Q U A LITY BA SICS
Root Cause Analysis
For Beginners
by J a m e s J . R o o n e y a n d L e e N . V a n d e n H e u v e l
ootcause analysis (RC A )is a process
R designed for use in investigating and cate-
gorizing the rootcauses ofevents w ith safe-
ty,health,environm ental,quality,reliability and
production im pacts.The term event is used to
In 50 W ords
O r Less
Rootcause analysis helps identify w hat,how
and w hy som ething happened,thus preventing
recurrence.
Rootcauses are underlying,are reasonably
identifiable,can be controlled by m anagem ent
and allow forgeneration ofrecom m endations.
The process involves data collection,cause
charting,rootcause identification and recom -
m endation generation and im plem entation.
generically identify occurrences thatproduce or
have the potentialto produce these types ofconse-
quences.
Sim ply stated,RC A is a tooldesigned to help
identify notonly w hatand how an eventoccurred,
butalso w hy ithappened.O nly w hen investiga-
tors are able to determ ine w hy an eventor failure
occurred w illthey be able to specify w orkable
corrective m easures thatpreventfuture events of
the type observed.
U nderstanding w hy an eventoccurred is the
key to developing effective recom m endations.
Im agine an occurrence during w hich an opera-
tor is instructed to close valve A ;instead,the
operator closes valve B.The typicalinvestiga-
tion w ould probably conclude operator error
w as the cause.
This is an accurate description ofw hathap-
pened and how ithappened.H ow ever,ifthe ana-
lysts stop here,they have notprobed deeply
enough to understand the reasons for the m istake.
Therefore,they do notknow w hatto do to pre-
ventitfrom occurring again.
In the case ofthe operator w ho turned the
w rong valve,w e are likely to see recom m enda-
tions such as retrain the operator on the proce-
dure,rem ind alloperators to be alertw hen
Q U A LITY BA SICS
m anipulating valves or em phasize to allpersonnel
thatcarefulattention to the job should be m ain-
tained atalltim es.Such recom m endations do little
to preventfuture occurrences.
G enerally,m istakes do notjusthappen butcan
be traced to som e w ell-defined causes.In the case
ofthe valve error,w e m ightask,W as the proce-
dure confusing? W ere the valves clearly labeled?
W as the operator fam iliar w ith this particular
task?
The answ ers to these and other questions w ill
help determ ine w hy the error took place and
w hatthe organization can do to preventrecur-
Identifying severe w eather
as the rootcause ofparts not
being delivered on tim e to
custom ers is notappropriate.
rence.In the case ofthe valve error,exam ple
recom m endations m ightinclude revising the
procedure or perform ing procedure validation to
ensure references to valves m atch the valve labels
found in the field.
Identifying rootcauses is the key to preventing
sim ilarrecurrences.A n added benefitofan effective
RC A is that,over tim e,the rootcauses identified
across the population ofoccurrences can be used to
targetm ajoropportunities forim provem ent.
If,forexam ple,a significantnum berofanalyses
pointto procurem entinadequacies,then resources
can be focused on im provem entofthis m anagem ent
system .Trending ofrootcauses allow s developm ent
ofsystem atic im provem ents and assessm entofthe
im pactofcorrective program s.
D efinition
A lthough there is substantialdebate on the defi-
nition ofrootcause,w e use the follow ing:
1. Rootcauses are specific underlying causes.
2. Rootcauses are those thatcan reasonably be
identified.
3. Rootcauses are those m anagem enthas control
to fix.
4. Rootcauses are those for w hich effective rec-
om m endations for preventing recurrences can
be generated.
Root cau ses are u n d erlyin g cau ses. The investi-
gators goalshould be to identify specific underly-
ing causes.The m ore specific the investigator can
be aboutw hy an eventoccurred,the easier itw ill
be to arrive atrecom m endations thatw illprevent
recurrence.
Root cau ses are th ose th at can reason ab ly b e
id en tified . O ccurrence investigations m ustbe cost
beneficial.Itis notpracticalto keep valuable m an-
pow er occupied indefinitely searching for the root
causes ofoccurrences.Structured RC A helps ana-
lysts getthe m ostoutofthe tim e they have invest-
ed in the investigation.
Root cau ses are th ose over w h ich m an agem en t
h as con trol. A nalysts should avoid using general
cause classifications such as operator error,equip-
m entfailure or externalfactor.Such causes are not
specific enough to allow m anagem entto m ake
effective changes.M anagem entneeds to know
exactly w hy a failure occurred before action can be
taken to preventrecurrence.
W e m ustalso identify a rootcause thatm anage-
m entcan influence.Identifying severe w eather
as the rootcause ofparts notbeing delivered on
tim e to custom ers is notappropriate.Severe w eath-
er is notcontrolled by m anagem ent.
Root cau ses are th ose for w h ich effective recom -
m en d ation s can b e gen erated . Recom m endations
should directly address the rootcauses identified
during the investigation.Ifthe analysts arrive at
vague recom m endations such as,Im prove adher-
ence to w ritten policies and procedures, then
they probably have notfound a basic and specific
enough cause and need to expend m ore effortin the
analysis process.
Four M ajor S teps
The RC A is a four-step process involving the fol-
low ing:
1. D ata collection.
2. C ausalfactor charting.
F IG U R E 1 C au sa l Fa cto r C h a rt

