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10/5/22, 10:11 AM Assignment 1 - RCA Exercise - Graded: Attempt review
Dashboard / My courses / ENGG 404 (LEC 501 550 SEM 601 602 651 652 Winter 2022) / Assignment 1 - Root Cause Analysis
/ Assignment 1 - RCA Exercise - Graded
Started on Saturday, 5 February 2022, 5:04 PM

State Finished
Completed on Saturday, 5 February 2022, 6:02 PM
Time taken 58 mins 3 secs
Marks 18.18/25.00
Grade 72.73 out of 100.00
https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=9815656&cmid=5830140 1/26
Question 1
Correct
Mark 1.00 out of 1.00
State the actual sequence of events by re-ordering the letters A), B), C), and D).
A. Upon hearing word from the industrial mechanics about a hot motor bearing that was threatening the operation
of a production line, John and
Mary immediately left their offices and walked rapidly through congested
walkway #3A in the plant, which served as a short-cut, rather than
taking the designated plant walkway #1, to
access the motor. While walking, they were preoccupied in conversation about a recent hockey game.
B. Prior to this, Dave and Doug, the two industrial mechanics, were relocating a gearbox with an overhead crane
and noticed gear oil leaking onto
walkway #3A beneath. The angle of the suspended gearbox caused oil to
leak from the filler tube, because they had neglected to reinstall the
filler cap. Seeing the spilt oil, they found
the local container with spill absorption compound to be empty, and so they went to a lower floor to find
some.
They were then called away to address a hot bearing on a motor that was restricting production.
C. As he was conversing with Mary, John slipped on the oil spill in walkway #3A and fell against the pipe causing
his hip to fracture on impact. It
was 5 months before John recovered to a point where he could work again,
although he will suffer from joint pain and restricted mobility for the
rest of his life.
D. Around the same time that Dave and Doug were called away, Bill the pipefitter placed a pipe on one side of the
walkway #3A. He did not flag
off the area and stepped over some spilled oil on his way back to get his toolbox
for installing the pipe.
Select one:
i. A,B,C,D cross out
ii. B,D,A,C
cross out
iii. B,D,C,A cross out
iv. D,B,C,A cross out
Your answer is correct.
The correct response is B,D,A,C:
B. (Prior to this i.e. A), Dave and Doug, the two industrial mechanics, were relocating a gearbox with an overhead crane and noticed gear oil
leaking onto walkway #3A beneath. The angle of the suspended gearbox caused oil to leak from the filler tube, because they had neglected to
reinstall the filler cap. Seeing the spilt oil, they found the local container with spill absorption compound to be empty, and so they went to a lower
floor to find some. They were then called away to address a hot bearing on a motor that was restricting production.
D. Around the same time that Dave and Doug were called away, Bill the pipefitter placed a pipe on one side of the walkway #3A. He did not flag
off the area and stepped over some spilled oil on his way back to get his toolbox for installing the pipe.
A. Upon hearing word from the industrial mechanics about a hot motor bearing that was threatening the operation of a production line, John and
Mary immediately left their offices and walked rapidly through congested walkway #3A in the plant, which served as a short-cut, rather than
taking the designated plant walkway #1, to access the motor. While walking, they were preoccupied in conversation about a recent hockey game.
C. As he was conversing with Mary, John slipped on the oil spill in walkway #3A and fell against the pipe causing his hip to fracture on impact. It
was 5 months before John recovered to a point where he could work again, although he will suffer from joint pain and restricted mobility for the
rest of his life.
The correct answer is: B,D,A,C
Question 2
Correct
Please organize the following causes in logical order to the missing section of the root cause labelled above (box "FIRST", box "SECOND", box
"THIRD"):
A: John was in a hurry to respond to a threat in the operation

B: The culture of the organization did not hold safety as a value
C: The organization prioritized production over safety
First
A 
Second C 
Third B 
Root Cause 1 - The correct response is:
John used Walkway 3A as a short-cut because:
A: John was in a hurry to respond to a threat in the operation, because

