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Root Cause Analysis Handbook : A Guide to Efficient and Effective Incident Investigation.

By: Contributor(s): Material type: TextTextPublisher: Brooksfield : Rothstein Associates, Incorporated, 2008Copyright date: ©2008Edition: 3rd edDescription: 1 online resource (322 pages)Content type:
  • text
Media type:
  • computer
Carrier type:
  • online resource
ISBN:
  • 9781931332729
Subject(s): Genre/Form: Additional physical formats: Print version:: Root Cause Analysis HandbookDDC classification:
  • 658.5/620285
LOC classification:
  • TS156 .R665 2008
Online resources:
Contents:
Cover Page -- Title page -- Copyright -- Table of Contents -- List of Figures -- List of Tables -- List of Acronyms -- Foreword -- Section 1: Basics of Incident Investigation -- 1.1 The Need for Incident Investigation -- 1.1.1 Rationale for Taking a Structured Approach to Incident Investigation -- 1.1.2 Depths of Analyses -- 1.1.3 Structured Analysis Process -- 1.2 Selecting Incidents to Investigate -- 1.3 The Investigation Thought Process -- 1.3.1 Differences Between Traditional Problem Solving and Structured RCA -- 1.3.2 The Typical Investigator -- 1.3.3 A Structured Approach to the Analysis -- 1.4 RCA Within a Business Context -- 1.5 The Elements of an Incident -- 1.6 Causal Factors and Root Causes -- 1.7 The Goal of the Incident Investigation Process -- 1.8 Overview of the SOURCE™ Methodology -- 1.9 The SOURCE™ Root Cause Analysis Process -- 1.9.1 Steps That Apply to Acute Incident Analyses -- 1.9.2 Steps That Apply to Chronic Incident Analyses -- 1.9.3 Steps That Apply When No Formal Analyses Are Performed -- 1.9.4 Steps That Apply to All Analyses -- 1.10 Levels of the Analysis: Root Cause Analysis and ApparentCause Analysis -- 1.11 Definitions -- 1.12 Summary -- Section 2: Initiating Investigations -- 2.1 Initiating the Investigation -- 2.2 Notification -- 2.3 Emergency Response Activities -- 2.4 Immediate Response Activities -- 2.5 Beginning the Investigation -- 2.6 Initial Incident Reports and Corrective Action Requests -- 2.6.1 Reasons to Generate an IIR or CAR -- 2.6.3 Using the IIR or CAR in the Incident Investigation Process -- 2.6.2 Typical Information Contained in an IIR or CAR -- 2.7 Incident Classification -- 2.8 Investigation Management Tasks -- 2.9 Assembling the Team -- 2.10 Briefing the Team -- 2.11 Restart Criteria -- 2.12 Gathering Investigation Resources -- 2.13 Summary -- Section 3: Gathering and Preserving Data.