Burner Partone
Electric
burner
shortsout
CF

Pan
Arcing heats
bottom of Had it
aluminum notbeen
pan originallycharged?
Fire
extinguisher

Pan
Aluminum Had it
melts, leaked?
Jane forming Fire extinguisher,
hole in pan floor
Jane comes
to the door W hat Had it
exactly been
Conclusion did she see? previouslyused?
Grease ignites M ary Inspection tag
when it
Jane,M ary contacts Assum ed M ary M ary
burner
Fire M arysees Fire extinguisher
Jane rings
How generates the fire isnot
the doorbell
much oilis smoke on the stove charged
used?How M ary
much chicken?
Fire starts
Chicken, on the
pan,oil M ary M ary Jane,M ary M ary M ary M ary
stove
M ary M aryleaves M arytries Fire extinguisher
Smoke M aryruns
begins the frying to use doesnot
detector into the
frying chicken M ary the fire operate when
alarms kitchen
chicken unattended extinguisher M arytriesto use it
5:00pm CF M arymeets About5:10pm CF
with Jane
Pan M ary
10m inutes
M ary M arypulls
usesan the plug
aluminum on the fire
pan extinguisher
DoesM ary
Is"plug" know how
the same to use a fire
aspin? extinguisher?
M ary M ary
CF = Causalfactor

Figure 1 continued on nextpage

Q U A LITY BA SICS

Parttw o

Did she know W hatis

thiswaswrong? Jane doing during
Lackofpractice thistime?
fighting fires?
Did she do M ary,Jane
M ary
anything else? M ary,pan
M ary How long
Fire wasa Did the FD
did ittake forthe
grease fire use the correct
W asM ary FD to arrive?
techniques?
trying to do this? FD
dispatcher FD
M ary
Kitchen
destroyed
M ary Kitchen,M ary M ary,FD Observation FD,observation byfire
M arythrows Fire spreads M arycallsthe
wateron Fire department Fire department
throughout fire department
the fire arrives putsoutfire
the kitchen
CF Otherlosses
Tim e? Tim e? Time?
from smoke and
waterdamage?

