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Root Cause Analysis Handbook (ABS Group)

[Item Image]
Root Cause Analysis Handbook: A Guide to
Effective Incident Investigation, by ABS
Group, Inc. . Includes CD + Root Cause
Map. 2008 3rd Edition, 300 pages.
Qty:
NR388
$129.00
ROOT CAUSE ANALYSIS HANDBOOK:
A GUIDE TO EFFICIENT AND EFFECTIVE INCIDENT INVESTIGATION
NEW Third Edition (July, 2008)
By ABS Consulting - Lee N. Vanden Heuvel, Donald K. Lorenzo, Walter E. Hanson, Laura
O. Jackson , James R. Rooney and David A. Walker

Includes:
- A 17 inch by 22 inch pull-out Root Cause Map;
- CD-ROM, PLUS
- Dedicated Web Resources (registration required)!

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Published by Rothstein Associates Inc.
ISBN #1-931332-51-7 (978-1-931332-51-4)

AVAILABLE: JULY, 2008

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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, the 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, ABS Consulting's SOURCE (Seeking Out the
Underlying Causes of Events) RCA 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
practices that result in major, long-term opportunities for improvement.

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

This is a complete revision to the 2005 edition of this book.

Special features include:
- A resource CD with:
- Example analyses
- -ABS Consulting's SOURCE Investigator's Toolkit - forms and checklists to use in
your
RCA/incident investigation program
- A sample RCA/incident investigation program
- Access to ABS Consulting's on-line RCA Resources
- Detailed guidance to using the Root Cause Map(tm)
- A 17 by 22 inch pull-out, color Root Cause Map - a powerful tool for identifying and
coding root causes
- Over 120 figures and tables

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SCOPE OF THE HANDBOOK

The focus of this handbook is on the application of structured analysis techniques, including
the use of ABS Consulting’s Root Cause Map(tm) to the root cause analysis (RCA) process.
There are two levels of analyses: apparent cause analyses (ACAs) and root cause analyses
(RCAs). RCAs involve a deeper level of analysis than ACAs. The sections in this handbook
generally apply to both levels of analyses. For example, data gathering is performed for both
ACAs and RCAs. However, more effort is usually required to gather data for an RCA than for
an ACA. This is generally true for most analysis activities.

This handbook provides instructions for performing RCA activities, including:
- Initiating the investigation: How to determine whether an incident has occurred, how
to
classify and categorize the incident, and how to decide whether to conduct an in-depth
investigation.
- Data gathering: How to collect data related to people, processes, procedures,
documents
(both hard copy and electronic), position, and physical data associated with an incident.
- Data analysis: How to analyze incidents to determine causal factors (see Subsection
1.11 for a definition of causal factors) using tools such as causal factor charts, timelines, and
cause and effect trees. Guidance is also provided on identifying root causes using ABS
Consulting’s Root Cause Map(tm).
- Developing recommendations: How to document causal factors and root causes
identified
during an analysis, including how to identify what changes (i.e., 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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WHAT’S NEW IN THE 2008 EDITION OF THE ROOT CAUSE ANALYSIS
HANDBOOK

The 2008 edition of the ROOT CAUSE ANALYSIS HANDBOOK incorporates many updates
and new features. ABS Consulting’s SOURCE(tm)incident investigation methodology
continues to evolve based on the experience of ABS Consulting personnel using the
technique, observation of customers using the tools we provide, and feedback from our
customers. The changes incorporated into this edition make the use of the SOURCE(tm)
methodology even more efficient and effective.

- MORE DETAIL. The most visible change is that the handbook has much more detail
on
how to perform an analysis. It includes detailed steps, checklists, and forms used to perform
an analysis. This should allow users to more effectively incorporate the methodology and
apply it to a variety of situations.