3.1 Introduction -- 3.2 General Data-gathering and Preservation Issues -- 3.2.1 Importance of Data-gathering -- 3.2.2 Types of Data -- 3.2.3 Prioritizing Data-gathering Efforts -- 3.2.3.1 People Data Fragility Issues -- 3.2.3.2 Electronic Data Fragility Issues -- 3.2.3.3 Physical/Position Data Fragility Issues -- 3.2.3.4 Paper Data Fragility Issues -- 3.3 Gathering Data -- 3.4 Gathering Data from People -- 3.4.1 Factors to Assess the Credibility of People Data -- 3.4.2 Initial Witness Statements -- 3.4.3 The Interview Process -- 3.4.3.1 Before the Interviews -- 3.4.3.2 Beginning the Interview -- 3.4.3.3 Conducting the Interview -- 3.4.3.4 Concluding the Interview -- 3.4.3.5 Follow-up Interviews -- 3.5 Physical Data -- 3.5.1 Sources of Physical Data -- 3.5.2 Types and Nature of Physical Data Analysis Questions -- 3.5.3 Basic Steps in Failure Analysis -- 3.5.4 Use of Physical Data Analysis Plans -- 3.5.5 Chain of Custody for Physical Data -- 3.5.6 Use of Outside Experts -- 3.6 Paper Data -- 3.7 Electronic Data -- 3.8 Position Data -- 3.8.1 Unique Aspects of Position Data -- 3.8.2 Collection of Position Data -- 3.8.3 Documentation of Photos and Videos -- 3.8.4 Alternative Sources of Position Data -- 3.9 Overall Data-collection Plan -- 3.10 Application to Apparent Cause Analyses andRoot Cause Analyses -- 3.11 Summary -- Section 4: Analyzin g Data -- 4.1 Introduction -- 4.2 Overview of Primary Techniques -- 4.3 Cause and Effect Tree Analysis -- 4.4 Timelines -- 4.5 Causal Factor Charts -- 4.6 Using Causal Factor Charts, Timelines, and Cause andEffect Trees Together During an Investigation -- 4.7 Application to Apparent Cause Analyses and Root CauseAnalyses -- 4.8 Summary -- Section 5: Identifying Root Causes -- 5.1 Introduction -- 5.2 Root Cause Analysis Traps -- 5.2.1 Trap 1 - Equipment Issues -- 5.2.2 Trap 2 - Human Performance Issues.
5.2.3 Trap 3 - External Event Issues -- 5.3 Procedure for Identifying Root Causes -- 5.4 ABS Consulting's Root Cause Map™ -- 5.5 Observations About the Structure of the Root Cause Map™ -- 5.6 Using the Root Cause Map™ -- 5.6.1 The Five Steps -- 5.6.2 Multiple Coding -- 5.6.3 Incorporating Organizational Standards, Policies, and Administrative Controls -- 5.6.4 Using the Root Cause Map™ Guidance During an Investigation -- 5.6.5 Typical Problems Encountered When Using the Root Cause Map™ -- 5.6.6 Advantages and Disadvantage of Using the Root Cause Map™ -- 5.7 Documenting the Root Cause Analysis Process -- 5.8 Application to Apparent Cause Analyses and Root CauseAnalyses -- 5.9 Summary -- Section 6: Developing Recommendations -- 6.1 Introduction -- 6.2 Timing of Recommendations -- 6.3 Levels of Recommendations -- 6.3.1 Level 1 - Address the Causal Factor -- 6.3.2 Level 2 - Address the Intermediate Causes of the Specific Problem -- 6.3.3 Level 3 - Fix Similar Problems -- 6.3.4 Level 4 - Correct the Process That Creates These Problems -- 6.4 Types of Recommendations -- 6.4.1 Eliminate the Hazard -- 6.4.2 Make the System Inherently Safer or More Reliable -- 6.4.3 Prevent Occurrence of the Incident -- 6.4.4 Detect and Mitigate the Loss -- 6.4.5 Implementing Multiple Types of Recommendations -- 6.5 Suggested Format for Recommendations -- 6.6 Special Recommendation Issues -- 6.7 Management Responsibilities -- 6.8 Examples of Reasons to Reject Recommendations -- 6.9 Assessing Benefit/Cost Ratios -- 6.9.1 Estimating the Benefits of Implementing a Recommendation -- 6.9.2 Estimating the Costs of Implementing a Recommendation -- 6.9.3 Benefit/Cost Ratios -- 6.10 Assessing Recommendation Effectiveness -- 6.11 Application to Apparent Cause Analyses and Root CauseAnalyses -- 6.12 Summary -- Section 7: Completing the Investigation -- 7.1 Introduction.