C: The organization prioritized production over safety, because
B: The culture of the organization did not hold safety as a value.
This root can be further improved as follows:
John used Walkway 3A as a short-cut because:
A: John was in a hurry to respond to a threat in the operation, because
C: The organization prioritized production over safety, because
B: The culture of the organization did not hold safety as a value, because
LC-S: The management and leadership program of the organization did not include a set of Core Safety Values. #1 MLCA
The correct answer is:
First → A, Second → C, Third → B
Question 3
Incorrect
Which RME (Risk Management System Element) is most applicable to the solved root?
1) Management Leadership, Commitment and Accountability.
2) Risk Assessment and Management of Risks.
3) Community Awareness and Emergency Preparedness.
4) Management of Change.
5) Incident Reporting, Investigation, Analysis and Actions.
6) Program Evaluation and Continuous Improvement.
7) Design, Construction and Start-up.
8) Operations and Maintenance.
9) Employee Competency and Training.
10) Contractor Competency and Integration.
11) Operations and Facilities Information and Documentation.
Select one:
a. #1 MLCA cross out
b. #6 PECI cross out
c. #9 EC&T cross out
d. #2 RA&MR cross out 
Your answer is incorrect.
The correct answer is: #1 MLCA
Question 4
Correct
Please organize the following causes in logical order to the missing section of the root cause labelled above
A: Bill did not receive training regarding appropriate procedures for pipe maintenance activities
B: Bill was unaware he shouldn't leave the pipe on walkway 3A
C:The employee training program did not include specific details for temporary placement of pipe during maintenance activities.
First
B 
Second
A 
Third
C 

B: Bill was unaware he shouldn't leave the pipe on walkway 3A, because
A: Bill did not receive training regarding appropriate procedures for pipe maintenance activities, because
C: The employee training program did not include specific details for temporary placement of pipe during maintenance activities.
The correct answer is: First → B, Second → A,
Third → C
Question 5
Correct
Select one:
a. #4 MOC cross out
b. #9 EC&T cross out
c. #11 OF&ID
cross out
d. #3 CA&EP cross out
The correct answer is: #9 EC&T
Question 6
Partially correct
A: No one assessed the risk of not flagging off the pipe
B: There was no flag off procedure for undesignated walkways
C: The risk assessment program did not include requirements/procedures for how to flag off hazards.
D: No one recognized the risk of not flagging off the pipe
First D 
Second
A 
Third
D 
Fourth
C 
Your answer is partially correct.

You have correctly selected 1.
B: There was no flag off procedure for undesignated walkways
D: No one recognized the risk of not flagging off the pipe

A: No one assessed the risk of not flagging off the pipe
C: The risk assessment program did not include requirements/procedures for how to flag off hazards.
The correct answer is: First → B, Second → D, Third → A, Fourth → C
Question 7
Correct


Select one:
a. #2 RA&MR cross out
b. #1 MLCA
cross out
c. #5 IRIAA cross out
d. #10 CC&I cross out
The correct answer is: #2 RA&MR
Question 8
Correct
A: Doug and Dave didn't understand the SMP
B: The evaluation program did not include review and improvement of the SMPs
C: Doug and Dave did not follow the SMP for relocating the gearbox
D: The SMP had not been reviewed in over five years
E: The SMP was long, complicated, and outdated
SMP = Standard Maintenance Procedure
First
C 
Second A 
Third E 
Fourth D 
Fifth B 

C: Doug and Dave did not follow the SMP for relocating the gearbox
A: Doug and Dave didn't understand the SMP
E: The SMP was long, complicated, and outdated
D: The SMP had not been reviewed in over five years
B: The evaluation program did not include review and improvement of the SMPs
The correct answer is: First → C, Second → A, Third → E, Fourth → D, Fifth → B
Question 9
Correct


Select one:
a. #8 O&M cross out
b. #9 EC&T cross out
c. #1 MLCA cross out
d. #6 PECI cross out

The correct answer is: #6 PECI
Question 10
Partially correct
A: The suspended gearbox leaked oil from the filler tube

B: The gearbox was tilted when lifting it
C: The risk from tilting the gearbox was not assessed
D: Oil spilled from gearbox

E: The risk from tilting the gearbox was not understood
First D 
Second
A 
Third
B 
Fourth C 
Fifth E 