- CHANGES TO THE ROOT CAUSE MAP(tm). The Root Cause Map(tm)has changed
significantly. For example:
- Two layers have been added. The two sections on
Administrative/Management
Systems related to Standards, Policies, and Administrative Controls (SPACs) have been
moved off of the main Root Cause Map(tm) and are now used following identification of a near
root cause. This should encourage users to dig deeper in finding underlying causes.
- It has been refined to more specifically address management of change.
Because
management of change is often a contributor to incidents, the steps involved in this process
have been specifically addressed on the Root Cause Map(tm).
- There is additional focus on quality issues. The latest version of the Root
Cause
Map(tm) incorporates changes aimed at addressing issues frequently encountered during the
analysis of product manufacturing and customer relations issues. In addition, the revised
handbook places a greater emphasis on detecting and correcting human and equipment
performance issues. As a result, quality activities that focus on this aspect of operations are
now specifically addressed on the Root Cause Map(tm).
- It incorporates facility-specific procedures and policies. Facility-specific
procedures
and policies can be incorporated into the use of the Root Cause Map(tm) by adding that
information to the coding of each root cause at the root cause level.

- NEW DEFINITIONS. In the prior edition, we defined causal factors as human errors
and
equipment failures. As we continued to work with national and international organizations, we
encountered difficulties in applying the definitions of error and failure. An error at one plant or
facility was perfectly acceptable at another based on operating characteristics and
requirements. We have adopted the use of front-line personnel performance gaps and
equipment performance gaps to replace human errors and equipment failures. These new
definitions force the user to specifically define both the actual and desired behavior of the
people and equipment for any causal factor. These definitions integrate better with the
concepts of human performance technology; antecedent, behavior, consequence (ABC)
analysis; and behavior-based risk management programs that many organizations are
already using. These changes should encourage users to more precisely define the
performance gaps present in their organization.

- ONLINE RESOURCES. ABS Consulting believes in providing the users of its
SOURCE(tm) methodology with the best tools to deploy the approach in their facilities. To
that end, ABS Consulting is providing an abundance of incident investigation resources on our
Web site. The Root Cause Ma(tm) guidance that was formerly included in the Root Cause
Analysis Handbook is now available on our Web site with an application that allows users to
rapidly access guidance on using the Root Cause Ma(tm) as well as accessing numerous
example analyses. The guidance still contains an explanation of the node, examples, and
recommendations. Enhanced cross-referencing to other nodes has also been provided to
allow users to more consistently code root causes. The online guidance will be updated
based on feedback from users of the Root Cause Map(tm). Send us your examples and we
will incorporate them into the online guidance.

- RESOURCE CD. In addition to the resources available on the Web, ABS Consulting
is
providing much of the same information on a resource CD that accompanies this handbook.
This should allow users without ready access to the Web to use much of the guidance
contained on the Web site.

- SOURCE(tm) INVESTIGATOR’S TOOLKIT. The SOURC(tm) Investigator’s Toolkit
has
always been available for users to download from the ABS Consulting Web site. This addition
to the handbook integrates the forms, checklists, and guidance from the toolkit into the
handbook text.

- USE OF TIMELINES. This version of the handbook provides an additional tool for
causal
factor identification. In the past, SOURC(tm) has used cause and effect trees (fault trees) and
causal factor charts for identification of causal factors. Now, in addition to these two tools,
graphical timelines have been included. Timelines share many of the same attributes as
causal factor charts; however, they do not incorporate the logic tests that causal factor charts
use. As a result, using timelines will not always result in identification of all of the causal
factors for an incident. However, they can be used to quickly identify many of the causal
factors. If the organization chooses not to invest heavily in an analysis of an incident,
timelines may be the tool of choice. However, the user must keep in mind the limitation of the
approach.

- TASK TRIANGLE MODEL. The task triangle model is used extensively to anchor the
concepts of the SOURCE(tm) methodology. Depth of analysis, causal factors, root causes,
and the scope of recommendations are all described in relationship to this model. This
provides the user with an easy model to understand and use throughout the analysis.


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ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOK

This is truly a handbook - it provides detailed information on how to perform a root cause
analysis, including step-by-step processes, flow diagrams, forms, and checklists. The book
covers all aspects of RCA/incident investigation from setting up the program, performing
investigations, recommendation followup, trending, and program management.

