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Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation

$127.99

The most complete, all-in-one package available for Root Cause Analysis, including 600+ pages of book and downloads; color-coded, 17″ x 22″ Root Cause Map; and licensed access to new/archival online resources. It’s a global classic many users call “in a league of its own” and “the best resource on the subject.”

 

Description

The Root Cause Analysis Handbook along with its downloadable resources and RCA Map are the gold standard in root cause analysis (RCA) for both practitioners and students worldwide.

It offers the unique breadth, depth, and practicality that can only come from six authors with a wellspring of 150+ years of combined consulting experience in the fields of risk/reliability engineering, risk management, incident investigation/root cause analysis, hazard analysis, process safety, environmental safety, loss prevention, asset integrity, and professional/ technical training.

  • Based on real-world, globally successful, proprietary methodology by an international consulting firm with 50+ years’ experience in 35+ countries, serving a impressive array of industries, NGOs, and government agencies. You’ll find field-tested, easily adaptable methods to improve your own processes and get management buy-in.
  • Practical 300-page download toolkit including examples of Cause and Effect Trees and sample template; examples of Cause and Effect Timelines and sample template; toolkits for Investigating, Data Gathering, Data Analysis, etc.; plentiful forms, checklists, questionnaires, and sample plans; and a resource list of recommended books, websites, organizations, etc.
  • Root Cause Map (full color wall chart 17″ x 22″), a powerful tool for staff to use in identifying and coding root causes.
  • Licensed access to ABS Consulting website for an abundant collection of new/archival articles, examples, charts, forms, etc., as an ongoing way to stay abreast of the field.
  • Chapter introductions/summaries; sample plans; examples of incidents drawn from many industries; five appendices packed with step-by-step instructions for conducting every phase of RCA; numerous charts, checklists, and reproducible forms; and a glossary all facilitate classroom use in college courses and professional development programs.

This comprehensive, 600-page package (book + downloads + RCA 17″ x 22″ map + online resources) presents the field-tested SOURCE methodology, or Seeking Out the Underlying Causes of Events, from ABS Consulting, an international firm with 50+ years of experience in 35+ countries. This model customizes, combines, and encapsulates global best practices for investigating incidents following any loss, whether related to people, equipment, software, structural failure, or other factors. The methodology addresses (1) incident investigation and (2) corrective and preventive action requirements found in many regulations, industry standards, and guidance documents.

The SOURCE system

The SOURCE system enables businesses to generate specific, concrete recommendations for preventing incident recurrences. Using the factual data of any incident, this model can help you implement more reliable and cost-effective practices that result in major, long-term improvements. Such process improvements increase your business’ ability to recover from and prevent incidents with financial, legal, health, and safety risks.

Included are tips and tools for developing an ongoing incident investigation program and — importantly — successfully dealing with the resulting management, corporate culture, and process changes often required.

SCOPE AND ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOK

The six authors use their collective global experience to guide you step-by-step through every phase of conducting a root cause analysis, including investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents with quality, reliability, environmental, health, safety, and production-process impacts.

They focus on how to apply structured analysis techniques, including the use of ABS Consulting’s Root Cause Map, to two levels of analyses: apparent cause analyses (ACAs) and root cause analyses (RCAs). They provide instructions for performing these activities along with flow diagrams, forms, checklists, charts, and sample plans:

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 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 , which is also included as a convenient pull-out, color-coded, 17″ x22″ chart.

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 use.

 

In addition to the 300 pages of downloads with forms, checklists, and sample plans, five detailed Appendices add to making this 600-page package the most comprehensive and real-world resource available for root cause analysis:

Appendix A: Glossary

Clarifies terms often used differently by different groups.

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 Map 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 Investigator’s Toolkit in Appendix F.

Appendix F: SOURCE Investigator’s Toolkit

(51 pages) provides summary guidance and resources (such as checklists and forms) that can be used to document incident investigation activities.

Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you’re responsible for quality, reliability, safety, and/or risk management, you’ll want this comprehensive and practical resource at your fingertips!

