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R
oot cause analysis (RCA) is a process generically identify occurrences that produce or
designed for use in investigating and cate- have the potential to produce these types of conse-
gorizing the root causes of events with safe- quences.
ty, health, environmental, quality, reliability and Simply stated, RCA is a tool designed to help
production impacts. The term “event” is used to identify not only what and how an event occurred,
but also why it happened. Only when investiga-
tors are able to determine why an event or failure
occurred will they be able to specify workable
corrective measures that prevent future events of
In 50 Words the type observed.
Or Less
Understanding why an event occurred is the
key to developing effective recommendations.
• Root cause analysis helps identify what, how Imagine an occurrence during which an opera-
and why something happened, thus preventing tor is instructed to close valve A; instead, the
operator closes valve B. The typical investiga-
recurrence.
tion would probably conclude operator error
was the cause.
• Root causes are underlying, are reasonably This is an accurate description of what hap-
identifiable, can be controlled by management pened and how it happened. However, if the ana-
lysts stop here, they have not probed deeply
and allow for generation of recommendations.
enough to understand the reasons for the mistake.
Therefore, they do not know what to do to pre-
• The process involves data collection, cause vent it from occurring again.
charting, root cause identification and recom- In the case of the operator who turned the
wrong valve, we are likely to see recommenda-
mendation generation and implementation.
tions such as retrain the operator on the proce-
dure, remind all operators to be alert when
manipulating valves or emphasize to all personnel 2. Root causes are those that can reasonably be
that careful attention to the job should be main- identified.
tained at all times. Such recommendations do little 3. Root causes are those management has control
to prevent future occurrences. to fix.
Generally, mistakes do not just happen but can 4. Root causes are those for which effective rec-
be traced to some well-defined causes. In the case ommendations for preventing recurrences can
of the valve error, we might ask, “Was the proce- be generated.
dure confusing? Were the valves clearly labeled? Root causes are underlying causes. The investi-
Was the operator familiar with this particular gator’s goal should be to identify specific underly-
task?” ing causes. The more specific the investigator can
The answers to these and other questions will be about why an event occurred, the easier it will
help determine why the error took place and be to arrive at recommendations that will prevent
what the organization can do to prevent recur- recurrence.
Root causes are those that can reasonably be
identified. Occurrence investigations must be cost
beneficial. It is not practical to keep valuable man-
Identifying “severe weather” power occupied indefinitely searching for the root
causes of occurrences. Structured RCA helps ana-
as the root cause of parts not lysts get the most out of the time they have invest-
ed in the investigation.
being delivered on time to Root causes are those over which management
has control. Analysts should avoid using general
customers is not appropriate. cause classifications such as operator error, equip-
ment failure or external factor. Such causes are not
specific enough to allow management to make
effective changes. Management needs to know
exactly why a failure occurred before action can be
rence. In the case of the valve error, example taken to prevent recurrence.
recommendations might include revising the We must also identify a root cause that manage-
procedure or performing procedure validation to ment can influence. Identifying “severe weather”
ensure references to valves match the valve labels as the root cause of parts not being delivered on
found in the field. time to customers is not appropriate. Severe weath-
Identifying root causes is the key to preventing er is not controlled by management.
similar recurrences. An added benefit of an effective Root causes are those for which effective recom-
RCA is that, over time, the root causes identified mendations can be generated. Recommendations
across the population of occurrences can be used to should directly address the root causes identified
target major opportunities for improvement. during the investigation. If the analysts arrive at
If, for example, a significant number of analyses vague recommendations such as, “Improve adher-
point to procurement inadequacies, then resources ence to written policies and procedures,” then
can be focused on improvement of this management they probably have not found a basic and specific
system. Trending of root causes allows development enough cause and need to expend more effort in the
of systematic improvements and assessment of the analysis process.
impact of corrective programs.
Four Major Steps
Definition The RCA is a four-step process involving the fol-
Although there is substantial debate on the defi- lowing:
nition of root cause, we use the following: 1. Data collection.
1. Root causes are specific underlying causes. 2. Causal factor charting.
Pan
Arcing heats
bottom of Had it
aluminum not been
pan originally charged?
Fire
extinguisher
Pan
Aluminum Had it
melts, leaked?
