ROOT CAUSE ANALYSIS HANDBOOK (ABS Group) plus ROOT CAUSE ANALYSIS (Latino)

ROOT CAUSE ANALYSIS HANDBOOK:
A GUIDE TO EFFECTIVE INCIDENT INVESTIGATION
by Risk & Reliability Division, ABS Group, Inc., JBF Associates

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ROOT CAUSE ANALYSIS:
IMPROVING PERFORMANCE FOR BOTTOM-LINE RESULTS (Second Edition)
Kenneth Latino & Robert J Latino

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ROOT CAUSE ANALYSIS:
IMPROVING PERFORMANCE FOR BOTTOM-LINE RESULTS (Second Edition)
Kenneth Latino & Robert J Latino

* Introduces Enterprise Reliability Management System technology to
identify the most costly events in an organization
* Updates the PROACT software chapter to reflect the newest version
* Includes new client case histories illustrating the application and success
of the PROACT process
* Updates RCA implementation strategies
* Emphasizes and updates data collection strategies
* Expands the understanding of Physical, Human, and Latent Root Causes
and their relationship to the mechanics of failures

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“Undesirable outcomes, chronic failure, incidents, and accidents… The cost of
such events to corporations is high, generally adding up to tens and hundreds of
millions of dollars in "accepted" losses. Why accept these losses? What if you
could understand why these errors occur and eliminate chronic events from
occurring altogether?

“Root Cause Analysis: Improving Performance for Bottom-Line Results, Second
Edition shows how to identify, understand, and prevent chronic problems that
hinder the attainment of organizational goals using Root Cause Analysis (RCA). In
addition, the PROACT software, voted "Product of the Year" by Plant Engineering
Magazine, and the steps outlined in this text teach you how to automate the RCA
process. Used effectively, the information in Root Cause Analysis will improve the
reliability of your plant assets and save your company precious time and money.”

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"Informative, well-illustrated and well-organized text…worthwhile reading for any
plant engineer seeking to understand why errors occur and how to eliminate them,
and have a direct positive impact on his company's bottom line."
- Jeanine Katzel, Plant Engineering Magazine

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"RCA should be used as a tool to help correct ongoing problems that are sucking
dollars from your organization…This book should be a standard part of any RCA
practitioner's 'toolbox'."
- Bret Ridgway, Maintenance Resources

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"…if you read this book…you will be able to "Talk the Talk", and with the help of
the methodology explained, "Walk the Walk" down the path of improved equipment
reliability and increased profits."
- John W. Vanauken, Inland Steel ISPAT

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"...Packed with a wide variety of subjects and detailed information for engineering
problem-solving...comprehensible and comprehensive...illuminating."
- Duy H. Hua, Kansas State University

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CONTENTS

Introduction to Root Cause Analysis
Failure Classification
Problems vs. Opportunities
Chronic vs. Sporadic Events
Creating the Environment to Succeed
The Role of the Champion
The Role of the Driver
The Role of the Analyst
Modified Failure Modes and Effects Analysis
The Manual Approach
Enterprise Reliability Management System (ERMS)
The Automated Approach
Preserving Event Data
The Error-Change Phenomenon
Data Collection Strategies for Chronic Events
Data Collection Strategies for Sporadic Events
Ordering the Analysis Team
The Ideal RCA Facilitator
The Ideal RCA Team Members
Their Roles
Analyzing the Data
Defining the TOP BOX
Developing Hypotheses
Validating Hypotheses
Identifying Physical, Human and Latent Root Causes
Communicating Recommendations & Findings
Developing, Prioritizing and Selling Recommendations
The Final Report
The Final Presentation
Tracking For Bottom-Line Results
Developing Tracking Metrics
Exploiting Successes
Creating the "Critical Mass"
Automating Root Cause Analysis
Introducing PROACT V2.0 Software
The Role of RCA in a CMMS Environment
Root Cause Analysis Case Histories
ISPAT Inland, Inc.
Eastman Chemical Company (Kingsport, TN)
LYONDELL-CITGO Refining
Eastman Chemical Company (Worldwide Customer Focus)
Alabama Power Company
Weyerhaeuser Company

Bibliography
Index

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ABOUT THE AUTHORS

“ROBERT J. LATINO is Vice President of Strategic Development for Reliability
Center, Inc. (RCI). RCI is a Reliability Engineering firm specializing in improving
equipment, process, and human reliability since 1972. Mr. Latino received his
bachelor's degree in business administration and management from Virginia
Commonwealth University. He has a special interest in the theory of human error
as applied to root cause analysis (RCA). Mr. Latino has been a practitioner of RCA
in the field with his clientele as well as an educator for 17 years.
Mr. Latino is an author of RCI's Root Cause Analysis Methods© course and
coauthor of Problem Solving Methods (PSM)© for Field Personnel. Mr. Latino has
been published in numerous trade magazines on the topic of RCA and is also a
frequent speaker on the topic at trade conferences.

