1. Root Cause Analysis for Effective Incident Investigation
Christy Wolter, CIH
Principal Consultant
Environmental and Occupational Risk Management (EORM®)
April 7, 2005

2. Outline Introduction What is Root Cause Analysis (RCA)?
How does RCA work?
Tips to make your RCA more effective
Interviewing techniques
© 2005 EORM, Inc.

3. What is Root Cause Analysis (RCA)?
One of several tools suitable for after the fact investigations
Most straightforward method sufficiently structured to identify, and determine relationships between, various events and issues that may have combined to produce the incident
© 2005 EORM, Inc.

4. How Does RCA Work? Symptoms vs. Roots Employee fell down
Employee was careless
Employee under time pressure
Under time pressure because of overlapping delivery dates
Delivery dates overlap because of poor communication between teams
Poor communication exists because…
Symptoms vs. Roots
Keep going further by asking “why?”
© 2005 EORM, Inc.

5. The Root The root cause is typically not simply machine failure
The root cause is more typically:
Machine failure due to improper maintenance, contributed to by both difficulty of maintenance access and unclear procedures, each exacerbated by lack of procedure review because no management of change process….(can we go further?)
© 2005 EORM, Inc.

6. Has a Root Cause Been Identified?
Thermocouple probe reading high
Wrong manual valve opened
Pressure set point incorrect
Object lifted was too heavy
Procedural step performed out of order
© 2005 EORM, Inc.

7. How Does RCA Work?
Start with a descriptive statement of the incident/near miss
Determine what conditions, events, and/or factors might have caused (alone) or contributed to (in combination with other conditions) the incident. These are your primary (1o) factors (i.e., Why?)
Determine conditions/events/factors that may have caused or contributed to the primary factors. These are your secondary (2o) factors (i.e., Why?)
© 2005 EORM, Inc.

8. Examples of RCA Documentation
Fishbone (cause and effect) diagram
Simplified logic diagram
© 2005 EORM, Inc.

9. Example Fishbone Diagram
© 2005 EORM, Inc.

10. Example Root Cause Diagram
© 2005 EORM, Inc.

11. Chronology of an Incident Investigation
Event occurs
Collect information from the scene of the event
Gather more information (witnesses, system information, etc.)
Conduct detailed RCA
Write an Action Plan
Implement the Action Plan
Review results
Modify Action Plan as necessary
© 2005 EORM, Inc.

12. Tips For More Effective RCAs
Factors concisely written yet sufficiently descriptive
Will the logic be understandable to persons not in the session, or to you a few years from now?
Speculation is clearly identified as such
Actionable items are clearly defined
Conduct analysis as soon as possible after data have been gathered
Disallow blame
© 2005 EORM, Inc.

13. Tips For More Effective RCAs
Assemble a knowledgeable team
Use the 80/20 Rule
Tackle one branch at a time…. this helps keep team’s thoughts organized
Use brainstorming techniques
Don’t disrupt the brainstorm by trying to perfect the flow/diagram!
Stay ½-step ahead of your team when diagramming
Prevent skipping levels or jumping to conclusions
© 2005 EORM, Inc.

14. Focusing the Analysis
Consider the likelihood and magnitude of impact of each potential cause, and assess most deeply (i.e., spend the most time on) those most likely or that may contribute most impact.
Although the team may brainstorm 20+ potential causes, they vary in placement along the continuum…
Defies the laws Happens every day of physics everywhere
© 2005 EORM, Inc.

15. Conducting RCA Interviews
Create a list of questions to ask in advance
Avoid conducting a Root Blame interview
Ask how injured employees are doing
© 2005 EORM, Inc.

16. Examples Of Questions To Ask
Process Equipment Questions
Were any operating parameters (e.g., temperature, pressure, flow rates) changed just prior to the incident (preceding minutes, hours, or days, depending on length of operation)?
Were operating conditions leading up to the incident recorded (e.g., strip charts, process control system print outs, instrumentation )?
Were any reactants changed just prior to the incident (e.g., new chemical used, change in chemical concentration, change in chemical vendor)?
Employee Interaction
Was the employee involved in the incident interacting with the process equipment at the time (e.g., adjusting valves, performing a manual procedure, servicing, troubleshooting, calibrating)?
Was the employee involved in the incident using support equipment at the time (e.g., ladder, extension cord, lift devices, portable pumps for maintenance)?
© 2005 EORM, Inc.

17. Examples Of Questions To Ask
Documentation
Do written procedures exist for the operation/activity performed at the time of the incident?
Do written maintenance procedures exist for the equipment involved in the incident?
Was maintenance performed on the equipment involved in the incident?
Did clearly-written procedures exist for all tasks required for this process/equipment?
Do written procedures describe the potential consequences of deviations?
Do written procedures describe the PPE required?
Systems Review
Was the appropriate PPE available and worn?
Have you received training on this process and equipment?
© 2005 EORM, Inc.

18. Focusing the Analysis
Consider the likelihood and magnitude of impact of each potential cause, and assess most deeply (i.e., spend the most time on) those which are most likely or which may contribute most of the impact. Although the team may brainstorm 20+ potential causes, they vary in their placement along the continuum…
Defies the laws of physics Happens every day everywhere
© 2005 EORM, Inc.

19. Summary
Use Root Cause Analysis for actual or near miss incidents, to prevent recurrence
Maximize effectiveness by gathering the right data and following the approach outlined in this course
Keep the analysis and its documentation as straightforward as possible, to enhance the probability you will continue to use it in the future!
© 2005 EORM, Inc.