 

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Contents

List of Figures
List of Tables
List of Acronyms

Foreword

Background The SOURCE(tm) Methodology (Seeking Out the Underlying Causes of Events)
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 (Seeking Out the Underlying Causes of Events)
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

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

5.5 Observations About the Structure of the Root Cause Map
5.6 Using the Root Cause Map
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
5.6.6 Advantages and Disadvantage of Using the Root Cause Map
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 Analysis
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 Companion Downloadable Resources (formerly on CD)

11.1 Introduction
11.2 Resources Available on the Companion Downloads and at www.absconsulting.com/RCAHandbookResources
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

APPENDICES

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® 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 Guidance

E.1 Instructions for Using This Appendix with the Root Cause Map
E.1.1 Types of Information Provided
E.1.2 Online Documentation
E.1.3 Working Your Way Through the Root Cause Map
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 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

List of Figures by Section and Appendix

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 Operation

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 Process3.1: 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
5.4: Levels of the Root Cause Map
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
6.2: Connecting Root Causes and Recommendations

7.1: Completing the Investigation Within the Context of the Overall Incident Investigation Process
7.2: Tracking Recommendations8.1: Selecting Incidents for Analysis Within the Context of the Overall Incident
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 Diagram
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
E.2: Sample Root Cause Map Documentation Page
E.3: Navigation Box for Online Documentation
E.4: Root Cause Map Paths

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Root Cause Analysis Handbook has been peer reviewed and selected by the American Society for Quality (ASQ), Risk and Insurance Management Society (RIMS), and other professional associations for inclusion in their online bookstores.

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Root Cause Analysis Handbook is written by a team of six international consultants with a combined experience of nearly 150 years in the fields of risk/reliability engineering, risk management, incident investigation/root cause analysis, hazard analysis, process safety, environmental safety, loss prevention, asset integrity, and professional/technical training.

They are all on the staff of ABS Consulting, a Houston-based firm specializing in global safety, risk, and integrity management for half a century and operating in over 35 countries. The company serves customers in the oil and gas, chemical, nuclear, maritime, renewable energy, mining, food processing, hospitality, and transportation industries as well as government agencies.

The author team is led by Lee N. Vanden Heuvel and includes Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, and David A. Walker:

LEE N. VANDEN HEUVEL is Manager of Incident Investigation/Root Cause Analysis Services and the Manager of Training Services for ABS Consulting, with 25+ years of experience in plant operations and analysis. He 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. 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 eight 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.

DONALD K. LORENZO is the Director of Training Services for ABS Consulting. He has 30+ years of experience in hazard analysis and risk assessment. He was previously a development engineer for Union Carbide Corporation. Mr. Lorenzo specializes in safety and environmental applications of ABS Consulting’s SOURCEâ„¢ methodology. He is a registered Professional Engineer in the state of Tennessee and a Certified Technical Trainer.

WALTER E. HANSON is a Project Manager and Risk/Reliability Engineer for ABS Consulting. He has 25+ 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 and other transportation and maritime clients. He was a primary developer of ABS Consulting s Marine Root Cause Analysis Technique (MaRCAT).

LAURA O. JACKSON is a Risk/Reliability Engineer for ABS Consulting. She has been involved in evaluating 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.

JAMES J. ROONEY is a Senior Risk/Reliability Engineer and Manager of Webinar Training Services for ABS Consulting. He has 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), ASQ-certified HACCP auditor, Certified Quality Auditor, Certified Quality Engineer, Certified Quality Improvement Associate, Certified Quality Manager, Certified Reliability Engineer and registered Professional Engineer in the state of Tennessee. He specializes in quality and medical applications of the SOURCEâ„¢ methodology.

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 more than 20 years. He is 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.

Contact Rothstein Associates, Inc. to request a complimentary copy to evaluate for classroom use.

Root Cause Analysis Handbook has been widely adopted for use in college courses and corporate professional development programs. The book itself and the accompanying free downloads contain many helpful tools that can be used for classroom instruction.

The book includes chapter introductions and summaries; sample plans; examples of incidents drawn from a wide variety of industries; five appendices packed with step-by-step instructions for conducting an incident investigation, writing reports and communicating about it, and implementing the recommendations; numerous charts, checklists, and reproducible forms; and a glossary.

Accompanying the book are practical tools that give students the opportunity to apply what they are learning, including:

  • Wall size (17″ x 22″), color-coded flow chart illustrating all the key steps in the root cause analysis process.
  • Companion downloads packed with…
    • Examples of Cause and Effect Trees and a sample template
    • Examples of Timelines and a sample template
    • Toolkits for Investigating, Data Gathering, Data Analysis, etc.
    • Plentiful forms and checklists
    • Resource list of recommended books, websites, organizations, etc.

See the EXCERPTS Tab above and click on Section 11 for a complete list of ancillary resources available in the companion downloads and the ABS Consulting website. Note; these resources are now included in downloads rather than on a CD.

Purchasers of the book also get licensed access to the ABS Consulting website for new and archival information about the field of root cause analysis, articles, examples, charts, forms, etc.

Contact Rothstein Associates, Inc. to request a complimentary copy to evaluate for classroom use.