Root Cause Analysis Report

Reza Javaherdashti, PhD, earned his PhD on full scholarship from Monash University, Victoria. He has more than 15 years of corrosion management experience in various industries and especially in oil and gas upstream and downstream. He has authored/coauthored more than 40 root-cause analysis reports for industries and is the author/coauthor of two books on corrosion published in the United Kingdom and the United States. He is a member of ACA, NACE, and the Institute of Corrosion. 

Burke, A., Root Cause Analysis, Report, 2002. Available from the Wild Iris Medical Association, P.O. Box 257, Comptche, California. 

FIGURE 6.6. SAMPLE ROOT CAUSE ANALYSIS REPORT... 

National Institute of Standards and Technology. 2009. Root Cause Analysis Report of Plutonium Spill at Boulder Laboratory. Gaithersburg, MD. http //www.nist.gov/public affairs/releases/upload/root cause plutonium 010709.pdf downloaded May 17, 2014. 

The test procedure shall state actions to be taken if the values are outside the allowable ranges (including root causes analysis, reporting requirements, and cessation of further testing, as appropriate). The procedure shall also require these actions to be completed in a timely, identified period. 

Check whether a documented system is in place, which covers the reporting, investigation, root cause analysis and corrective actions taken. 

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. 

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. 

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. 

Armstrong, M. E., Cecil, W. L., Taylor, K. (1988). "Root Cause Analysis Handbook." Report No. DPSTOM-81, E. I. DuPont De Nemours Co., Savannah River Laboratory, Aiken, SC 29808. 

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. 

The proposed integration of management tools and systems in the areas of Health, Safety, Environment and Reliability was widely applauded, specifically as to their reporting and root-cause analysis. 

Barriers to medication error reporting should be eliminated and a non-punitive culture encouraged. This will allow a well-developed medication error reporting system to be developed to collect vital information for root cause analysis and risk assessment. 

A written report is required. This particular regulation does not call for a root cause analysis per se, but such an analysis will generally be carried out for an incident that is serious enough to require regulatory involvement. 

Team issues its first report which summarizes the major issues to do with the incident. The formal investigation team issues one or more interim reports as it progresses with its work. Lastly, the analysis team delivers the final report, containing both the root cause analysis, the findings, and suggested action items. 

Did the report provide a satisfactory root cause analysis How were internal communications during the investigation How effective were communications with those involved in the incident ... 

After any remedial maintenance has been completed, a brief report on the repairs or replacanents carried out should be prepared. The component that failed, its mode of failure, the ranedial action taken, the total repair time, the total outage time and the state of the systan after completion of the remedial maintenance work should be identified. For major failures of components important to safety, a root cause analysis should be carried out in order to prevent recurrence. 

Wald, H., Shojania, K. G., Root Cause Analysis, in Making Health Care Safer A Critical Analysis of Patient Safety Practices, edited by A.J. Markowitz, Report No. 43, Agency for Health Care Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland, 2001, Chapter 5, pp. 1-7. 

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