Checklists root cause determination

FIGURE 9-27. Flowchart for root cause determination— predefined tree/checklist. 

This chapter addresses methods and tools used successfully to identify multiple root causes. Process safety incidents are usually the result of more than one root cause. This chapter provides a structured approach for determining root causes. It details some powerful, widely used tools and techniques available to incident investigation teams including timelines, logic trees, predefined trees, checklists, and fact/hypothesis. Examples are included to demonstrate how they apply to the types of incidents readers are likely to encounter. 

In general, the companies surveyed use one of two main methodologies to determine root causes. The first involves timeline construction followed by logic tree development. The second involves timeline construction, identification of causal factors, followed by the use of predefined trees or checklists. These two approaches are discussed in detail in Chapter 9. 

Checklist analysis tools can be a user-friendly means to assist investigation teams as they conduct root cause analysis.h) Each causal factor is reviewed against the checklist to determine why that factor existed at the time of the incident. The Systematic Cause Analysis Technique (SCAT)(9> is an example of a proprietary checklist tool. 

A disadvantage is that a checklist may allow an investigation team to jump to conclusions, and does not provide the opportunity to think outside the box. This is especially important if the checklist is one of the less comprehensive types. It is also tempting to use the checklist too early, before all causal factors have been identified. Be sure to determine what happened and how it happened before determining why it happened. Otherwise, the team will think it has identified the right root causes, when in reality not all of the root causes have been determined. 

Conducting frequent inspections, using a checklist, to evaluate physical conditions. Investigating loss-producing events thoroughly to determine the root cause and how hazards can be minimized or controlled. 

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See also in sourсe #XX -- [ , ]

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