3. Rootcause identification. drive the data collection process by identifying

4. Recom m endation generation and im plem enta-
tion.
Step on ed ata collection . The firststep in the
analysis is to gather data.W ithoutcom plete infor-
m ation and an understanding ofthe event,the
causalfactors and rootcauses associated w ith the
eventcannotbe identified.The m ajority oftim e
spentanalyzing an eventis spentin gathering
data.
Step twoCausal factor charting. Causalfactor
charting providesa structure forinvestigatorsto orga-
nize and analyze the inform ation gathered during
the investigation and identify gaps and deficiencies
in know ledge as the investigation progresses.The
causalfactor chartis sim ply a sequence diagram
w ith logic tests thatdescribes the events leading up
to an occurrence,plus the conditions surrounding
these events (see Figure 1,p.47).
Preparation ofthe causalfactor chartshould
begin as soon as investigators startto collectinfor-
m ation aboutthe occurrence.They begin w ith a
skeleton chartthatis m odified as m ore relevant
facts are uncovered.The causalfactor chartshould
data needs.
D ata collection continues untilthe investigators
are satisfied w ith the thoroughness ofthe chart
(and hence are satisfied w ith the thoroughness of
the investigation).W hen the entire occurrence has
been charted out,the investigators are in a good
position to identify the m ajor contributors to the
incident,called causalfactors.C ausalfactors are
those contributors (hum an errors and com ponent
failures)that,ifelim inated,w ould have either pre-
vented the occurrence or reduced its severity.
In m any traditionalanalyses,the m ostvisible
causalfactor is given allthe attention.Rarely,how -
ever,is there justone causalfactor;events are usu-
ally the resultofa com bination ofcontributors.
W hen only one obvious causalfactor is addressed,
the listofrecom m endations w illlikely notbe com -
plete.C onsequently,the occurrence m ay repeat
itselfbecause the organization did notlearn allthat
itcould from the event.
Step th reeroot cau se id en tification . A fter all
the causalfactors have been identified,the investi-
gators begin rootcause identification.This step
involves the use ofa decision diagram called the
RootC ause M ap (see Figure 2,p.50)to identify the
underlying reason or reasons for each causalfactor.
The m ap structures the reasoning process ofthe
investigators by helping them answ er questions
aboutw hy particular causalfactors existor
occurred.The identification ofrootcauses helps
the investigator determ ine the reasons the event
occurred so the problem s surrounding the occur-
rence can be addressed.
Step fou rrecom m en d ation gen eration an d
im p lem en tation . The nextstep is the generation of
recom m endations.Follow ing identification ofthe
rootcauses for a particular causalfactor,achievable
recom m endations for preventing its recurrence are
then generated.
The rootcause analystis often notresponsible
for the im plem entation ofrecom m endations gener-
ated by the analysis.H ow ever,ifthe recom m enda-
tions are notim plem ented,the effortexpended in
perform ing the analysis is w asted.In addition,the
events thattriggered the analysis should be expect-
ed to recur.O rganizations need to ensure thatrec-
om m endations are tracked to com pletion.
P resentation of R esults
Rootcause sum m ary tables (see Table 1,p.52)
can organize the inform ation com piled during data
analysis,rootcause identification and recom m en-
dation generation.Each colum n represents a m ajor
aspectofthe RC A process.
In the firstcolum n,a generaldescription ofthe
causalfactor is presented along w ith sufficient
background inform ation for the reader to be
able to understand the need to address this
causalfactor.
The second colum n show s the Path or Paths
through the RootC ause M ap associated w ith
the causalfactor.
The third colum n presents recom m endations
to address each ofthe rootcauses identified.
U se ofthis three-colum n form ataids the investi-
gator in ensuring rootcauses and recom m enda-
tions are developed for each causalfactor.
The end resultofan RC A investigation is gener-
ally an investigation report.The form atofthe
reportis usually w elldefined by the adm inistrative
docum ents governing the particular reporting sys-
tem ,butthe com pleted causalfactor chartand
causalfactor sum m ary tables provide m ostofthe
inform ation required by m ostreporting system s.
Exam ple P roblem
The follow ing exam ple is nontechnical,allow ing
the reader to focus on the analysis process and not
the technicalaspects ofthe situation.The follow ing
narrative is the accountofthe eventaccording to
M ary:
It w as 5 p.m .I w as frying chicken.M y friend
Jane stopped by on her w ay hom e from the doc-
tor, and she w as very upset. I invited her into
the living room so w e could talk.A fter about10
m inutes, the sm oke detector near the kitchen
cam e on.I ran into the kitchen and found a fire
on the stove.I reached for the fire extinguisher
and pulled the plug. N othing happened. The
fire extinguisher w as not charged. In despera-
tion, I threw w ater on the fire. The fire spread
throughout the kitchen.I called the fire depart-
m ent, but the kitchen w as destroyed. The fire
departm ent arrived in tim e to save the rest of
the house.
D ata gathering began as soon as possible after
the eventto preventloss or alteration ofthe data.
The RC A team toured the area as soon as the fire
In m any traditionalanalyses,
the m ostvisible causalfactor
is given allthe attention.
departm entdeclared itsafe.Because data from
people are the m ostfragile,M ary,Jane and the fire-
fighters w ere interview ed im m ediately after the
fire.Photographs w ere taken to record physical
and position data.
The analysts then developed the causalfactor
chart(see Figure 1,p.47)to clearly define the
sequence ofevents thatled to the fire.The causal
factor chartbegins w ith the event;M ary begins fry-
ing chicken at5 p.m .A s the chartdevelops from
Q U A LITY BA SICS