Each of the first 10 sections of this handbook focuses on one aspect of the incident
investigation process. Section11 includes additional resources that may be helpful when
performing investigations. The handbook sections areas follows:

- Section 1 - Basics of Incident Investigation (22 pages) presents a basic overview of
the
SOURCE(tm)investigation process. It describes the reasons why an organization should
perform investigations and includes basic definitions of terms used in the handbook.
- Section 2 - Initiating Investigations (10 pages) describes the steps an organization
must
perform before the actual investigation begins, such as setting up processes for incident
classification and team selection.
- Section 3 - Gathering and Preserving Data (24 pages) provides guidance for gathering
and
preserving the different types of data that are needed for an investigation.
- Section 4 - Analyzing Data (18 pages) discusses three different methods (cause and
effect trees, timelines, and causal factor charts) for analyzing the data that have been
collected.
- Section 5 - Identifying Root Causes (18 pages) describes the use of ABS
Consulting's
Root Cause Ma(tm) to assist in identifying the underlying causes of incidents.
- Section 6 - Developing Recommendations (12 pages) explains the different types of
recommendations that should be developed to ensure that the highest return is obtained from
the analysis.
- Section 7 - Completing the Investigation (10 pages) describes the activities that
should be
performed to complete an investigation.
- Section 8 - Selecting Incidents (14 pages) for Analysis provides guidance on
determining
which incidents need to be analyzed.
- Section 9 - Data and Results Trending (6 pages) explains the method for setting up
and
monitoring a trending system. Trending is used to identify chronic incidents that trigger
analyses.
- Section 10 - Program Development (14 pages) describes the process of setting up
the
overall incident investigation program.
- Section 11 - Contents of the Companion CD and Downloadable Resources (2 pages)
provides a brief description of the contents of the companion CD and forms and checklists
that can be downloaded from the ABS Consulting Web site.

Additional information that can help the reader use the SOURCE(tm) approach is provided in
the following appendices:
- Appendix A - Glossary (6 pages) provides definitions of and notes on terms used in
this
handbook.
- Appendix B - Cause and Effect Tree Details (22 pages) provides in-depth information
about the use, development, and construction of cause and effect trees. Example cause and
effect trees are also included. This appendix supplements information provided in Section 4,
"Analyzing Data."
- Appendix C - Timeline Details (28 pages) provides in-depth information about the use,
development, and construction of timelines. Example timelines are also included. This
appendix supplements information provided in Section 4, "Analyzing Data."
- Appendix D - Causal Factor Charting Details (26 pages) provides in-depth information
about the use, development, and construction of causal factor charts. Example causal factor
charts are also included. This appendix supplements information provided in Section 4,
"Analyzing Data."
- Appendix E - Root Cause Ma(tm) Guidance (8 pages) describes each segment of the
Root Cause Map™ and presents detailed descriptions of the individual nodes (or items) on
the map. The Root Cause Map(tm) itself is included as part of the SOURCE(tm) Investigator's
Toolkit in Appendix F.
- Appendix F - SOURCE(tm) Investigator's Toolkit (51 pages) provides summary
guidance
and resources (such as checklists and forms) that can be used to document incident
investigation activities. This same material, as well as other investigation resources, can be
obtained from the ABS Consulting Web site.

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AN EXCERPT FROM THE FORWARD OF THE HANDBOOK

“Organizations in all industries experience incidents that range from near misses to major
accidents. These incidents should be investigated because many regulations require it and
industry initiatives encourage it. More importantly, the root cause analysis process helps
organizations learn from past performance and develop strategies to improve safety,
reliability, quality, and financial performance.

“ABS Consulting's SOURCE(tm) (Seeking Out the Underlying Root Causes of Events)
methodology, presented in this handbook, is designed for use in investigating and
categorizing the underlying causes of incidents (including accidents and near misses) with
safety, health, environmental, quality, reliability, production, security, and financial impacts.
The term "incident" is used to generically identify situations that have any one or more of
these types of consequences.

