Cause Analysis Manual : Incident Investigation Method and Techniques.

Cover -- Title -- Copyright -- Table of Contents -- Acknowledgments -- Preface -- Foreword by Ben Whitmer -- Foreword by John D. Schnack -- Foreword by Mark Reidmeyer -- Introduction: Getting Started with Cause Analysis -- 0.1 Defining Cause Analysis -- 0.1.1 Purpose -- 0.1.2 Method -- 0.2 Successful and Unsuccessful Results -- 0.2.1 Success (Positive Results) -- 0.2.2 Failure (Negative Results) -- 0.3 Human Behavior -- 0.3.1 Behavior Model 1 -- 0.3.2 Behavior Model 2 -- 0.3.3 Behavior Model 3 -- 0.3.4 Behavior Model 4 -- 0.4 Accountability -- 0.4.1 Personal and Organizational Accountability -- 0.5 Investigator Attitude (Mindset) -- 0.6 Investigation Steps -- 0.6.1 Job Task Analysis -- 0.6.2 The Seven-Step Methodology -- Step 1: Scope the Problem -- 1.1 Problem Statement -- 1.1.1 Problem Statement Examples -- 1.2 Problem Description -- 1.2.1 Problem Description Examples -- 1.3 Difference Mapping -- 1.3.1 Difference Mapping Examples -- 1.4 Extent of Condition Review -- 1.4.1 Extent of Condition Review Examples -- Step 2: Investigate the Factors -- 2.1 Evidence Preservation -- 2.1.1 Preserve and Control Evidence -- 2.1.2 Collect Physical Evidence -- 2.1.3 Collect Documentary Evidence -- 2.1.4 Collect Human Evidence -- 2.2 Witness Recollection Statement -- 2.3 Interviewing -- 2.3.1 Lines of Inquiry: Question Generators -- 2.3.2 Question Generator: Individual Mindset -- 2.3.3 Question Generator: Personal and Organizational Accountability -- 2.3.4 Question Generator: Management Control Elements -- 2.4 Pareto Analysis -- 2.4.1 Pareto Chart Template -- 2.4.2 Pareto Analysis Examples -- Step 3: Reconstruct the Story -- 3.1 Fault Tree Analysis -- 3.1.1 Fault Tree Example -- 3.2 Task Analysis -- 3.2.1 Task Analysis Example -- 3.3 Critical Activity Charting(Critical Incident Technique) -- 3.3.1 Critical Activity Chart Example.

3.4 Actions and Factors Charting -- 3.4.1 Actions and Factors Chart Example -- 3.4.2 Notes -- Step 4: Establish Contributing Factors -- 4.1 Contributing Factor Test -- 4.2 "Five" WHYs -- 4.2.1 "Five" WHYs Example -- 4.2.2 Exxon-Valdez Oil Spill Example -- 4.2.3 Tokai-Mura Criticality Incident Example -- 4.2.4 Reactor Trip Example -- 4.3 Cause and Effect Trees -- 4.3.1 Cause and Effect Tree Examples -- 4.4 Difference Analysis (a.k.a. Change Analysis) -- 4.4.1 Broken Back Example -- 4.4.2 Falling Objects Example -- 4.4.3 Breaker Trip Example -- 4.5 Defense Analysis (a.k.a. Barrier Analysis) -- 4.5.1 Breaker Fire Example -- 4.6 Structure Tree Diagrams -- 4.6.1 Fishbone (Ishikawa) Diagram -- 4.6.1.1 Forearm Fracture Example -- 4.6.1.2 Poor Safety Culture Example -- 4.6.2 Defense-in-Depth Analysis -- 4.6.3 MORT Analysis -- 4.6.3.1 MORT Maintenance Example -- 4.6.4 Production/Protection Strategy Analysis -- 4.6.5 Safety Culture Analysis -- Step 5: Validate Underlying Factors -- 5.1 Support/Refute Methodology -- 5.1.1 Truck Will Not Start Example -- 5.1.2 Crane Incident Example -- 5.2 WHY Factor Staircase -- 5.2.1 Lost Time Away Injury Example -- 5.2.2 Criticality Incident Example -- 5.2.3 Broken Back Example -- 5.3 Root Cause Test -- 5.4 Cause Evaluation Matrix -- 5.4.1 Dump Truck Example -- 5.5 Extent of Cause Review -- 5.5.1 Example 1: Flood Protection Strategy Inadequate -- 5.5.2 Example 2: Leak Due To Stress Corrosion Cracking -- 5.5.3 Example 3: Rental Car Flat Tire -- 5.5.4 Example 4: Waste Not Labeled as Required -- Step 6: Plan Corrective Actions -- 6.1 Action Plan -- 6.1.1 Change Management -- 6.1.2 S.M.A.R.T.E.R -- 6.1.2.1 Safety Precedence Sequence (Hierarchy of Corrective Action Effectiveness) -- 6.1.3 Barriers and Aids Analysis (Pros and Cons) -- 6.1.4 Solution Selection Tree -- 6.1.5 Solution Selection Matrix -- 6.1.6 Contingency Plan.

6.1.7 Lessons To Be Learned Communication Plan -- 6.1.8 Institutionalization/Active Coaching Plan -- 6.2 Effectiveness Review -- 6.2.1 Performance Indicator Development -- Step 7: Report Learnings -- 7.1 Preparing to Create Your Report -- 7.2 Report Template -- 7.2.1 Sample Incident Analysis Report Template -- 7.3 Grade Cards/Scoresheets -- 7.3.1 Root Cause Analysis - Sample Organizational Learning Scoresheet -- Appendix A: Creating Working Definitions -- Appendix B: Common Factor Analysis -- Glossary -- Index -- Credits -- About the Author.

A failure or accident brings your business to a sudden halt. How did it happen? What's at the root of the problem? What keeps it from happening again? Good detective work is needed -- but how do you go about it? In this new book, industry pioneer Fred Forck's seven-step cause analysis methodology guides you to the root of the incident, enabling you to act effectively to avoid loss of time, money, productivity, and quality.

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