,smrof
,stsilkcehc dna ecnadiug morf eht tiklot otni eht kobdnah .txet
• sU e o f tilem inse . sihT noisrev fo eht kobdnah sedivorp na lanoitida lot rof lasuac rotcaf .noitacifitnedi
nI eh t ,t s a p ™E C R U O S sa h de s u es u a c dn a tc e f f e se e r t tl u a f ( )s e e r t dn a la s u a c ro t c a f st r a h c ro f no i t a c i f i t n e d i
of causal factors. Now, in addition to these two tools, graphical timelines have been included. Timelines
erahs ynam fo eht emas setubirta sa lasuac rotcaf ;strahc , revewoh yeht od ton etaroprocni eht cigol stset
taht lasuac rotcaf strahc .esu sA a ,tluser gnisu senilemit liw ton syawla tluser ni noitacifitnedi fo la fo eht
causal factors for an incident. However, they can be used to quickly identify many of the causal factors.
fI eht noitazinag ro sesohc ton ot tsevni ylivaeh ni na sisylana fo na ,tnedicni senilemit yam eb eht lot fo
choice. However, the user must keep in mind the limitation of the approach.
• sa T k tir na gl e om led . ehT ksa t elg n a i r t led o m si des u yle v i s n e t x e ot roh c n a eht stp e c n o c fo eht ™EC R U O S
methodology. Depth of analysis, causal factors, root causes, and the scope of recommendations are all
debircsed ni pihsnoitaler ot siht .ledom sihT sedivorp eht resu htiw na ysae ledom ot dnatsrednu dna esu
tuohguorht eht .sisylana
e W h o p e t h a t t h e s e c h a n g e s i m p r o v e t h e us a b i l i t y a n d ef fe c t i v e n e s s o f th e me t h o d o l o g y a t ea c h f a c i l i t y w h e r e i t
i s ap p l i e d . e W w e l c o m e yo u r fe e d b a c k an d co n t i n u e d as s i s t a n c e in im p r o v i n g ou r ap p r o a c h an d ou r se r v i c e t o
o u r cu s t o m e r s . Us e ou r eb W s i t e to as k qu e s t i o n s , pr o v i d e fe e d b a c k , an d su b m i t ex a m p l e s fo r in c l u s i o n on ou r
e b W s i t e .
Lee N. Vanden Heuvel
reganaM – tnedicnI noitagitsevnI dna toR esuaC sisylanA secivreS
SBA gnitlusnoC
Table of Contents
iL st o f iF guser . vx
iL st o f lba T se . ivx ii
iL st o f Aorc nsmy . ix x
drowe roF . 1
Bgkca or und . 1
ehT SCRUO ™E teM oh od logy . 1
Scope of the Handbook . 2
Contents of the Handbook . 3
noitceS :1 scisaB fo tnedicnI noitagitsevnI . 5
1.1 The Need for Incident Investigation . 5
1.1.1 taR ionla of r ika T ng a Stur tc u der Aorp hca to nI ic ned t nI sev tigta ion . 5
1.1.2 Depths of Analysis . 6
3.1.1 Stur tc u der Anla sy is orP sec s . 6
2.1 Sle tce ing nI ic ned ts to nI sev tigta e . 8
3.1 ehT nI sev tigta ion ohT ugth orP sec s . 8
1.3.1 Differences Between Traditional Problem Solving and Structured RCA . 8
2.3.1 ehT ipy T lac nI sev tigta or . 10
3.3.1 A Stur tc u der Aorp hca to t eh Anla sy is . 10
4.1 CR A iW tih n a Businse s Conttxe . 1 1
5.1 ehT lE neme ts o f na nI ic ned t . 21
1.6 Causal Factors and Root Causes . 31
1.7 The Goal of the Incident Investigation Process . 41
1.8 Overview of the SOURCE™ Methodology . 51
1.9 The SOURCE™ Root Cause Analysis Process . 16
1.9.1 Steps That Apply to Acute Incident Analyses . 16
1.9.2 Steps That Apply to Chronic Incident Analysis . 18
1.9.3 Steps That Apply When No Formal Analyses Are Performed. 19
1.9.4 Steps That Apply to All Analyses . 19
1.10 Levels of the Analysis: Root Cause Analysis and Apparent Cause Analysis . 20
1.11 Definitions . 2
21.1 Suyram . 42
noitceS :2 gnitaitinI snoitagitsevnI . 72
1.2 nI itita ing t eh nI sev tigta ion . 72
2.2 Notification . 28
3.2 gremE ne yc seR op ns e Atc iiv tise . 28
4.2 idemI ta e seR op ns e Atc iiv tise . 28
5.2 Bge inning t eh nI sev tigta ion . 29
2.6 Initial Incident Reports and Corrective Action Requests . 29
2.6.1 Reasons to Generate an IIR or CAR . 30
2.6.2 Typical Information Contained in an IIR or CAR . 30
2.6.3 Using the IIR or CAR in the Incident Investigation Process . 13
7.2 nI ic ned t Clsa siif tac ion . 13
2.8 Investigation Management Tasks . 23
2.9 Assembling the Team . 3
2.10 Briefing the Team. 43
1 1.2 seR ttra Cir tire a . 43
ABS Consulting ROOT CAUSE ANALYSIS HANDBOOK vii
2.12 Gathering Investigation Resources . 53
31.2 Suyram . 53
noitceS :3 gnirehtaG dna gnivrese rP ataD . 73
1.3 nI tor ud tc ion . 73
3.2 General Data-gathering and Preservation Issues . 73