F IG U R E 2 R oo t C au se M a p

Section one Starthere with each causalfactor. 1

1

Equipmentdifficulty 2

Equipm ent Equipment Equipment

reliabilityprogram Installation/
design problem fabrication misuse
5 problem 6 7 8
2

Equipm ent Equipmentreliability Equipmentreliability Adm inistrative/

Design input/ Procedures
output records program design program im plem entation management
15 18 lessthan adequate (LTA) 21 LTA 28 systems 55 111

Design input Equipment No program 22 Corrective maintenance Proactive maintenance

LTA 16 design records LTA 29 LTA 41
Program LTA 23
Design output LTA 19 Analysis/design Troubleshooting/corrective Eventspecification
LTA 17 Equipment procedure LTA 24 action LTA 30 LTA 42
operating/ Inappropriate type Repairim plem entation M onitoring LTA 43
m aintenance ofmaintenance LTA 31 Scope LTA 44
historyLTA 20 assigned 25 Preventive maintenance Activityimplementation
Riskacceptance LTA 32 LTA 45
criteria LTA 26 FrequencyLTA 33 Failure finding m aintenance
Allocation of Scope LTA 34 LTA 46
resourcesLTA 27 Activityim plementation FrequencyLTA 47
LTA 35 Scope LTA 48
Predictive maintenance Troubleshooting/
LTA 36 corrective action LTA 49
Detection LTA 37 Repairimplementation 50
M onitoring LTA 38 Routine equipm ent
Troubleshooting/ roundsLTA 51
corrective action LTA 39 FrequencyLTA 52
Note:Node numberscorrespond to matching page in AppendixA ofthe Activityim plementation Scope LTA 53
Root Cause Analysis Handbook. LTA 40 Activityimplementation
LTA 54

