Start here with each causal factor

Root Cause Chart™ Equipment Personnel Natural Sabotage/

Other Difficulty
Difficulty 5
Difficulty 5 Phenomena 5 Horseplay 6 6

Design Equipment Administrative/ Human Factors Immediate

Input/Output Reliability Management Procedures Engineering Training Communication Fitness for Duty
Systems Supervision
7 Program 7 7 8 8 8 8 9 9

Design Input NI 11 Preparation NI 52 Sensory/

• Design Input Overall Program Equipment/ Reliability Program 14 Reliability Task 14 Perceptual 60
NI 14 Reliability 14 • No Preparation 53
Cannot Be Met 12 Implementation NI Execution NI Capabilities NI
Records NI • Job Plan NI 53
• Design Input • No Program 15 • Equipment Missing • Reactive/Corrective Personal Stress
• Equipment from Reliability Maintenance NI 19 • Instructions to Workers NI
Obsolete 12
• Procedure for 53 ID/management
Design Records System 17 • Preventive • Walkthrough NI 53 system NI 60
• Design Input Not Determining • Scheduling NI 54
Correct 12 Needs for NI 16
• Selection of Type of Maintenance NI 19 Motor/Physical
Equipment NI 15 • Equipment Task NI 17 • Predictive • Worker Selection/ Capabilities NI 60
• Necessary
Design Input Not Operating/ • Task Frequency/ Maintenance NI 19 Assignment NI 54
• Risk Acceptance Substance Abuse
Available 12 Criteria NI Reliability History Trigger Identification • Proactive Supervision During Issue 61
15 NI
Design Output NI 11 16 or Adjustment NI 17 Maintenance NI 19 Work NI 52
• Allocation of Rest/Sleep NI
• Scope 13 Resources NI 15 • Task Initiation NI 18 • Failure Finding • No Supervision 55 (Fatigue) 61
• Tracking/Closure of Maintenance NI 20
• Design Output • Supervision NI 55 Illness/Medication
Not Clear 13 Task NI 18 • Routine Equipment Problems 61
Rounds NI 20
• Design Output
Not Correct 13

• Inconsistent
Design Output 13
No Communication or Misunderstood Work/Shift
• Design Input Not Not Timely 56 Communication 56
Addressed in Turnover NI 56
Design Output 13 • Method Not Available • Standard • Communication
or NI 57 Terminology Not Within Shifts NI 59
• Communication Between Used 58 • Communication
Work Groups NI 57 • Verification/ Between Shifts NI 59
1 • Communication Between Repeat-back Not
Shift Workers and Used 58
Standards, Standards, Safety/Hazard/Risk Problem Product/Material Procurement Control Document and
Policies, or Policies, or Review NI 22 Identification, Control NI 22 NI 23 Configuration Management NI 57 • Long Message 58
Administrative Administrative Investigation, and Control NI 23 • Communication with • Speech
• Risk Review NI 27 • Handling NI 29 • Product Acceptance Interference 58
Controls (SPACs) Controls (SPACs) Control NI 22 • Change Not Contractors NI 57
NI 22 Not Used 22 • Not Performed 27 • Storage NI 29 Requirements Do Not
• Problem Reporting • Communication with
• Recommendations • Packaging NI 29 Match Design Identified or
• No SPACs 24 • Communication of NI 28 Reviewed 32 Customers NI 57
Not Yet • Shipping NI 29 Requirements 30
• Not Strict Enough 24 SPACs NI 26 • Problem • Control (and
Implemented 27 • Shelf Life • Control of Changes to
• Confusing or • Recently Changed 26 Investigation/ 29 verfication) of No Training 47 Training Records Training NI 47
• Risk Acceptance Exceeded Procurement System NI 47
Incomplete 24 • Enforcement NI 26 Analysis NI 28 Design/Field • Decision Not to • Job/Task Analysis
Criteria NI 27 • Unauthorized Specifications/
• Technical Error 24 • Difficult to Changes NI Train 48 • Training Records NI 50
• Review Procedure • Corrective Action NI Product/Material Purchase Orders NI 31
• Responsibility for Implement 26 28 (No PSSR) 32 • Training Incorrect 49 • Program Design
or Leader Training • Corrective Action Substitution 30 • Fabricated Item Does
Item/Activity Not • Documentation Requirements Not • Training Records NI 50
NI 27 Not Yet • Product/Material Not Meet Specs 31
Adequately Not Up-to-Date Identified 48 Not Up-to-Date 49 • Training
Implemented 28 Inspections NI 30 • Incorrect Item 32
Defined 25 • Control of Objectives NI 50
Received 31
• Contradictory Documents NI • Lesson Content
• Product/Service 32
Requirements 25 NI 50
Accept. Req. NI 31
• Scheduling/ Shape Description Workplace Layout Work Environment Workload NI 39 Intolerant System 39 • On-the-Job
Tracking System NI 39 NI 39 • Knowledge-based • Errors Not Training NI 50
NI 25 Procedure Not Misleading/Confusing 33 Wrong/Incomplete 33
• Qualification
Used 33 • Controls NI 40 • Housekeeping NI 42 Decision Required 44 Detectable 46
• Employee Causal Factor Type • Typographical Error 38
• Format Confusing or NI 35 • Displays NI 40 • Climate NI 42 • Excessive Control • Errors Not Testing NI 50
Screening/ • Not Available or • More Than One Action per Step • Sequence Wrong 38 • Continuing
35 • Control/Display • Lighting NI 42 Action Required 44 Recoverable 46
Selection NI 25 Inconvenient to • No Checkoff Space Provided but • Facts Wrong/ Training NI 51
Root Cause Category Integration NI 40 • Excessive Noise 42 • Unrealistic
Obtain 34 Should Be Requirements Not • Training Support
35 • Conflicting • PPE NI 43 Monitoring
• Procedure Difficult • Inadequate Checklist 35 Correct 38 Equipment NI 51
Layouts 41 • Other Required 45
Bold Near Root Cause to Use 34 • Wrong Revision Used 38
• Graphics NI 35 • Reach or Visual Environmental • Excessive Mental • Instructor
• Use Not Required • Inconsistency
• Ambiguous or Confusing Envelope NI 41 Stressors NI 43 Math, Memory, Qualifications NI 51
Root Cause but Should Be 34 Between 38
Instructions/Requirements 36 • Labeling NI 41 Logic Required 45 • Training on New
• No Procedure for • Data/Computations Wrong/ Requirements Work Methods NI 51
Note: Node numbers correspond to the Task 34 Incomplete 36 • Incomplete/Situation • Abnormal Events/
matching page numbers in PII's Root Cause
• Equipment Identification NI 36 Not Covered 38 Emergency
Coding Guide. There are typically more than
one node per page • Excessive References 36 Training NI 51
• Multiple Area References 36 • Qualifications
• Identification of Revised Steps Standard NI 51
Note: NI = Needs Improvement NI 37

US • Presentation of Limits NI
37
Copyrighted by: Process Improvement Institute, 2003; Rev.6, April 2009. Adapted from
DOE Root Cause Coding Tree and supplemented by User’s Guide for Reactor Incident Root
Cause Coding Tree, revision five, DPST-87-209, E.I. duPont de Nemours, Savannah River
Laboratory, 1986. www.piii.com wbridges@piii.com