7.2 Writing Investigation Reports -- 7.2.1 Typical Items to Be Included in an Investigation Report -- 7.2.2 Tips for Writing Reports -- 7.3 Communicating Investigation Results -- 7.3.2 Decide How to Distribute the Report -- 7.3.1 Decide to Whom the Results Should Be Communicated -- 7.3.3 Document the Communication -- 7.4 Resolving Recommendations and CommunicatingResolutions -- 7.4.1 Tracking Recommendations -- 7.4.2 Report Resolution Phase and Closure of Files -- 7.5 Addressing Final Issues -- 7.5.1 Enter Trending Data -- 7.5.2 Evaluate the Investigation Process -- 7.6 Application to Apparent Cause Analyses and Root CauseAnalyses -- 7.7 Summary -- Section 8: Selecting Incidents for Analysis -- 8.1 Introduction -- 8.2 Why Be Careful When Selecting Incidents for Investigation? -- 8.3 Some General Guidance -- 8.3.1 Incidents to Investigate (High Potential Learning Value) -- 8.3.2 Incidents to Trend (Low to Moderate Potential Learning Value) -- 8.3.3 No Investigation (Low Potential Learning Value) -- 8.4 Performing the Investigation -- 8.4.1 Incidents to Investigate Immediately (Acute Incidents) -- 8.4.2 Incidents to Trend (Potentially Chronic Incidents) -- 8.5 Near Misses -- 8.5.1 Factors to Consider When Defining Near Misses -- 8.5.2 Reasons Why Near Misses Should Be Investigated -- 8.5.3 Barriers to Getting Near Misses Reported -- 8.5.4 Overcoming the Barriers -- 8.6 Acute Analysis Versus Chronic Analysis -- 8.7 Identifying Chronic Incidents That Should Be Analyzed -- 8.7.1 Using Pareto Analysis for Environmental, Health, and Safety Incidents -- 8.7.1.1 Examples of Pareto Analysis -- 8.7.1.2 Weaknesses of Pareto Analysis -- 8.7.2 Chronic Analysis of Reliability Problems -- 8.7.2.1 Prioritizing the RCA Efforts -- 8.7.2.2 Repeating the Process -- 8.7.3 Chronic Analysis for Quality Incidents -- 8.7.3.1 Prioritizing the RCA Efforts.
8.7.3.2 Repeating the Process -- 8.7.4 Other Data Analysis Tools -- 8.8 Summary -- Section 9: Data and Results Trending -- 9.1 Introduction -- 9.2 Benefits of a Trending Program -- 9.3 Determining the Data to Collect -- 9.3.1 Deciding What Data to Collect -- 9.3.2 Defining the Data to Collect -- 9.3.3 Other Data-collection Guidance -- 9.4 Data Analysis -- 9.4.1 Interpreting Data Trends -- 9.5 Application to Apparent Cause Analyses and Root CauseAnalyses -- 9.6 Summary -- Section 10: Program Development -- 10.1 Introduction -- 10.2 Program Implementation Process -- 10.2.1 Design the Program -- 10.2.2 Develop the Program -- 10.2.3 Implement the Program -- 10.2.4 Monitor the Program's Performance -- 10.2.5 Improve the Program -- 10.3 Key Considerations -- 10.3.1 Legal Considerations and Guidelines -- 10.3.2 Media Considerations -- 10.3.3 Some Regulatory Requirements and Industry Standards -- 10.3.4 Training -- 10.4 Management Influence on the Program -- 10.5 Common Investigation Problems and Solutions -- 10.5.1 There Is No Business Driver to Change -- 10.5.2 There Is No Organizational Champion for the Program -- 10.5.3 The Organization Never Leaves the Reactive Mode -- 10.5.4 The Organization Must Find an Individual to Blame -- 10.5.5 Personnel Are Unwilling to Critique Management Systems -- 10.5.6 Reward Implementation of Recommendations -- 10.5.7 The Organization Tries to Investigate Everything -- 10.5.8 The Organization Only Performs Incident Investigations on Large Incidents -- 10.5.9 Recommendations Are Never Implemented -- 10.6 Summary -- Section 11: Contents of the Downloadable Resources -- 11.1 Introduction -- 11.2 Resources Available on the Companion CD and atwww.absconsulting.com/RCAHandbookResources -- 11.2.1 SOURCE™ Investigator's Toolkit -- 11.2.2 Updates and Modifications to the Root Cause Map™ Guidance (only available onthe Web site).