“The SOURCE(tm) methodology provides an effective and efficient approach for investigating
incidents of any magnitude. ABS Consulting developed the methodology by customizing and
combining the best techniques available. Application of the SOURCE(tm) techniques by ABS
Consulting personnel and our clients ensures that these methodologies are field-proven, not
just theories. The objectives of the SOURCE(tm) approach are as follows:
- Provide a technique that will guide incident investigators in analyzing root causes and
identifying, documenting, addressing, and trending the causes of accidents and near misses.
- Provide organizations with a structured approach for developing recommendations to
address the immediate and underlying causes of incidents.
- Assist clients with the investigation of a variety of types of incidents (including fires,
manufacturing errors, equipment malfunctions, and customer complaints) with consequences
ranging from minor to major.
- Facilitate analysis of losses whether they are related to safety, the environment,
security,
reliability, quality, or business losses.
- Provide a technique that is sufficiently flexible to allow customization to a client's
own
management system; health, safety, and environment programs; or related initiatives.
- Support compliance with root cause analysis and incident investigation-related
industry
guidelines and regulations.

The SOURCE(tm) Methodology

“The SOURCE(tm) methodology encapsulates a process for conducting investigations
following losses whether they are related to people, equipment, software, or other factors.
This model is described further in Section 1.The RCA methodology described in this
handbook addresses the (1) incident investigation and (2) corrective and preventive action
program requirements found in many regulations, industry standards, and guidance
documents.”

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TABLE OF CONTENTS

List of Figures
List of Tables
List of Acronyms
Foreword
Background
The SOURCE(tm) Methodology
Scope of the Handbook
Contents of the Handbook

SECTION 1: BASICS OF INCIDENT INVESTIGATION
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 SOURCE(tm) Methodology
1.9 The SOURCE(tm) 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

SECTION 2: INITIATING INVESTIGATIONS
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 Action Requests
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

SECTION 3: GATHERING AND PRESERVING DATA
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
3.2.3.1 People Data Fragility Issues
3.2.3.2 Electronic Data Fragility Issues
3.2.3.3 Physical/Position Data Fragility Issues
3.2.3.4 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
3.4.3.1 Before the Interviews
3.4.3.2 Beginning the Interview
3.4.3.3 Conducting the Interview
3.4.3.4 Concluding the Interview
3.4.3.5 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

SECTION 4: ANALYZING DATA
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

SECTION 5: IDENTIFYING ROOT CAUSES
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 Map(tm)
5.5 Observations About the Structure of the Root Cause Map(tm)
5.6 Using the Root Cause Map(tm)
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 Map(tm)
5.6.6 Advantages and Disadvantage of Using the Root Cause Map(tm)
5.7 Documenting the Root Cause Analysis Process
5.8 Application to Apparent Cause Analyses and Root Cause Analyses
5.9 Summary

SECTION 6: DEVELOPING RECOMMENDATIONS
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

SECTION 7: COMPLETING THE INVESTIGATION
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

SECTION 8: SELECTING INCIDENTS FOR ANALYSIS
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
8.7.1.1 Examples of Pareto Analysis
8.7.1.2 Weaknesses of Pareto Analysis
8.7.2 Chronic Analysis of Reliability Problems
8.7.2.1 Prioritizing the RCA Efforts
8.7.2.2 Repeating the Process
8.7.3 Chronic Analysis for Quality Incidents
8.7.3.1 Prioritizing the RCA Efforts
8.7.3.2 Repeating the Process
8.7.4 Other Data Analysis Tools
8.8 Summary

SECTION 9: DATA AND RESULTS TRENDING
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 Analysis36
9.4.1 Interpreting Data Trends
9.5 Application to Apparent Cause Analyses and Root Cause Analyses
9.6 Summary

SECTION 10: PROGRAM DEVELOPMENT
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

SECTION 11: CONTENTS OF THE COMPANION CD AND DOWNLOADABLE RESOURCES
11.1 Introduction
11.2 Resources Available on the Companion CD and at www.absconsulting.com
11.2.1 SOURCE(tm) 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

