Root Cause Analysis

for Effective Incident Investigation

Outline
Introduction
What is Root Cause Analysis (RCA)?
How does RCA work?
Tips to make your RCA more effective
Interviewing techniques

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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

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How Does RCA Work?
Employee fell down Symptoms vs. Roots
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 Keep going further
exists because by asking why?

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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?)
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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

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How Does RCA Work?
1. Start with a descriptive statement of the
incident/near miss
2. 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?)
3. Determine conditions/events/factors that
may have caused or contributed to the
primary factors. These are your secondary
(2o) factors (i.e., Why?)

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 Examples of RCA
Documentation
Fishbone (cause and effect) diagram

Simplified logic diagram

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 Example Fishbone Diagram

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 Example Root Cause
Diagram

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 Chronology of an Incident
Investigation
1. Event occurs
2. Collect information from the scene of
the event
3. Gather more information (witnesses,
system information, etc.)
4. Conduct detailed RCA
5. Write an Action Plan
6. Implement the Action Plan
7. Review results
8. Modify Action Plan as necessary
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 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

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 Tips For More Effective
RCAs
Assemble a knowledgeable team
Use the 80/20 Rule
Tackle one branch at a time.
this helps keep teams thoughts organized
Use brainstorming techniques
Dont disrupt the brainstorm by trying to perfect
the flow/diagram!
Stay -step ahead of your team when
diagramming
Prevent skipping levels or jumping to conclusions

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 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
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 Conducting RCA
Interviews
Create a list of
questions to ask in
advance
Avoid conducting a
Root Blame
interview
Ask how injured
employees are
doing

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 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
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 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?
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 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

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 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!

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