11.2.3 Examples Specific to Handbook Sections.
Summary: Most complete, all-in-one package for root cause analysis, including 600+ pages of book and downloadable resources; color-coded, 17" x 22" Root Cause MapTM; and licensed access to extensive online resources. Based on globally successful, proprietary.
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Cover Page -- Title page -- Copyright -- Table of Contents -- List of Figures -- List of Tables -- List of Acronyms -- Foreword -- Section 1: Basics of Incident Investigation -- 1.1 The Need for Incident Investigation -- 1.1.1 Rationale for Taking a Structured Approach to Incident Investigation -- 1.1.2 Depths of Analyses -- 1.1.3 Structured Analysis Process -- 1.2 Selecting Incidents to Investigate -- 1.3 The Investigation Thought Process -- 1.3.1 Differences Between Traditional Problem Solving and Structured RCA -- 1.3.2 The Typical Investigator -- 1.3.3 A Structured Approach to the Analysis -- 1.4 RCA Within a Business Context -- 1.5 The Elements of an Incident -- 1.6 Causal Factors and Root Causes -- 1.7 The Goal of the Incident Investigation Process -- 1.8 Overview of the SOURCE™ Methodology -- 1.9 The SOURCE™ Root Cause Analysis Process -- 1.9.1 Steps That Apply to Acute Incident Analyses -- 1.9.2 Steps That Apply to Chronic Incident Analyses -- 1.9.3 Steps That Apply When No Formal Analyses Are Performed -- 1.9.4 Steps That Apply to All Analyses -- 1.10 Levels of the Analysis: Root Cause Analysis and ApparentCause Analysis -- 1.11 Definitions -- 1.12 Summary -- Section 2: Initiating Investigations -- 2.1 Initiating the Investigation -- 2.2 Notification -- 2.3 Emergency Response Activities -- 2.4 Immediate Response Activities -- 2.5 Beginning the Investigation -- 2.6 Initial Incident Reports and Corrective Action Requests -- 2.6.1 Reasons to Generate an IIR or CAR -- 2.6.3 Using the IIR or CAR in the Incident Investigation Process -- 2.6.2 Typical Information Contained in an IIR or CAR -- 2.7 Incident Classification -- 2.8 Investigation Management Tasks -- 2.9 Assembling the Team -- 2.10 Briefing the Team -- 2.11 Restart Criteria -- 2.12 Gathering Investigation Resources -- 2.13 Summary -- Section 3: Gathering and Preserving Data.

3.1 Introduction -- 3.2 General Data-gathering and Preservation Issues -- 3.2.1 Importance of Data-gathering -- 3.2.2 Types of Data -- 3.2.3 Prioritizing Data-gathering Efforts -- 3.2.3.1 People Data Fragility Issues -- 3.2.3.2 Electronic Data Fragility Issues -- 3.2.3.3 Physical/Position Data Fragility Issues -- 3.2.3.4 Paper Data Fragility Issues -- 3.3 Gathering Data -- 3.4 Gathering Data from People -- 3.4.1 Factors to Assess the Credibility of People Data -- 3.4.2 Initial Witness Statements -- 3.4.3 The Interview Process -- 3.4.3.1 Before the Interviews -- 3.4.3.2 Beginning the Interview -- 3.4.3.3 Conducting the Interview -- 3.4.3.4 Concluding the Interview -- 3.4.3.5 Follow-up Interviews -- 3.5 Physical Data -- 3.5.1 Sources of Physical Data -- 3.5.2 Types and Nature of Physical Data Analysis Questions -- 3.5.3 Basic Steps in Failure Analysis -- 3.5.4 Use of Physical Data Analysis Plans -- 3.5.5 Chain of Custody for Physical Data -- 3.5.6 Use of Outside Experts -- 3.6 Paper Data -- 3.7 Electronic Data -- 3.8 Position Data -- 3.8.1 Unique Aspects of Position Data -- 3.8.2 Collection of Position Data -- 3.8.3 Documentation of Photos and Videos -- 3.8.4 Alternative Sources of Position Data -- 3.9 Overall Data-collection Plan -- 3.10 Application to Apparent Cause Analyses andRoot Cause Analyses -- 3.11 Summary -- Section 4: Analyzin g Data -- 4.1 Introduction -- 4.2 Overview of Primary Techniques -- 4.3 Cause and Effect Tree Analysis -- 4.4 Timelines -- 4.5 Causal Factor Charts -- 4.6 Using Causal Factor Charts, Timelines, and Cause andEffect Trees Together During an Investigation -- 4.7 Application to Apparent Cause Analyses and Root CauseAnalyses -- 4.8 Summary -- Section 5: Identifying Root Causes -- 5.1 Introduction -- 5.2 Root Cause Analysis Traps -- 5.2.1 Trap 1 - Equipment Issues -- 5.2.2 Trap 2 - Human Performance Issues.

