Root cause definition

Predefined tree has to have specific properties in order to be suitable for the integrated approach. It covers not only all components of the SMS but also all components of safety culture. Hence, also the root cause definition has to be modified. It identifies a correctable failure(s) in management system or in safety culture. 

A uniform definition of a failure and a method of classifying failures is essential if data from different sources are to be compared. The anatomy of a failure includes the initiating or root cause of a failure that is propagated by contributory causes and results in a failure mode—the effect by which a failure occurs or is observed. Modes include failure to operate, no output, failure to alarm on demand. The end result of a failure sequence is the failure effect, such as no fluid is pumped to the absorber, or a tank overflows. As discussed in Appendix A of IEEE Std. 500-1984, only the equipment failure mode is relevant for data that are needed in a CPQRA. The failure model used in this book is based upon those in the IEEE publication and IPRDS. ... 

Probably the most interesting and enlightening analysis you could ever perform is to analyze why failure analysis fails. By its pure definition, it is impossible for failure analysis to fail—so how come it does The answers (root causes) often lie with the problem solvers themselves, as well as their management support groups. 

ROOT CAUSE TEST - Most root cause methodologies will provide a specific definition of the term root cause and will require examination for confirmation that the causes that have been identified as root causes are indeed root causes. 

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 terms root cause or multiple root causes appear several times without a clear definition. When Jack Philley teaches the Investigating Process Safety Incidents course for the AIChE, he offers several clear definitions. He describes a root cause as a prime reason, underlying cause, and most often associated with breakdowns or flaws in the management systems. Furthermore, Philley s class notes point out definitions from the Department of Energy Guidelines in his handout, which states ... 

Whenever a proactive maintenance strategy is applied, three steps are necessary to ensure that its benefits are achieved. Since proactive maintenance, by definition, involves continuous monitoring and controlling of machine failure root causes, the first step is simply to set a target, or a standard, associated with each root cause. In oil analysis, the most important root causes relate to fluid contamination (particles, moisture, heat, coolant, etc.). 

Definition of Classes and Potential Root Causes for Exceptions in a Laboratory... 

Because the term root cause is inherently abstract and, because it means different things to different people, it is difficult to come up with an agreed-upon definition, as described in the following quotation (Nehns, 2007) ... 

Another investigator may find that the maintenance technician who installed the seal had not been provided with accurate procedures and had never received training for the installation of this type of seal. Therefore, his root cause trail will scrutinize the process for writing procedures and for making sure that people are properly trained in the use of those procedures. His definition for the root cause of the failure may be Failure to write adequate maintenance procedures and to properly train maintenance technicians. ... 

Yet, in spite of all the difficulties outlined above a working definition for the term root cause is needed. The Center for Chemical Process Safety (CCPS, 2003) provides the following definition for the term root cause. 

The above definition highlights some of the difficulties with defining the term root cause that have already been discussed. For example, the definition assumes that fundamental causes... 

A key word in the above definition is correctable. Managers at all levels need the root cause analysis to provide them with practical guidance—something that will help them correct their problems, and thereby improve their culture. The need for defining root causes that can help lead to solutions is demonstrated in the following paraphrased definition, adapted from Mark Paradies,... 

A summary of the root causes and the process that was used for identifying them should be provided, along with a working definition of the term root cause. ... 

The principle of safety definition states that the basic or root causes must be identified before a remedy is prescribed. Safety culture and climate surveys can assist in determining the strengths and weaknesses of a safety culture and help identify the basic causes of a less than acceptable culture. Once the problems have been identified, actions can then be effectively taken. 

In this paper, the author attempts to integrate general assmnptions about the structure of safety management into one picture which constitutes the backgroimd for root cause analysis, nowadays the most recommended investigation method. Initial representation of the structure (Fig. 2) is complemented by the definition of the boimdary of internal safety management. The definition e q)loits the tool called Root Cause Map. After the addition of two basic assumptions... 

However, for an incident investigation practitioner the definition of root causes is not as important as procedure how to obtain them. The guideline CCPS... 

Modified definitions of predefined tree and Root Cause Map encompassing the safety culture components were proposed since they seem to be useful and natural. 

When we look at the factors that are identified in the interviews, we can see that the different factors, and hence, the related explicit uncertainty that is caused by them, can all be related to the different stages of the product lifecycle as, for example, defined by Bedford, Quigley and Walls (Bedford et al. 2006), i.e. concept and definition, design and development, manufacturing and installation, operation and maintenance. We see for example that the concept root-cause analysis (here, uncertainty is caused by this concept because we do not know the extent to which we are able to find the root-cause) can typically be related to the operation and maintenance phase. On the other hand, the concept supplier management (here, uncertainty is caused by the unknown level of quahty with which supplier management is applied) typically relates to the design and development phase. 

Phase 1 develops the strategy, including as-is documentation and evaluation, definition of the destination, and identification of gaps and root causes. Phase 2, to implement the strategy, addresses the barriers to improvement described in Section 13.1.2. These barriers are lack of focus, confusion about technology and costs, motivators, boundaries, and slowness due to rigidity. 

The procedure continues until there is a root cause. It is possible that analysis does not uncover a root cause that meets the definition. 

The main benefit is the reduction in the number of accidents that cause injury to employees and damage to property. Another major benefit of near miss reporting is that it is easier to get to the root causes of the event since nobody has been injured or killed, so there is no pressing need for a cover-up. According to Jones et al. (1999), case studies of offshore oil rigs have indicated a 60-percent reduction in disabling injuries after the 10-fold increase in near miss incident reporting. Other reports indicate that there is a definite correlation between the number of near miss incidents reported and the reduction in the number of serious injuries experienced. The results... 

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