Jane forming Fire extinguisher,
hole in pan floor
Jane comes
to the door What Had it
exactly been
Conclusion did she see? previously used?
Grease ignites Mary Inspection tag
when it
Jane, Mary contacts Assumed Mary Mary
burner
Fire Mary sees Fire extinguisher
Jane rings
How generates the fire is not
the doorbell
much oil is smoke on the stove charged
used? How Mary
much chicken?
Fire starts
Chicken, on the
pan, oil Mary Mary Jane, Mary Mary Mary Mary
stove
Mary Mary leaves Smoke Mary runs Mary tries Fire extinguisher
begins the frying detector into the to use does not
frying chicken Mary
alarms kitchen the fire operate when
chicken unattended extinguisher Mary tries to use it
5:00 pm CF Mary meets About 5:10 pm CF
with Jane
Pan Mary
10 minutes
Mary Mary pulls
uses an the plug
aluminum on the fire
pan extinguisher
Does Mary
Is "plug" know how
the same to use a fire
as pin? extinguisher?
Mary Mary
CF = Causal factor
Part two
Equipment difficulty 2
No training 164 Training records Training LTA 170 Preparation 181 Problem
• Decision not system LTA 167 • Job/task analysis • No preparation 182 detection LTA 209
to train 165 • Training records LTA 171 • Job plan LTA 183 *Sensory/perceptual
• Training incorrect 168 • Program design/ • Instructions to workers capabilities LTA 210
requirements not • Training records objectives LTA 172 LTA 184
identified 166 not up to date 169 • Lesson content • Walkthrough LTA 185 *Reasoning
LTA 174 • Scheduling LTA 186 capabilities LTA 211
• On-the-job • Worker selection/ *Motor/physical
training LTA 175 assignment LTA 187 capabilities LTA 212
• Qualification Supervision during
testing LTA 176 *Attitude/attention
work 188 LTA 213
• Continuing • Supervision LTA 189
training LTA 177 • Improper performance *Rest/sleep LTA
• Training not corrected 190 (fatigue) 214
resources LTA 178 • Teamwork LTA 191
• Abnormal events/ *Personal/medication
emergency problems 215
training LTA 179
No communication or Misunderstood Wrong Job turnover LTA 205 *PSSR = Project scope summary report
not timely 194 communication 200 instructions 204 • Communication
• Method unavailable or • Standard within shifts LTA 206
LTA 195 terminology not • Communication
• Communication between used 201 between shifts
work groups LTA 196 • Verification/ LTA 207
• Communication between repeat back not
shifts and management used 202
LTA 197 • Long message 203
• Communication with Shape Description
contractors LTA 198
• Communication with
customers LTA 199 Primary difficulty source
Problem category
Workplace layout 140 Work environment 148 Workload 155 Intolerant
• Controls/displays • Housekeeping LTA 149 • Excessive control system 160 Root cause category
LTA 141 • Tools LTA 150 action • Errors not
• Control/display • Protective clothing/ requirements 156 detectable 161
integration/ equipment LTA 151 • Unrealistic • Errors not Near root cause
arrangement LTA 143 • Ambient monitoring correctable 162
• Location of conditions LTA 152 requirements 157 Root cause
controls/displays • Other environmental • Knowledge based
LTA 144 stresses excessive 154 decision
• Conflicting layouts 145 required 158 © 1995, 1997, 1999, 2000 and 2001, ABSG Consulting Inc.
• Equipment • Excessive
location LTA 146 calculation or
• Labeling of data manipulation *Note: These nodes are for descriptive
equipment or required 159 purposes only.
locations LTA 147
Event description: Kitchen is destroyed by fire and damaged by smoke and water. Event #: 2003-1
Description: • Personnel difficulty. • Implement a policy that hot oil is never left
Mary leaves the frying chicken unattended. • Administrative/management systems. unattended on the stove.
• Standards, policies or administrative • Determine whether policies should be
controls (SPACs) less than adequate (LTA). developed for other types of hazards in the
• No SPACs. facility to ensure they are not left unattended.
• Modify the risk assessment process or
procedure development process to address
requirements for personnel attendance
during process operations.
BIBLIOGRAPHY