Root cause analysis system

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. 

However, in the case of a root cause analysis system, a much more comprehensive evaluation of the structure of the accident is required. This is necessary to unravel the often complex chain of events and contributing causes that led to the accident occurring. A number of techniques are available to describe complex accidents. Some of these, such as STEP (Sequential Timed Event Plotting) involve the use of charting methods to track the ways in which process and human events combine to give rise to accidents. CCPS (1992d) describes many of these techniques. A case study involving a hydrocarbon leak is used to illustrate the STEP technique in Chapter 7 of this book. The STEP method and related techniques will be described in Section 6.8.3. 

In the case of root cause analysis systems, more comprehensive evaluations of PIFs will normally be carried out as part of a full-scale human factors audit. This could make use of the types of comprehensive PIF evaluation methods described in Chapter 2 (see Section 2.7.7 and Figure 2.12). 

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. 

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. 

Development of reactive programs including data collection and root cause analysis systems... 

Bagian J P, Gosbee J, Lee C Z, Williams L, McKnight S D, Mannos D M (2002). The Veterans Affairs root cause analysis system in action. t Comm J Qual Improv 28 531-545. 

Cornelison, J.D., 1989. MORT based root cause analysis. Systems Safety Development Center, EG G Idaho, Inc., Working paper No. 27, Idaho Falls, Idaho. 

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