ROOT CAUSE ANALYSIS REPORT Report No: <ORIP/MTA ID> DD/MM/YY

Problem Definition
Problem statement is factual, defines undesirable consequence and desired outcome, quantifies
Problem Statement the gap/deviation in terms of risk, and provides clear direction to the team on what needs to be
solved.

Date Occurred As recorded in ORIP/EC

Installation Majnoon Plant FLOC As per SAP

RAM Details As per ORIP/MTA RAM. Cut and paste as per example below.

Production Loss
Maintenance Costs Approx $ 000,000.0 repair costs.
Reputation N/A
Frequency

Total Cost

Leadership Engagement
The sponsor creates the terms of reference (scope, team, timing, resources, facilities,
investigation steps), makes resources available, outlines expected deliverables, formally
Sponsor approves each step of the investigation process per the agreed framework, provides guidance
on depth and breadth of investigation, engages peers as necessary to progress actions and
address issues, ensures the team is held accountable for the solutions to be effective

Summary ToR
Scope
Team
Timing
Resources
Facilities
Investigation steps
Terms of Reference Depth of Investigation
An agreed framework has been created and followed in which potential risk or actual
consequence drives depth of investigation with sponsor agreement

Data Quality
Sponsor defines when data quality is required to be documented. Data is assessed, defined, and
trends towards high quality data (fact, inference, hypothesis). Sponsor accepts data quality (may
not be required for small investigations).

Investigation Team
Team Composition
An agreed framework has been created and followed in which risk (potential or actual) drives
team size and composition, and includes facilitator, solution owner, and sponsor roles. Ideal
team composition for large incidents is led by a facilitator and includes reliability, operations,
disciplines, and external cold eye team member. Teams should be provided adequate
continuous time to complete the investigation (not 1/hr a week). Size of the team is appropriate
for the actual or potential consequence. Large investigations - 3-5 people, small investigations
- 1-2.

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Skill Level
Large investigation facilitators have had 5 day Causal Learning facilitator training and has
facilitated at least 5 problem solving sessions. Team includes range of discipline expertise and
60%+ has received causal reasoning training. For small investigations peer reviewer has had
5 day Causal Learning facilitator training and has facilitated at least 5 problem solving
sessions.

Summary Of Investigation

Incident Description:

CONCLUSION (refer to cause and effect diagram)

To summarise:

Short/moderate Actions
Causes Corrective Actions Assigned to Due Done

Long term Actions

Causes Corrective Actions Assigned to Due Done

REPORT WRITER:

REPORT DATE:

APPROVAL: Name: Title: Date:

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Causal Tree

<Insert Causal Tree Here>

Cause Analysis
Rigorous causal reasoning is used with no logical gaps or inconsistencies
.

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