“Kenneth C. Latino has a bachelor's of science degree in computerized information
systems. He began his career developing and maintaining maintenance software
applications for the continuous process industries. After working with clients to
help them become more proactive in their maintenance activities, he began
instructing industrial plants on reliability methods and technologies to help improve
the reliability of their facilities.
Over the past few years, a majority of his time has been spent developing reliability
approaches with a heavy emphasis on root cause analysis (RCA). He has trained
thousands of engineers and technical representatives on how to implement a
successful RCA strategy at their respective facilities. He has coauthored two RCA
training seminars for engineers and hourly people respectively.

“Mr. Latino is also the software designer of the RCA program entitled PROACT°.
PROACT° was a Gold Medal Award winner in Plant Engineering's 1998 and 2000
Product of the Year competitions for its first two versions on the market. He is
currently working with client companies of Meridium, Inc. to integrate all of their
reliability data and initiatives into an automated enterprise reliability management
system.”

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ROOT CAUSE ANALYSIS HANDBOOK:
A GUIDE TO EFFECTIVE INCIDENT INVESTIGATION
2005 Edition
By ABS Consulting - Lee N. Vanden Heuvel, Donald K. Lorenzo, Randal L.
Montgomery, Walter E. Hanson, and James R. Rooney

Includes a 17 inch by 22 inch pull-out Root Cause Map

This is a new printing of the 2000 edition of this book

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Published by Rothstein Associates Inc.
ISBN #1-931332-30-4
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ROOT CAUSE ANALYSIS HANDBOOK: A GUIDE TO EFFECTIVE INCIDENT
INVESTIGATION presents a proven system designed for investigating,
categorizing, and ultimately eliminating, root causes of incidents with safety,
health, environmental, quality, reliability, and production-process impacts.

Defined as a tool to help investigators describe what happened, to determine how it
happened, and to understand why it happened, the Root Cause Analysis System
enables businesses to generate specific, concrete recommendations for preventing
incident recurrences.

Using the factual data of the incident, the system also allows quality, safety, and
risk and reliability managers an opportunity to implement more reliable and more
cost-effective policies that result in major, long-term opportunities for improvement.

Such process improvements increase a business' ability to recover from and
prevent disasters with both financial and health-and-safety implications.

Special features include a 17 inch by 22 inch pull-out Root Cause Map, a powerful
tool for identifying and coding root causes.

The book helps readers to understand why root causes are important, to identify
and define inherent problems, to collect data for problem solving, to analyze data
for root causes, and to generate practical recommendations.

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ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOK

The focus of this handbook is on the application of the Root Cause Map to the root
cause analysis process. The Root Cause Map is used in one of the later steps of
the root cause analysis process to identify the underlying management systems
that caused the event to occur or made the consequences of the event more
severe. The first five chapters of this handbook are an overview of the root cause
analysis process. These provide the context for use of the Root Cause Map.
Chapter 6 provides references.

Chapter 1, "Introduction to Root Cause Analysis," presents a basic overview of the
SOURCE (Seeking Out the Underlying Root Causes of Events) root cause
analysis process. Chapter 2, "Collecting and Preserving Data for Analysis,"
outlines the types of data and data sources that are available. Chapters 3, 4, and 5
describe the three major steps in the root cause analysis process.

Chapter 3, "Data Analysis Using Causal Factor Charting," provides a step-by-step
description of causal factor charting techniques. Chapter 4, "Root Cause
Identification," explains the organization and use of the Root Cause Map. Chapter
5, "Recommendation Generation and Implementation," provides guidance on
developing and implementing corrective actions. The references section, Chapter 6,
provides additional information for those interested in learning more about specific
items contained in the handbook.

Appendix A, "Root Cause Map Node Descriptions," describes each segment of the
Root Cause Map and presents detailed descriptions of the individual nodes on the
map. Appendix B is the Root Cause Map itself.”

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EXCERPT FROM THE INTRODUCTION TO THE 2005 EDITION

This edition of the Root Cause Analysis Handbook is a reprinting of the version
originally published in 1999. In the six years since the original book was published,
organizations have come under increasing pressure to produce more with less and
to produce higher quality outcomes (products and services). Organizations are
constantly striving to meet these demands through the implementation of a variety
of different strategies, such as:

- Lean strategies (sharing of work between operations and maintenance)
- Reliability improvements (reliability-centered maintenance, predictive
maintenance, and improved use of maintenance resources)
- Quality initiatives (ISO certification, setting up critical variables to monitor
and adjust, quality circles and teams, and six-sigma)
- Improved data collection and analysis (both internal and external to the
business unit)
- Workplace culture improvements (behavior-based safety and risk
management)
- Staff reductions, both in central corporate support and resources at
production facilities.

However, certain issues remain constant: societal and management demands for
continuous improvement in safety, reliability, environmental stewardship, and
quality. Incidents that impact these areas are not acceptable and, worldwide,
organizations are being required to improve their operations and culture to address
these issues. While some industries have made significant progress, governmental
entities and the public often demand more.

It is easy to say that it cannot be done. We are already so much better than we
were in the past. But some organizations (including some of your competitors)
continue to improve. To remain competitive, your organization must maximize the
efficiency with which it spends resources. Your organization must recognize the
changing climate and accept the challenge of achieving better results with fewer
resources.