5.2.3 Trap 3 - External Event Issues -- 5.3 Procedure for Identifying Root Causes -- 5.4 ABS Consulting's Root Cause Map™ -- 5.5 Observations About the Structure of the Root Cause Map™ -- 5.6 Using the Root Cause Map™ -- 5.6.1 The Five Steps -- 5.6.2 Multiple Coding -- 5.6.3 Incorporating Organizational Standards, Policies, and Administrative Controls -- 5.6.4 Using the Root Cause Map™ Guidance During an Investigation -- 5.6.5 Typical Problems Encountered When Using the Root Cause Map™ -- 5.6.6 Advantages and Disadvantage of Using the Root Cause Map™ -- 5.7 Documenting the Root Cause Analysis Process -- 5.8 Application to Apparent Cause Analyses and Root CauseAnalyses -- 5.9 Summary -- Section 6: Developing Recommendations -- 6.1 Introduction -- 6.2 Timing of Recommendations -- 6.3 Levels of Recommendations -- 6.3.1 Level 1 - Address the Causal Factor -- 6.3.2 Level 2 - Address the Intermediate Causes of the Specific Problem -- 6.3.3 Level 3 - Fix Similar Problems -- 6.3.4 Level 4 - Correct the Process That Creates These Problems -- 6.4 Types of Recommendations -- 6.4.1 Eliminate the Hazard -- 6.4.2 Make the System Inherently Safer or More Reliable -- 6.4.3 Prevent Occurrence of the Incident -- 6.4.4 Detect and Mitigate the Loss -- 6.4.5 Implementing Multiple Types of Recommendations -- 6.5 Suggested Format for Recommendations -- 6.6 Special Recommendation Issues -- 6.7 Management Responsibilities -- 6.8 Examples of Reasons to Reject Recommendations -- 6.9 Assessing Benefit/Cost Ratios -- 6.9.1 Estimating the Benefits of Implementing a Recommendation -- 6.9.2 Estimating the Costs of Implementing a Recommendation -- 6.9.3 Benefit/Cost Ratios -- 6.10 Assessing Recommendation Effectiveness -- 6.11 Application to Apparent Cause Analyses and Root CauseAnalyses -- 6.12 Summary -- Section 7: Completing the Investigation -- 7.1 Introduction.