APPENDIX A: GLOSSARY

APPENDIX B: CAUSE AND EFFECT TREE DETAILS
B.1 Introduction to Cause and Effect Tree Analysis
B.1.1 The Basic Structure of Cause and Effect Trees
B.2 Cause and Effect Tree Examples
B.2.1 Example 1: Spill from a Tank
B.2.2 Example 2: Lighting Failure
B.2.3 Example 3: Hand Injury During Sandblasting
B.3 Cause and Effect Tree Symbols
B.4 Using “AND” Gates
B.4.1 Multiple Elements Required
B.4.2 Multiple Pathways Required
B.4.3 Redundant Equipment Must Fail
B.4.4 Initial Event Combined with a Safeguard Failure
B.5 Using “OR” Gates
B.5.1 One of More of Multiple Elements Fail
B.5.2 Component Failures
B.5.3 Inadvertent Actuation of Safeguards
B.6 Example Cause and Effect Tree Structures
B.7 Procedure for Creating a Cause and Effect Tree
B.7.1 Step 1 – Define an Event of Interest as the Top Event of the Cause and Effect
Tree
B.7.2 Step 2 – Define the Next Level of the Tree
B.7.3 Step 3 – Develop Questions to Examine the Credibility of Branches
B.7.4 Step 4 – Gather Data to Answer Questions
B.7.5 Step 5 – Determine Whether the Branch Is Credible
B.7.6 Step 6 – Determine Whether the Branch Is Sufficiently Developed
B.7.7 Step 7 – Stop Branch Development
B.7.8 Step 8 – Stop When the Scenario Model Is “Complete”
B.7.9 Step 9 – Identify Causal Factors
B.8 Drawing the Cause and Effect Tree
B.9 Additional Examples of Cause and Effect Trees

APPENDIX C: TIMELINE DETAILS
C.1 Introduction
C.2 Timeline Example
C.3 Overall Timeline Guidance
C.3.1 Use Different Colors of Post-it® Notes for Different Types of Data
C.3.2 Use a Simple, Flexible Format
C.3.3 Keep the Level of Detail Manageable
C.4 Rules for Building Blocks
C.4.1 Use Complete Sentences
C.4.2 Use Only One Idea Per Building Block
C.4.3 Be as Specific as Possible
C.4.4 Document the Source for Each Event and Condition
C.5 Rules for Questions
C.6 Timeline Construction
C.6.1 Step 1 – Identify the Loss Events
C.6.2 Step 2 – Identify the Actors
C.6.3 Step 3 – Develop Building Blocks and Add Them to the Timeline
C.6.4 Step 4 – Generate Questions and Identify Data Sources to Fill in Gaps
C.6.5 Step 5 – Gather Data
C.6.6 Step 6 – Add Additional Building Blocks to the Timeline
C.6.7 Step 7 – Determine Whether the Sequence of Events Is Complete
C.6.8 Step 8 – Identify Causal Factors and Items of Note
C.7 Example Timeline Development
C.7.1 Step 1 – Identify the Loss Events
C.7.2 Step 2 – Identify the Actors
C.7.3 Step 3 – Develop Building Blocks and Add Them to the Timeline
C.7.4 Step 4 – Generate Questions and Identify Data Sources to Fill in Gaps
C.7.5 Step 5 – Gather Data
C.7.6 Step 6 – Add Additional Building Blocks to the Timeline
C.7.7 Step 7 – Determine Whether the Sequence of Events Is Complete
C.7.8 Step 8 – Identify Causal Factors and Items of Note