Standards, Safety/hazard/ Product/material Procurem ent Documentand Custom er

policiesor risk review 72 control 85 control 93 configuration interface/
administrative Review LTA or Handling LTA 87 Purchasing control 100 services 106
controls(SPACs) notperformed 74 Storage LTA 88 specificationsLTA 95 Change not Custom er
LTA 57 Recom mendationsnot Packaging/ Controlofchanges identified 102 requirements
No SPACs 59 yetimplemented 75 shipping LTA 89 to procurem ent Verification ofdesign/ notidentified 108
Notstrict Riskacceptance Unauthorized m aterial specificationsLTA 96 field changesLTA Custom erneeds
enough 60 criteria LTA 76 substitution 90 M aterialacceptance (no PSSR*) 103 notaddressed 109
Confusing, Review procedure Productacceptance requirem entsLTA 97 Documentation Implementation
contradictoryor LTA 77 criteria LTA 91 M aterialinspections contentnotkept LTA 110
incom plete 61 Productinspections LTA 98 up to date 104
Technicalerror 62 LTA 92 Contractorselection Controlofofficial
Responsibility LTA 99 documentsLTA 105
foritem/activity
notadequately
defined 63 Problem
Planning,scheduling SPACsnotused 67 identification
ortracking ofwork Communication of control 78 M isleading/confusing 117 W rong/incomplete 130
activitiesLTA 64 SPACsLTA 69 Problem reporting Formatconfusing or Typographicalerror 131
Rewards/incentives Recentlychanged 70 LTA 80 LTA 118 Sequence wrong 132
LTA 65 EnforcementLTA 71 Problem analysis M ore than one action Factsw rong/
Employee screening/ LTA 81 perstep 120 requirem entsnot
hiring LTA 66 AuditsLTA 82 No checkoffspace correct 133
Corrective action provided butshould be 121 W rong revision or
LTA 83 Inadequate checklist 122 expired procedure
Corrective actionsnot GraphicsLTA 123 revision used 134
yetimplemented 84 Am biguousorconfusing Inconsistency
Notused 112 instructions/ between
Notavailable or requirem ents 124 requirem ents 135
inconvenientto Data/computations Incom plete/situation
obtain 113 w rong/incom plete 125 notcovered 136
Procedure difficult Insufficientorexcessive Overlap orgaps
to use 114 references 126 between
Use notrequired Identification ofrevised procedures 137
butshould be 115 stepsLTA 127
No procedure for LevelofdetailLTA 128
task 116 Difficultto identify 129 Figure 2 continued on nextpage
 Starthere with each causalfactor. 1 Section Tw o

Personaldifficulty 3 Otherdifficulty 4

Company Contract Natural Sabotage/ External

Other
employee employee phenomena horseplay events
9 10 11 12 13 14

Human factors Immediate Personal

Training Com munications
engineering supervision performance
138 163 180 192 208

No training 164 Training records Training LTA 170
Decision not system LTA 167 Job/taskanalysis
to train 165 Training records LTA 171
Training incorrect 168 Program design/
requirementsnot Training records objectivesLTA 172
identified 166 notup to date 169 Lesson content
LTA 174
On-the-job
training LTA 175
Qualification
testing LTA 176
Continuing
training LTA 177
Training
resources LTA 178
Abnorm alevents/
emergency
training LTA 179
Preparation 181 Problem
No preparation 182 detection LTA 209
Job plan LTA 183 *Sensory/perceptual
Instructionsto workers capabilitiesLTA 210
LTA 184
W alkthrough LTA 185 *Reasoning
Scheduling LTA 186 capabilitiesLTA 211
W orkerselection/ *M otor/physical
assignmentLTA 187 capabilitiesLTA 212
Supervision during
*Attitude/attention
w ork 188 LTA 213
Supervision LTA 189
Im properperformance *Rest/sleep LTA
notcorrected 190 (fatigue) 214
TeamworkLTA 191
*Personal/medication
problems 215

No communication or M isunderstood W rong Job turnoverLTA 205 *PSSR = Projectscope sum maryreport
nottimely 194 communication 200 instructions 204 Communication
M ethod unavailable or Standard within shiftsLTA 206
LTA 195 terminologynot Communication
Communication between used 201 betw een shifts
workgroupsLTA 196 Verification/ LTA 207
Communication between repeatbacknot
shiftsand management used 202
LTA 197 Long message 203
Communication with Shape Description
contractorsLTA 198
Communication with
customersLTA 199 Primarydifficultysource