7.2 Writing Investigation Reports -- 7.2.1 Typical Items to Be Included in an Investigation Report -- 7.2.2 Tips for Writing Reports -- 7.3 Communicating Investigation Results -- 7.3.2 Decide How to Distribute the Report -- 7.3.1 Decide to Whom the Results Should Be Communicated -- 7.3.3 Document the Communication -- 7.4 Resolving Recommendations and CommunicatingResolutions -- 7.4.1 Tracking Recommendations -- 7.4.2 Report Resolution Phase and Closure of Files -- 7.5 Addressing Final Issues -- 7.5.1 Enter Trending Data -- 7.5.2 Evaluate the Investigation Process -- 7.6 Application to Apparent Cause Analyses and Root CauseAnalyses -- 7.7 Summary -- Section 8: Selecting Incidents for Analysis -- 8.1 Introduction -- 8.2 Why Be Careful When Selecting Incidents for Investigation? -- 8.3 Some General Guidance -- 8.3.1 Incidents to Investigate (High Potential Learning Value) -- 8.3.2 Incidents to Trend (Low to Moderate Potential Learning Value) -- 8.3.3 No Investigation (Low Potential Learning Value) -- 8.4 Performing the Investigation -- 8.4.1 Incidents to Investigate Immediately (Acute Incidents) -- 8.4.2 Incidents to Trend (Potentially Chronic Incidents) -- 8.5 Near Misses -- 8.5.1 Factors to Consider When Defining Near Misses -- 8.5.2 Reasons Why Near Misses Should Be Investigated -- 8.5.3 Barriers to Getting Near Misses Reported -- 8.5.4 Overcoming the Barriers -- 8.6 Acute Analysis Versus Chronic Analysis -- 8.7 Identifying Chronic Incidents That Should Be Analyzed -- 8.7.1 Using Pareto Analysis for Environmental, Health, and Safety Incidents -- 8.7.1.1 Examples of Pareto Analysis -- 8.7.1.2 Weaknesses of Pareto Analysis -- 8.7.2 Chronic Analysis of Reliability Problems -- 8.7.2.1 Prioritizing the RCA Efforts -- 8.7.2.2 Repeating the Process -- 8.7.3 Chronic Analysis for Quality Incidents -- 8.7.3.1 Prioritizing the RCA Efforts.

8.7.3.2 Repeating the Process -- 8.7.4 Other Data Analysis Tools -- 8.8 Summary -- Section 9: Data and Results Trending -- 9.1 Introduction -- 9.2 Benefits of a Trending Program -- 9.3 Determining the Data to Collect -- 9.3.1 Deciding What Data to Collect -- 9.3.2 Defining the Data to Collect -- 9.3.3 Other Data-collection Guidance -- 9.4 Data Analysis -- 9.4.1 Interpreting Data Trends -- 9.5 Application to Apparent Cause Analyses and Root CauseAnalyses -- 9.6 Summary -- Section 10: Program Development -- 10.1 Introduction -- 10.2 Program Implementation Process -- 10.2.1 Design the Program -- 10.2.2 Develop the Program -- 10.2.3 Implement the Program -- 10.2.4 Monitor the Program's Performance -- 10.2.5 Improve the Program -- 10.3 Key Considerations -- 10.3.1 Legal Considerations and Guidelines -- 10.3.2 Media Considerations -- 10.3.3 Some Regulatory Requirements and Industry Standards -- 10.3.4 Training -- 10.4 Management Influence on the Program -- 10.5 Common Investigation Problems and Solutions -- 10.5.1 There Is No Business Driver to Change -- 10.5.2 There Is No Organizational Champion for the Program -- 10.5.3 The Organization Never Leaves the Reactive Mode -- 10.5.4 The Organization Must Find an Individual to Blame -- 10.5.5 Personnel Are Unwilling to Critique Management Systems -- 10.5.6 Reward Implementation of Recommendations -- 10.5.7 The Organization Tries to Investigate Everything -- 10.5.8 The Organization Only Performs Incident Investigations on Large Incidents -- 10.5.9 Recommendations Are Never Implemented -- 10.6 Summary -- Section 11: Contents of the Downloadable Resources -- 11.1 Introduction -- 11.2 Resources Available on the Companion CD and atwww.absconsulting.com/RCAHandbookResources -- 11.2.1 SOURCE™ Investigator's Toolkit -- 11.2.2 Updates and Modifications to the Root Cause Map™ Guidance (only available onthe Web site).

11.2.3 Examples Specific to Handbook Sections.

Most complete, all-in-one package for root cause analysis, including 600+ pages of book and downloadable resources; color-coded, 17" x 22" Root Cause MapTM; and licensed access to extensive online resources. Based on globally successful, proprietary.

Description based on publisher supplied metadata and other sources.

Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2024. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.

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