APPENDIX D: CAUSAL FACTOR CHARTING DETAILS
D.1 Introduction
D.2 Causal Factor Chart Example
D.3 Overall Causal Factor Chart Guidance
D.3.1 Use Different Colors of Post-it(r) Notes for Different Types of Data
D.3.2 Use a Simple, Flexible Format
D.3.3 Keep the Level of Detail Manageable
D.4 Rules for Building Blocks
D.4.1 Use Complete Sentences
D.4.2 Use Only One Idea Per Building Block
D.4.3 Be as Specific as Possible
D.4.4 Document the Source for Each Event and Condition
D.5 Rules for Questions
D.6 Causal Factor Chart Construction
D.6.1 Step 1 – Identify the Loss Event(s)
D.6.2 Step 2 – Take a Small Step Back in Time and Add a Building Block to the
Chart
D.6.3 Step 3 – Perform Sufficiency Testing
D.6.4 Step 4 – Gather Data to Answer Questions Developed in Step 3
D.6.5 Step 5 – Add Building Blocks to the Chart
D.6.6 Step 6 – Determine Whether the Sequence of Events Is Complete
D.6.7 Step 7 – Repeat Sufficiency Testing for All Items on the Chart
D.6.8 Step 8 – Perform Necessity Testing
D.6.9 Step 9 – Identify Causal Factors and Items of Note
D.7 Example Development of A Causal Factor Chart
D.7.1 Step 1 – Identify the Loss Event(s)
D.7.2 Step 2 – Take a Small Step Back in Time and Add a Building Block to the
Chart
D.7.3 Step 3 – Perform Sufficiency Testing
D.7.4 Step 4 – Gather Data to Answer Questions Developed in Step 3
D.7.5 Step 5 – Add Building Blocks to the Chart
D.7.6 Step 6 – Determine Whether the Sequence of Events Is Complete
D.7.7 Step 7 – Repeat Sufficiency Testing for All Items on the Chart
D.7.8 Step 8 – Perform Necessity Testing
D.7.9 Step 9 – Identify Causal Factors and Items of Note

APPENDIX E: ROOT CAUSE MAP(TM) GUIDANCE
E.1 Instructions for Using This Appendix with the Root Cause Map(tm)
E.1.1 Types of Information Provided
E.1.2 Online Documentation
E.1.3 Working Your Way Through the Root Cause Map(tm)
E.1.4 Special Considerations
E.2 Clarifications and Updated Guidance

APPENDIX F: SOURCE(TM) INVESTIGATOR’S TOOLKIT
Table of Contents
Pocket Guide to Incident Investigation/Root Cause Analysis
Index of Incident Investigation Forms, Checklists, and Support Materials
Responsibilities of the Team Leader
Investigator’s Log
Simple Investigation Plan
Detailed Investigation Plan
Investigation Data Needs Form
Investigation Data Needs Checklist
Initial Incident Scene Tour Checklist
List of Contacts
List of Meeting Attendees
Interview Scheduling Form
Initial Witness Statement
Interview Preparation and Documentation Form
Interview Documentation Form
Physical Data Analysis Plan - Parts Analysis
Physical Data Analysis Plan - Sample/Chemical Analysis
Guidelines for Collecting Paper Chart Data
Photography Guidelines
Photographic Record
Position Data Form
Data Log Form
Data Correspondence Log
Data Tracking Form
Procedure for Creating a Cause and Effect Tree
Testing an OR Gate
Testing an AND Gate
Procedure for Creating a Timeline
Building a Timeline from Witness Statements
Procedure for Creating a Causal Factor Chart
Building a Causal Factor Chart from Witness Statements
Root Cause Map(tm)
Causal Factor, Root Cause, and Recommendation Checklist
Root Cause Summary Table Form
Instructions for Completing the Incident Investigation Report Form
Incident Investigation Report Form
Report and Investigation Checklist
Open Issues Log