D: Oil spilled from gearbox, because
A: The suspended gearbox leaked oil from the filler tube, because
B: The gearbox was tilted when lifting it, because
E: The risk from tilting the gearbox was not understood, because
C: The risk from tilting the gearbox was not assessed, because
LC: The evaluation program did not include review and improvement of the SMPs #6 PECI
The correct answer is: First → D, Second → A, Third → B, Fourth → E, Fifth → C
Question 11
Incorrect
Risk Management System (APEGA Model):


Select one:
b. #5 IRIAA cross out
c. #10 CCI cross out 
d. #2 RA&MR cross out
The correct answer is: #2 RA&MR
Question 12
Partially correct
Please organize the following causes in logical order to the missing section of the root cause labelled above:
A: It would take time and effort to document and report an oil spill
B: The reporting program did not include criteria that specified that an oil spill during maintenance must be reported.
C: No one wanted to document and report the spill
First
C 
Second
B 
Third
A 

C: No one wanted to document and report the spill, because
A: It would take time and effort to document and report an oil spill, because
B: The reporting program did not include criteria that specified that an oil spill during maintenance must be reported.
The correct answer is: First → C, Second → A, Third → B
Question 13
Correct


Select one:
a. #4 MOC
cross out
b. #1 MLCA
cross out
c. #7 DC&SU
cross out
d. #5 IRIAA cross out
The correct answer is: #5 IRIAA
Question 14
Correct
A: The maintenance program did not include a schedule for weekly inspections of the spill clean-up kit
B: The spill clean-up container was empty

C: Employees could not find absorptive agent
D: The weekly inspection of the spill clean-up container was not completed
First
C 
Second B 
Third
D 
Fourth A 

Employees did not clean up the spill, because
C: Employees could not find absorptive agent, because
B: The spill clean-up container was empty, because
Nobody refilled the empty spill clean-up container with absorptive agent, because
D: The weekly inspection of the spill clean-up container was not completed, because
A: The maintenance program did not include a schedule for weekly inspections of the spill clean-up kit.
The correct answer is: First → C, Second → B, Third → D, Fourth → A
Question 15
Correct

Select one:
a. #4 MOC cross out
b. #1 MLCA cross out
c. #7 DC&SU
cross out
d. #8 O&M
cross out

The correct answer is: #8 O&M
Question 16
Correct
A: No one was aware the container was empty
B: Employees could not find absorptive agent
C: The container was empty
First
B 
Second
C 
Third
A 

B: Employees could not find absorptive agent
C: The spill clean-up container was empty, because
Nobody refilled the container, because

A: No one was aware the container was empty
The correct answer is:
First → B, Second → C, Third → A
Question 17
Incorrect
Which RME (Risk Management System Element) is most applicable to both of the solved roots?

Select one:
a. #1 MLCA
cross out
b. #9 EC&T
cross out
c. #6 PECI
cross out
d. #11 OF&ID
cross out 
You will note that the two roots are NOT re-combined even though the latent causes relate to the same RME #6 PECI. It is bad practice to re-
combine any roots at any point in a RCA Chart.
The correct answer is: #6 PECI
Question 18
Correct
A: Employees prioritized responding to the threat to production over safety
B: Safety was not recognized or held as a value in the organization
C: Employees left spill, a hazard, to respond to threat to production
First
C 
Second
A 
Third
B 

C: Employees left spill, a hazard, to respond to threat to production, because
A: Employees prioritized responding to the threat to production over safety, because
B: Safety was not recognized or held as a value in the organization
This root can be further improved as follows:
C: Employees left spill, a hazard, to respond to threat to production, because
A: Employees prioritized responding to the threat to production over safety, because
B: Safety was not recognized or held as a value in the organization, because

LC: The management and leadership program of the organization did not include a set of Core Safety Values. #1 MLCA
The correct answer is: First → C, Second → A, Third → B
Question 19
Correct

Select one:
a. #2 RA&MR cross out
b. #6 PECI cross out
c. #1 MLCA cross out
d. #7 DC&SU cross out
Question 20
Correct
A: The spill clean-up container was empty
B: No one followed the operations schedule for refilling the spill clean-up container
C: The operations program did not include a procedure to check and replenish the spill clean-up kit.
D: Employees could not find absorptive agent
First
D 
Second A 
Third
B 
Fourth C 

Root Cause 10 - The correct response is
D: Employees could not find absorptive agent, because
A: The spill clean-up container was empty, because
Nobody refilled the spill clean-up container, because