3.2.1 Importance of Data-gathering . 73
3.2.2 Types of Data . 38
3.2.3 Prioritizing Data-gathering Efforts . 38
3.2.3.1 People Data Fragility Issues . 39
3.2.3.2 Electronic Data Fragility Issues . 40
3.2.3.3 Physical/Position Data Fragility Issues . 40
3.2.3.4 Paper Data Fragility Issues . 14
3.3 Gathering Data . 14
3.4 Gathering Data from People . 14
3.4.1 Factors to Assess the Credibility of People Data . 24
2.4.3 nI itila iW tnse s Stta neme ts . 34
3.4.3 ehT nI tivre we orP sec s . 34
1.3.4.3 Bofe er t eh nI tivre swe . 34
2.3.4.3 Bge inning t eh nI tivre we . 46
3.3.4.3 Conud tc ing t eh nI tivre we . 74
4.3.4.3 Conlc uid ng t eh nI tivre we . 74
5.3.4.3 oF llou-w p nI tivre swe . 48
3.5 Physical Data . 48
3.5.1 Sources of Physical Data . 48
3.5.2 Types and Nature of Physical Data Analysis Questions . 49
3.5.3 Bsa i c Stspe in iaF lu er Anla sy is . 50
3.5.4 Use of Physical Data Analysis Plans . 25
3.5.5 Chain of Custody for Physical Data . 35
3.5.6 Use of Outside Experts . 45
3.6 Paper Data . 45
3.7 Electronic Data . 5
3.8 Position Data . 5
3.8.1 Unique Aspects of Position Data . 5
3.8.2 Collection of Position Data . 5
3.8.3 Documentation of Photos and Videos . 5
3.8.4 Alternative Sources of Position Data . 56
3.9 Overall Data-collection Plan . 56
3.10 Application to Apparent Cause Analyses and Root Cause Analyses . 75
1 1.3 Suyram . 58
noitceS :4 gnizylanA ataD . 16
1.4 nI tor ud tc ion . 61
2.4 ivrevO we o f irP yram nhce T iuq se . 62
3.4 Cua s e na d tcef fE er T Anla sy is . 63
4.4 iT lem inse . 68
5.4 Cua sla tcaF o r Ctrah s . 27
4.6 Using Causal Factor Charts, Timelines, and Cause and Effect Trees Together During
na nI sev tigta ion . 57
7.4 Alp itac ion to Anerap t Cua s e Anla sy se na d oR ot Cua s e Anla sy se . 57
4.8 Summary . 76
viii ABS Consulting ROOT CAUSE ANALYSIS HANDBOOK
Stce ion :5 nedI tiiyf ng oR ot Cua sse . 97
1.5 noitcudortnI . 79
2.5 toR esuaC sisylanA spar T . 80
1.2.5 par T 1 – tnempiuqE seusI . 80
5.2.2 Trap 2 – Human Performance Issues . 81
3.2.5 par T 3 – lanretxE tnevE seusI . 81
3.5 erudecorP rof gniyfitnedI toR sesuaC . 81
4.5 SBA s ’gnitlusnoC toR esuaC ™paM . 82
5.5 snoitavresbO tuobA eht erutcurtS fo eht toR esuaC ™paM . 82
5.6 Using the Root Cause Map™ . 84
5.6.1 The Five Steps . 84
5.6.2 Multiple Coding . 85
5.6.3 Incorporating Organizational Standards, Policies, and Administrative Controls . 85
5.6.4 Using the Root Cause Map™ Guidance During an Investigation . 85
5.6.5 Typical Problems Encountered When Using the Root Cause Map™ . 86
5.6.6 Advantages and Disadvantage of Using the Root Cause Map™ . 88
5.7 Documenting the Root Cause Analysis Process . 88
5.8 Application to Apparent Cause Analyses and Root Cause Analyses . 95
5.9 Summary . 95
Stce ion :6 leveD oip ng oceR nem tad ions . 79
6.1 Introduction . 97
6.2 Timing of Recommendations . 99
6.3 Levels of Recommendations . 100
6.3.1 Level 1 – Address the Causal Factor . 100
6.3.2 Level 2 – Address the Intermediate Causes of the Specific Problem . 100
6.3.3 Level 3 – Fix Similar Problems . 100
6.3.4 Level 4 – Correct the Process That Creates These Problems . 100
6.4 Types of Recommendations . 101
6.4.1 Eliminate the Hazard . 101
6.4.2 Make the System Inherently Safer or More Reliable . 101
6.4.3 Prevent Occurrence of the Incident . 101
6.4.4 Detect and Mitigate the Loss . 101
6.4.5 Implementing Multiple Types of Recommendations. 102
6.5 Suggested Format for Recommendations . 102
6.6 Special Recommendation Issues . 102
6.7 Management Responsibilities . 102
6.8 Examples of Reasons to Reject Recommendations . 103
6.9 Assessing Benefit/Cost Ratios . 104
6.9.1 Estimating the Benefits of Implementing a Recommendation . 104
6.9.2 Estimating the Costs of Implementing a Recommendation . 104
6.9.3 Benefit/Cost Ratios . 105
6.10 Assessing Recommendation Effectiveness . 105
6.11 Application to Apparent Cause Analyses and Root Cause Analyses . 107
6.12 Summary . 107
Stce ion :7 Colpm te ing t eh nI sev tigta ion . 901
1.7 noitcudortnI . 109
2.7 gnitir W noitagitsevnI strop eR . 109
1.2.7 lacipy T smetI ot eB dedulcnI ni na noitagitsevnI trop eR . 109
2.2.7 spi T rof gnitir W stropeR . 1 1 1
ABS Consulting ROOT CAUSE ANALYSIS HANDBOOK ix