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LIST OF FIGURES
F.1: ABS Consulting’s SOURCE(tm) Incident Investigation Model
1.1: Task Triangle Showing Possible Depths of Analyses
1.2: Overlap of Multiple Task Triangles
1.3: Differences Between Traditional Problem Solving and Structured Root Cause Analysis
1.4: Relationship Among Proactive Analysis, Reactive Analysis, and Management Systems
1.5: Idealized Operation
1.6: Realistic Operation4
1.7: Steps in the SOURCE(tm)Methodology
1.8: Steps That Apply to Acute Incident Analyses
1.9: Steps That Apply to Chronic Incident Analyses
1.10: Steps That Apply When No Formal Analyses Are Performed
1.11: Levels of Analysis
1.12: Connection Between Causal Factors and Root Causes
2.1: Initiating Investigations Within the Context of the Overall Incident Investigation Process
3.1: Gathering Data Within the Context of the Overall Incident Investigation Process
3.2: Types of Data Resources
3.3: Fragility of Data Types
3.4: Flowchart of Typical Interview Sequence
3.5: Basic Steps in Failure Analysis
4.1: Analyzing Data Within the Context of the Overall Incident Investigation Process
4.2: Example Cause and Effect Tree
4.3: How to “Read” the Cause and Effect Tree in Figure 4.2
4.4: Cause and Effect Tree Showing a Multiple-event Failure
4.5: Sandblasting Cause and Effect Tree Example
4.6: Cause and Effect Tree for Number 2 Compressor Crank Failure
4.7: Sandblasting Timeline Example
4.8: Sandblasting Causal Factor Chart Example
5.1 Identifying Root Causes Within the Context of the Overall Incident Investigation Process
5.2: Connection Between the Steps of the Investigation
5.3: Structure of ABS Consulting’s Root Cause Map(tm)
5.4: Levels of the Root Cause Map(tm)
5.5: Document Hierarchy
5.6: Explanation of the Root Cause Summary Table Structure
5.7: Root Cause Summary Table Form (First Example)
5.8: Root Cause Summary Table Form (Second Example)
5.9: Root Cause Summary Table Form (Third Example)
5.10: Root Cause Summary Table Form (Fourth Example)
5.11: Completing the Three-column Form
6.1: Developing Recommendations Within the Context of the Overall Incident Investigation
Process
6.2: Connecting Root Causes and Recommendations
7.1: Completing the Investigation Within the Context of the Overall Incident Investigation
Process
7.2: Tracking Recommendations
8.1: Selecting Incidents for Analysis Within the Context of the Overall Incident Investigation
Process
8.2: Investigation Cycle if Too Many Investigations Are Performed
8.3: Hierarchy of Accidents, Near Misses, and Unsafe Acts/Unsafe Conditions
8.4: Pareto Charts Developed Using Two Different Attributes
8.5: Example Chronic Cause and Effect Tree #1 (Based on 40 Incidents)
8.6: Example Cause and Effect Tree #2 (Based on 23 Incidents)
8.7: Example Cause and Effect Tree #3 (Based on 143 Incidents)
9.1: Results Trending Within the Context of the Overall Incident Investigation Process
10.1: Overall Incident Investigation Process
A.1: Relationship Among Incident Investigation Terms
B.1: AND Gate Structure
B.2: OR Gate Structure
B.3: Example Tree with Multiple Levels
B.4: Cause and Effect Tree for a Tank Spill
B.5: Circuit Diagram4
B.6: Cause and Effect Tree for a Lighting Failure
B.7: Cause and Effect Tree with Events A, B, and C Only
B.8: Cause and Effect Tree for Hand Injury During Sandblasting
B.9: Cause and Effect Tree Symbols
B.10: Example Cause and Effect Tree with Supporting Data Shown
B.11: Cause and Effect Tree for Master and Articulating Rod Failure Following Reassembly
B.12: Multiple Elements Required
B.13: Multiple Pathways Required - No Flow
B.14: Multiple Pathways Required - Misdirected Flow
B.15: Redundant Equipment Must Fail
B.16: Equipment Failure and Safeguards Failure
B.17: Human Error and Safeguards Failure
B.18: One of More of Multiple Elements Fail
B.19: Oil Tank Release
B.20: Inadvertent Actuation of Safeguards
B.21: Common-mode Failure
B.22: Human Error with Impact
B.23: Procedure for Creating a Cause and Effect Tree
B.24: Testing AND Gate Logic
B.25: Testing OR Gate Logic
B.26: Testing Credibility
B.27: Determining Branch Credibility
B.28: Determining Branch Development
B.29: Branch Development Results
C.1: Sandblasting Timeline Example
C.2: Process for Developing a Timeline
C.3: Step 1 – Identifying the Loss Event(s)
C.4: Step 2 – Identify the Actors
C.5: Step 3 – Develop Building Blocks and Add Them to the Timeline
C.6: Step 3 – Develop Building Blocks and Add Them to the Timeline
C.7: Step 4 – Generate Questions
C.8: Step 6 – Add Additional Building Blocks
C.9: Step 8 – Identify Causal Factors and Items of Note
D.1: Sandblasting Causal Factor Chart Example
D.2: Process for Developing a Causal Factor Chart
D.3: Step 1 – Identify the Loss Event(s)
D.4: Step 2 – Take a Step Backward
D.5: Step 3 – Sufficiency Testing - Questions 1 and 2
D.6: Step 3 – Sufficiency Testing - Question 3
D.7: Step 2 – Take a Small Step Back in Time
D.8: Step 3 – Sufficiency Testing - Questions 1 and 2
D.9: Step 3 – Sufficiency Testing - Question 3
D.10: Add Remaining Questions to Chart
D.11: Step 4 – Gather Data
D.12: Step 5 – Add Building Blocks to the Chart
D:13: Step 7 – Repeat Sufficiency Testing for All Items on the Chart
D.14: Step 8 – Perform Necessity Testing
D.15: Step 9 – Identify Causal Factors and Items of Note
E.1: Section of the Root Cause Map(tm)
E.2: Sample Root Cause Map(tm) Documentation Page
E.3: Navigation Box for Online Documentation
E.4: Root Cause Map(tm) Paths

