1. Root Cause Analysis Systems Safety Technique used to identify the “Root Causes” of accidents A root cause is the most basic cause for a accident that can be identified. Effective recommendations can be made to fix the problem.

2. Root Cause Analysis Process Determine what happened in a particular accident Determine how it happened Determine why it happened

3. Steps in the process Accident occurs Collect evidence Analyze information Identify root causes Develop recommendations

4. Data to collect People Physical evidence Position (location of people and physical evidence) Paper

5. Causal Factor Charting Determine: Loss events: what prompted the need for the investigation Primary events: Actions leading up to the loss event Secondary event: Actions or happenings that led to the primary events Conditions: Circumstances pertinent to the loss event

6. Causal Factor Charting Develop building blocks Identify actions or conditions One actor and one verb Time of the events or conditions Location

7. Identifying Causal Factors With the events charted out, identify the causal factors Causal factors are those contributors (both human actions and component failures) that if eliminated, would have prevented the occurrence or reduced its severity.

8. Root Cause Levels Root Cause Map used to identify the root causes

9. Levels of the Root Cause Map Primary Difficulty Source Equipment, People, or Other Problem Categories Equipment Reliability Root Cause Category Admin, Procedures, Training, etc. Near Root Cause Circle items Root Causes Bottom level

10. Using the Root Cause Map Map is read from the top down May be used multiple times with one accident Depends upon the number of root causes Shape next to descriptor represents the map level Numbers in the shapes represent the page number in the book.

11. Using the Root Cause Map Start with the causal factor Determine the Primary Difficulty Source Determine the problem category Determine Root Cause Category Any root cause category may be analyzed under each Problem Category (Except Equipment Design) Determine Root Causes

12. Developing Recommendations For each node (Root cause box), typical recommendations are provided to offset that particular root cause.

13. Summarizing Findings of Root Cause Analysis Set up a table with 3 columns Column #1: Description of the causal factor Column #2: Paths through the Root Cause map Column #3: Recommendations