B: No one followed the operations schedule for refilling the spill clean-up container
C: The operations program did not include a procedure to check and replenish the spill clean-up kit.
The correct answer is: First → D, Second → A, Third → B, Fourth → C
Question 21
Correct

Select one:
a. #8 O&M cross out
b. #1 MLCA cross out
c. #11 OF&ID cross out
d. #4 MOC cross out
The correct answer is: #8 O&M
Question 22
Correct
A: No one communicated the value of safety to the employees
B: Employees didn't think it was their job to clean up the spill
C: Employees didn't know that oil spills were everyone's responsibility

D: The management program did not include a standard to check that employees could explain that safety is a value
E: Employees were not aware of the value of safety in the organization

First B 
Second C 
Third E 
Fourth A 
Fifth D 

Root Cause 11 - The correct response is
Employees did not clean-up the spill, because
B: Employees didn't think it was their job to clean up the spill, because
C: Employees didn't know that oil spills were everyone's responsibility, because
E: Employees were not aware of the value of safety in the organization, because
A: No one communicated the value of safety to the employees, because
D: The management program did not include a standard to check that employees could explain that safety is a value
The correct answer is: First → B, Second → C, Third → E, Fourth → A, Fifth → D
Question 23
Incorrect

Select one:
b. #3 CA&EP cross out 
c. #7 DC&SU cross out
d. #9 EC&T cross out
Question 24
Correct
For the gate labelled "A", is it an AND gate or an OR gate?
Select one:
a. AND cross out
b. OR cross out
The correct answer is: OR
Question 25
Incorrect
For the gate labelled "B", is it an AND gate or an OR gate?
Select one:
a. AND cross out
b. OR cross out 
The correct answer is: AND
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10/5/22, 10:11 AM Assignment 1 - RCA Exercise - Graded: Attempt review

Started on Saturday, 5 February 2022, 5:04 PM

Mark 1.00 out of 1.00

iii. B,D,C,A cross out

iv. D,B,C,A cross out

Your answer is correct.

The correct response is B,D,A,C:

The correct answer is: B,D,A,C

Mark 1.00 out of 1.00

A: John was in a hurry to respond to a threat in the operation

C: The organization prioritized production over safety

Your answer is correct.

Root Cause 1 - The correct response is:

John used Walkway 3A as a short-cut because:

A: John was in a hurry to respond to a threat in the operation, because

C: The organization prioritized production over safety, because

The correct answer is:

First → A, Second → C, Third → B

Mark 0.00 out of 1.00

b. #6 PECI cross out

c. #9 EC&T cross out

d. #2 RA&MR cross out 

Your answer is incorrect.

The correct answer is: #1 MLCA

Mark 1.00 out of 1.00

B: Bill was unaware he shouldn't leave the pipe on walkway 3A

Your answer is correct.

The correct answer is: First → B, Second → A,

Mark 1.00 out of 1.00

b. #9 EC&T cross out

d. #3 CA&EP cross out

Your answer is correct.

The correct answer is: #9 EC&T

Mark 0.25 out of 1.00

A: No one assessed the risk of not flagging off the pipe

B: There was no flag off procedure for undesignated walkways

D: No one recognized the risk of not flagging off the pipe

Your answer is partially correct.

B: There was no flag off procedure for undesignated walkways

D: No one recognized the risk of not flagging off the pipe

Mark 1.00 out of 1.00

1) Management Leadership, Commitment and Accountability.

c. #5 IRIAA cross out

d. #10 CC&I cross out

Your answer is correct.

The correct answer is: #2 RA&MR

Mark 1.00 out of 1.00

A: Doug and Dave didn't understand the SMP

D: The SMP had not been reviewed in over five years

E: The SMP was long, complicated, and outdated

SMP = Standard Maintenance Procedure

Your answer is correct.

The correct answer is: First → C, Second → A, Third → E, Fourth → D, Fifth → B

Mark 1.00 out of 1.00

1) Management Leadership, Commitment and Accountability.

b. #9 EC&T cross out

c. #1 MLCA cross out

d. #6 PECI cross out

Your answer is correct.

Mark 0.60 out of 1.00

A: The suspended gearbox leaked oil from the filler tube

D: Oil spilled from gearbox