Incident analysis root cause

BP (formerly BP Amoco). Incident Investigation. Root Cause Analysis Training. Comprehensive List of Causes. London, 1999. 

Once the actual incident scenario is understood and its multiple causal factors identified, this information may be used to determine the incident s root causes. One means of performing root cause analysis involves the use of ready-made, predefined trees. A predefined tree provides a systematic approach for analyzing and selecting the relevant elements of the incident scenario. It is a deductive approach, looking backward in time to examine preceding events necessary to produce the specified incident. 

ABS Consulting. Incident Investigation/Root Cause Analysis Training Results Trending and Assessment. Knoxville, TN ABS Consulting, 2001. 

Identify multiple system-related root causes determined by the investigation team after a systematic analysis. Root causes reported should not be limited to the opinion or judgment of a participant or witness of the incident. 

Warnings went unheeded - Findings indicated that most incidents were often preceded by a series of smaller accidents, near misses, or accident precursors. Operations and maintenance procedures must include analysis, root cause investigation, and corrective action. 

Personally participate in a significant incident investigation/root cause analysis. TeU my story around incidents/errors that I have been involved with and the systems improvements that could have prevented them. 

In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

Analysis of Incident Root Causes Using the Sequential Error Model... 

Root cause analysis systems, intended to provide in-depth evaluations of major incidents... 

The types of data required for incident reporting and root cause analysis systems are specified. Data Collection practices in the CPI are described, and a detailed specification of the types of information needed for causal analyses is provided. 

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

In the following sections, a number of methodologies for accident analysis will be presented. These focus primarily on the sequence and structure of an accident and the external causal factors involved. These methods provide valuable information for the interpretation process and the development of remedial measures. Because most of these techniques include a procedure for delineating the structure of an incident, and are therefore likely to be time consuming, they will usually be applied in the root cause analysis of incidents with severe consequences. 

In general, the value of a psychological perspective in incident analysis is that it directs the analyst to search for causes that would not otherwise have been considered. This means that the development of preventative strategies will be better informed. In addition, an evaluation of causes from a psychological perspective can be useful when the "root cause" appears to be an otherwise incomprehensible failure on the part of an individual. A psychological analysis can break the "causal log jam" by providing an explanation. 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

The first case study describes the application of the sequentially timed event plotting (STEP) technique to the incident investigation of a hydrocarbon leak accident. Following the analysis of the event sequence using STEP, the critical event causes are then analyzed using the root cause tree. 

In the second case study, variation tree analysis and the events and causal factors chart/root cause analysis method are applied to an incident in a resin plant. This case study illustrates the application of retrospective analysis methods to identify the imderlying causes of an incident and to prescribe remedial actions. This approach is one of the recommended strategies in the overall error management framework described in Chapter 8. 

The case study has documented the investigation and root cause analysis process applied to the hydrocarbon explosion that initiated the Piper Alpha incident. The case study serves to illustrate the use of the STEP technique, which provides a clear graphical representation of the agents and events involved in the incident process. The case study also demonstrates the identification of the critical events in the sequence which significantly influenced the outcome of the incident. Finally the root causes of these critical events were determined. This allows the analyst to evaluate why they occurred and indicated areas to be addressed in developing effechve error reduchon strategies. 

This case study illustrates how the methodologies described in Chapter 6 can be used to analyze plant incidents and identify the root causes of the problems. Based on this information, specific error reduction strategies can be developed to prevent similar incidents from occurring in the future. Also, the findings of such an analysis can provide the basis for more general discussions about the prevalence of similar error inducing conditions in other plant areas. 

To gather information about the factors which contributed to the above incident, interviews were held with the workers and their management. Relevant documentation such as standard operating procedures and documentation relating to the incident was also collected. A task analysis (see Case Study 3) of the job of the top floor person was carried out in order to examine the operations involved and the factors which could affect job performance. Two techniques were used for the analysis of this incident, namely variation tree analysis and root cause analysis. 

This useful companion disk contains root cause analysis examples, predefined tree examples, practical checklists that can be customized, and incident evidence photograph examples. It includes a quick checklist for investigators traveling to an incident, examples of methodologies that may be usefiil in training the onsite team, and checklists and samples from the text that can be printed out at the incident site to help organize the team s work. 

One approach is to mesh all investigation and root cause analysis activities under one management system for investigation. Such a system must address all four business drivers (1) process and personnel safety, (2) environmental responsibility, (3) quality, and (4) profitability. This approach works well since techniques used for data collection, causal factor analysis, and root cause analysis can be the same regardless of the type of incident. Many companies realize that root causes of a quality or reliability incident may become the root cause of a safety or process safety incident in the future and vice versa. 

To be effective the investigation must apply an approach which is based on basic incident causation theories and use tested data analysis techniques. Investigating incidents to determine root causes and make recommendations can be as much an art as a science. Within the industry, best practices in incident investigation have evolved substantially in the last 20 years. This chapter provides a brief overview of some of the more relevant causation theories. 

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. 

Another type of logic tree, the event tree, is an inductive technique. Event Tree Analysis (ETA) also provides a structured method to aid in understanding and determining the causes of an incident.(i) While the fault tree starts at the undesired event and works backward to identify root causes, the event tree looks forward to display the progression of various combinations of equipment failures and human errors that result in the incident graphically. 

ABS Consulting. Root Cause Analysis Handbook A guide to effective Incident Investigation. Knoxville, TN ABS Group Inc., 1999. 

Consider having one incident reporting system with one approach for teaching employees the definition of a near miss and with one approach for doing incident investigations including one approach for root cause analysis. 

This chapter addresses typical data gathering needs of major investigations. A team may need to augment the activities in this chapter for the unique circumstances of the incident. Performing the activities oudined in this chapter plus special activities provides the incident investigation team with the data needed to complete the next step—systematic determination of the multiple root causes of the incident. However, data gathering and analysis typically involve much iteration as shown in Figure 8-1. 

Causal factor identification is relatively easy to learn and apply to simple incidents. For more complex incidents with complicated timelines, one or more causal factors can easily be overlooked, however, which inevitably will result in failure to identify their root causes. There are a number of tools, such as Barrier Analysis, Change Analysis, and Fault Tree Analysis, that can assist with bridging gaps in data and the identification of causal factors. Each of these tools has merits that can assist the investigator in understanding what happened and how it happened. 

If the answer is YES, that is, the incident would have heen prevented or mitigated, and it is a negative event or undesirable condition, then the fact is a causal factor. Generally, process safety incidents involve multiple causal factors. This technique is equivalent to step 15 in Figure 9-7. Once identihed, the causal factors become the candidates to undergo root cause analysis. 

The identification of causal factors points us to the key areas that need to he examined further for why that factor existed. It acts as a filter to limit the number of areas that are subjected to further analysis to determine root causes. This critical activity must be performed diligently and systematically to identify every causal factor applicable to the specific incident. If a causal factor is missed, one or more root causes will likely be omitted as well, which could lead to similar incidents in the future. 

Checklists of varying content and detail are used in incident investigation methodologies as a user-friendly tool to assist root cause analysis. Sometimes a comprehensive checklist may be used as the primary root cause analysis tool, or alternatively a checklist may be simply used to supplement another primary tool. 

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