ALBA PS5B4 PROJECT

Incident Reporting and Investigation Procedure - Attachment 5

Causal Factor/Issue:
Root Cause Tree
(Section 1)
START HERE with each causal factor/issue and select or eliminate each category to find root causes

HUMAN EQUIPMENT NATURAL OTHER

PERFORMANCE DIFFICULTY DISASTER/ (SPECIFY)
DIFFICULTY SABOTAGE

TOLERABLE DESIGN EQUIPMENT/ PREVENTIVE/ REPEAT

FAILURE PARTS PREDICTIVE FAILURE
DEFECTIVE MAINTENANCE

PROCUREMENT PM NI MANAGEMENT SYSTEM

DESIGN SPECS DESIGN REVIEW
MANUFACTURING Corrective
Actions
SPECS DESIGN NOT PROBLEM NOT INDEPENDANT No PM for PM for
NI TO SPECS ANTICIPATED REVIEW NI HANDLING Equipment
Equipment NI
Corrective Action NI
Equipment Management of STORAGE Corrective Action not
Environment Change (MOC) NI yet implemented
Not Considered
Hazard Analysis NI
QUALITY CONTROL Trending NI

Human Performance NI = NEEDS IMPROVEMENT

Troubleshooting
(15 Questions)
Directions:
Answer all questions and
then refer to the indicated
Basic Cause Categories on
the next sheet to investigate
the causes of the problem.
Basic Cause Categories on next May also substitute LTA (Less Than Adequate
Individual sheet to investigate or PIO (Potential Improvement Opportunity
Performance
Team Basic Cause Categories on next
Performance sheet to investigate
Was person excessively fatigued, HUMAN ENGINEERING
YES
impaired, upset, bored, distracted
or overwhelmed ? WORK DIRECTION
Did verbal communications or shift
change play a role in this problem ? YES
COMMUNICATIONS

Should the person have had and WORK DIRECTION

used a written procedure but did YES TRAINING
PROCEDURES Did failure to agree about the who/ YES
not ?
what/ when/ where of performing
HUMAN ENGINEERING the job play a role in this problem? COMMUNICATIONS

WORK DIRECTION
Was a mistake made while using a YES
procedure? PROCEDURES
Was communication needed across
YES
organisational boundaries or with
COMMUNICATIONS
other facilities?
Were alarms or displays to
recognise or to respond to a YES
HUMAN ENGINEERING
condition unavailable or
misunderstood ?

Management
TRAINING System
Were displays, alarms, controls,
tools, or equipment identified or YES
PROCEDURES
operated improperly?
HUMAN ENGINEERING

Was a task performed in a hurry or YES

MANAGEMENT SYSTEM
Did the person need more skill/ a short cut used?
TRAINING
knowledge to perform the job or to YES WORK DIRECTION
respond to conditions or to
understand system response ? WORK DIRECTION
Had management been warned of YES
this problem or had it happened MANAGEMENT SYSTEM
before?
Was work performed in an adverse
environment (Such as hot, humid, YES
dark, cramped, or hazardous ? HUMAN ENGINEERING
MANAGEMENT SYSTEM
Were policies, admin, controls, or YES
procedures not used, missing, or in WORK DIRECTION
need of improvement?

TRAINING PROCEDURES
Did work involve repetitive motion,
uncomfortable positions, vibration, YES
or heavy lifting ? HUMAN ENGINEERING
Should an independant quality YES
WORK DIRECTION control check have caught the QUALITY CONTROL
problem?

Continue on the next sheet by analysing the indicated Basic Cause Categories