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LIST OF TABLES
2.1: General Incident Classification Criteria
3.1: Forms of Data Fragility
3.2: Factors to Assess the Credibility of People Data
3.3: Application of Data-collection Methods
4.1: Summary of Analysis Technique Characteristics
4.2: Applicability of Analysis Techniques
4.3: Guidance on Using Causal Factor Charts, Timelines, and Cause and Effect Trees
6.1: Effectiveness of Various Shift Turnover Assessment Strategies
6.2: Recommendations for Apparent Cause Analyses and Root Cause Analyses
7.1: Typical Items to Include in Investigation Reports
7.2: Investigation Completion Activities for Apparent Cause Analyses and Root Cause
Analyses
8.1: Learning Potential for Types of Incidents
10.1: Suggested Training Topics and Levels
10.2: Destructive and Supportive Investigation Evaluation Criteria
11.1: Resources Available on the Companion CD and ABS Consulting’s Web Site

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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 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.

- - - - - - -

MR. DONALD K. 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 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; 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.

- - - - - - -

MR. WALTER E. 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
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 Consulting’s Marine Root Cause Analysis
Technique (MaRCAT). He is the lead instructor for ABS Consulting’s Maritime Root Cause
Analysis course.

- - - - - - -

MS. LAURA O. 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
coinstructs 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.

- - - - - - -

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(tm) technique.

- - - - - - -

MR. DAVID A. 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. Mr. Walker is a recognized practice leader in the following areas:
- Risk-based decision making
- Enterprise risk management
- Security risk assessment applications
- Risk-based asset integrity management
- Manufacturing reliability and asset utilization
- Incident investigation and root cause analysis
- Development of tools/software/job aids for risk and reliability management
- Development of training courses for institutionalizing risk and reliability management
applications.

- - - - - - -

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.

RCA Training:
Training from 4-hours to 4-days to meet your specific needs from ABS Consulting -
www.absconsulting.com/RCATraining
RCA Investigation Assistance:
ABS Consulting can help you investigate the safety, reliability, production,
environmental,
or security-related issues that most affect your organization. Call us 24/7 at (865) 368-4357,
or www.absconsulting.com/RCA
RCA Software:
Use ABS Consulting's RootCause LEADER software to document and track your
analyses. - www.absconsulting.com/LEADERSoftware/RCL.html

- - - - - -
2008, 300 pages plus 17 inch by 22 inch pull-out Root Cause Map and CD-ROM
Order #DR388.

Published by Rothstein Associates Inc.
ISBN #1-931332-51-7 (978-1-931332-51-4)
AVAILABLE: JULY, 2008

- - - - - - - - - -
ALSO AVAILABLE: Limited stock of the 2005 (Second) Edition is still available.
Contact
info@rothstein.com for details.
- - - - - - - - - -
Registered purchasers of the 2005 Edition are entitled to an upgrade discount offer.
Contact info@rothstein.com for details.
- - - - - - - - - -
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Telephone: 203.740.7444; 888.768.4783
Fax: 203.740.7401
E-Mail: info@rothstein.com




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