If you find yourself in this position, root cause analysis (RCA) and ABS
Consulting's SOURCE (Seeking Out the Underlying Root Causes of Events)
technique for performing RCAs (which is described in this handbook) can benefit
your organization. The handbook describes a simple, step-by-step method for
performing RCAs.

RCA is a structured method for determining whether all these new programs and
initiatives are really helping your organization and how these programs (and their
interactions and interrelationships) can be improved by learning from experience.
RCA methods can be applied to a wide spectrum of problems, including those with
safety, reliability, environmental, quality, productivity, and security consequences.
And, not only can these methods be applied to acute, one-time incidents, they can
also be used to understand the underlying or chronic problems within the
organization.

We try hard to make implementation of any new program go well. But our first
efforts often leave room for improvement. RCA provides a structured approach for
identifying and targeting those improvements, and it allows us to see how our
organization is functioning.

Why not continue to do it the old way? Why use a structured approach?
Accidents, errors, problems, near misses, and deficiencies all provide an
opportunity to learn about our organization's performance at many levels.

Most organizations don't get beyond the human error or equipment failure level
without a structured program. They are able to correct one problem, at least
temporarily. But they fail to dig deeper to generate permanent solutions. RCA
processes help organizations identify and justify leveraged changes to improve
their organization's performance. By investing resources in an RCA, the
organization solves problems once, not repeatedly.

Lee N. Vanden Heuvel
Manager, Incident Investigation and Root Cause
Analysis Services
Operational Risk and Performance Consulting
Division
ABS Consulting, June 2005

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TABLE OF CONTENTS

Organization of the Root Cause Analysis Handbook
Acronyms and Nomenclature
Limitations of Liability
Acknowledgments
Chapter 1 Introduction to Root Cause Analysis
Chapter 2 Collecting and Preserving Data for Analysis
Chapter 3 Data Analysis Using Causal Factor Charting
Chapter 4 Root Cause Identification
Chapter 5 Recommendation Generation and Implementation
Chapter 6 References
Appendix A Root Cause Map Indexes Node Descriptions
Appendix B Root Cause Map

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ABOUT THE AUTHORS

ABOUT THE AUTHORS

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 20 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 also led and participated in investigations in many types of
industries, including chemical, refining, healthcare, manufacturing, machining,
pharmaceuticals, waste disposal, nuclear power, and food processing. He is a
coauthor of Guidelines for the Investigation of Chemical Process Incidents, Second
Edition, published by the American Institute of Chemical Engineers' Center for
Chemical Process Safety.

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, safety analyses, and economic/decision analyses.
He is the prime developer of ABS Consulting's incident investigation course and
has taught RCA techniques to thousands of students.

MR. DONALD K. LORENZO is the Director of Training Services for ABS
Consulting. He has more than 25 years of experience in hazard analysis and risk
assessment. He was previously a development engineer for Union 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 (published by the Center for Chemical Process Safety).

Mr. Lorenzo specializes in safety and environmental applications of ABS
Consulting's SOURCE technique. He is a registered Professional Engineer in the
state of Tennessee and a Certified Technical Trainer.

MR. RANDAL L. MONTGOMERY is the Manager of Business and System
Performance Solutions for ABS Consulting. His experience includes conducting
reliability-centered maintenance analyses and developing planned maintenance
programs for industry and government clients. In addition, he has developed
process safety management (PSM) and mechanical integrity (MI) programs and
has written maintenance procedures for the petroleum, chemical, and pulp and
paper industries. He is a coauthor of Guidelines to Effective Mechanical Integrity
Programs, published by the Center for Chemical Process Safety. Mr. Montgomery
has performed numerous root cause analyses focusing on reliability issues and
machinery applications.

Mr. Montgomery previously worked at Henkel Corporation, where he served as MI
coordinator, implemented management systems to meet PSM regulations, and
managed production and maintenance groups.

MR. WALTER E. HANSON is a Project Manager and Risk/Reliability Engineer for
ABS Consulting. He has more than 15 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 U.S. Coast Guard (Coast Guard) and
other transportation and maritime clients. Before joining ABS Consulting, Mr.
Hanson had 13 years of safety management responsibilities as a commissioned
officer of the Coast Guard. He completed nearly 25 years of commissioned service
and attained the rank of captain.

Mr. Hanson was a primary developer of ABS's Marine Root Cause Analysis
Technique (MaRCAT). He is the lead instructor for ABS Consulting's Maritime Root
Cause Analysis course.

MR. JAMES J. 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 technique.

ABS GROUP INC., is an engineering firm that specializes in reliability, system
safety, environmental engineering, process safety management, risk management
planning and communication, and quantitative risk assessment. Its training
divisions provide more than 200 courses each year in more than 35 topics. The
company's principle engineers are internationally recognized experts who have
extensive experience in all areas of safety, reliability, and risk assessment.

2005, 215 pages plus 17 inch by 22 inch pull-out Root Cause Map.

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