Problem category
W orkplace layout 140 W ork environment 148 W orkload 155 Intolerant
Controls/displays Housekeeping LTA 149 Excessive control system 160 Rootcause category
LTA 141 ToolsLTA 150 action Errorsnot
Control/display Protective clothing/ requirements 156 detectable 161
integration/ equipmentLTA 151 Unrealistic Errorsnot Nearrootcause
arrangementLTA 143 Ambient m onitoring correctable 162
Location of conditionsLTA 152 requirements 157 Rootcause
controls/displays Otherenvironmental Knowledge based
LTA 144 stressesexcessive 154 decision
Conflicting layouts 145 required 158 1995,1997,1999,2000and 2001,ABSG Consulting Inc.
Equipment Excessive
location LTA 146 calculation or
Labeling of data manipulation *Note:These nodesare fordescriptive
equipmentor required 159 purposesonly.
locationsLTA 147
Q U A LITY BA SICS
T A B LE 1 R oo t C au se S um m a ry Ta b le
Eventdescription:Kitchen is destroyed by fire and dam aged by sm oke and w ater.
Causalfactor# 1 Paths Through RootCause M ap
Description: Personneldifficulty.
M ary leaves the frying chicken unattended. Adm inistrative/m anagem entsystem s.
Standards,policies oradm inistrative
controls (SPACs)less than adequate (LTA).
No SPACs.
Causalfactor# 2 Paths Through RootCause M ap
Description: Equipm entdifficulty.
Electric burnerelem entfails (shorts out). Equipm entreliability program problem .
Equipm entreliability program design LTA.
No program .
Causalfactor# 3 Paths Through RootCause M ap
Description: Equipm entdifficulty.
Fire extinguisherdoes notoperate w hen Equipm entreliability program problem .
M ary tries to use it. Equipm entproactive m aintenance LTA.
Activity im plem entation LTA.
Equipm entdifficulty.
Equipm entreliability program problem .
Adm inistrative/m anagem entsystem s.
Problem identification and controlLTA.
Causalfactor# 4 Paths Through RootCause M ap
Description: Personneldifficulty.
M ary throw s w ateron fire. Com pany em ployee.
Training.
Training LTA.
Abnorm alevents/em ergency training LTA.
Paths Through RootCause M ap is a tradem ark ofABSG Consulting.
Event#:2003-1
Recom m endations
Im plem enta policy thathotoilis neverleft
unattended on the stove.
Determ ine w hetherpolicies should be
developed forothertypes ofhazards in the
facility to ensure they are notleftunattended.
M odify the risk assessm entprocess or
procedure developm entprocess to address
requirem ents forpersonnelattendance
during process operations.
Recom m endations
Replace allburners on stove.
Develop a preventive m aintenance strategy
to periodically replace the burnerelem ents.
Consideralternative m ethods forpreparing
chicken thatm ay involve few erhazards,
such as baking the chicken orpurchasing
the finished productfrom a supplier.
Recom m endations
Refillthe fire extinguisher.
Inspectotherfire extinguishers in the
facility to ensure they are full.
Have incidentreports describing the use of
fire protection equipm entrouted to
m aintenance to triggerrefilling ofthe fire
extinguishers.
Add this fire extinguisherto the auditlist.
Verify thatallfire extinguishers are on the
quarterly fire extinguisherauditlist.
Have allm aintenance w ork requests that
involve fire protection equipm entrouted to
the safety engineerso the quarterly
checklists can be m odified as required.
Recom m endations
Provide practical(hands-on)training
on the use offire extinguishers.Classroom
training m ay be insufficientto adequately
learn this skill.
Review otherskillbased activities to
ensure appropriate levelofhands-on training
is provided.
Review the training developm entprocess
to ensure adequate guidance is provided for
determ ining the propertraining setting (for
exam ple,classroom ,lab,sim ulator,on the job
training,com puterbased training).
leftto right,the sequences begin to unfold.The loss
events kitchen destroyed by fire and other losses
from sm oke and w ater dam age are the shaded
rectangles in the causalfactor chart.
A lthough w e read the chartfrom leftto right,it
is developed from rightto left(backw ards).
D evelopm entalw ays starts atthe end because that
is alw ays a know n fact.Logic and tim e tests are
used to build the chartback to the beginning of
the event.N um erous questions are usually gener-
ated thatidentify additionalnecessary data.
A fterthe causalfactorchartw as com plete (addi-
tionaldata w ere gathered to answ erthe questions
show n in Figure 1),the analysts identified the fac-
tors thatinfluenced the course ofevents.There are
fourcausalfactors forthis event(see Table 1).
Elim ination ofthese causalfactors w ould have
eitherprevented the occurrence orreduced its sever-
ity.N ote the recom m endations in Table 1 are w ritten
as ifM arys house w ere an industrialfacility.
N otice thatcausalfactor tw o m ay be unexpect-
ed.Itw asntoverheating ofthe oilor splattering of
the oilthatignited the fire.Ifthe w rong causalfac-
tor is identified,the w rong corrective actions w ill
be developed.
The application ofthe technique identified that
the electric burner elem entfailed by shorting out.
The shortm elted M arys alum inum pan,releasing
the oilonto the hotburner,starting the fire.
The analystm ustbe w illing to probe the data
firstto determ ine w hathappened during the occur-
rence,second to describe how ithappened,and
third to understand w hy.
RootCause A nalysis H andbook,W SRC -IM -91-3,D epartm entof
Energy,1991 (and earlier versions).
RootCause A nalysis H andbook:A G uide to Effective
Investigation,A BSG C onsulting Inc.,1999.
U sers G uide for Reactor IncidentRootCause Coding Tree,revi-
sion five,D PST-87-209,E.I.duPontde N em ours,Savan-
nah River Laboratory,1986.
JA M ES J.RO O N EY isa seniorrisk and reliability engineer
w ith A BSG Consulting Inc.sRisk Consulting D ivision in
Knoxville,TN .H eearned a m astersdegreein nuclearengi-
neering from theU niversity ofTennessee.Rooney isa Fellow
ofA SQ and an A SQ certified quality auditor,quality audi-
tor-hazard analysisand criticalcontrolpoints,quality engi-
neer,quality im provem entassociate,quality m anagerand
reliability engineer.
LEE N .VA N D EN H EU V EL isa seniorrisk and reliability
engineerw ith A BSG Consulting Inc.sRisk Consulting
D ivision in Knoxville,TN .H eearned a m astersdegreein
nuclearengineering from theU niversity ofW isconsin.
Vanden H euvelco-authored theRootCause A nalysis
H andbook:A G uide to Effective IncidentInvestiga-
tion,co-developed theRootC ause Leadersoftw areand w as
a co-authoroftheCenterforChem icalProcessSafetys
G uidelines forInvestigating Chem icalProcess
Incidents.H edevelopsand teachescourseson thesubject.

B IB L IO G R A P H Y

A ccident/IncidentInvestigation M anual,second edition,

D O E/SSD C 76-45/27,D epartm entofEnergy.
Events and CausalFactors Charting,D O E/SSD C 76-45/14,
D epartm entofEnergy,1985.
Ferry,Ted S.,M odern A ccidentInvestigation and A nalysis,sec- P lease
ond edition,John W iley and Sons,1988. com m ent
G uidelines for Investigating Chem icalProcess Incidents,
Ifyou w ould like to com m enton this article,
A m erican Institute ofC hem icalEngineers,C enter for
please postyour rem arks on the Q uality Progress
C hem icalProcess Safety,1992.
D iscussion Board atw w w .asq.org,or e-m ailthem
O ccupationalSafety and H ealth A dm inistration A ccident
to editor@ asq.org.
Investigation Course,O ffice ofTraining and Education,1993.