Root Cause Map™

Start here with each

causal factor
1

Equipment Personnel Other

Difficulty 2 Difficulty 3 Difficulty 4

Equipment
Equipment Installation/ Equipment Company Contract Natural Sabotage/ External
Reliability Other
Design Problem Fabrication Misuse Employee Employee Phenomena Horseplay Events
Program Problem
5 6 7 8 9 10 11 12 13 14

Equipment Equipment Administrative/ Human

Design Equipment Reliability Reliability Program Immediate Personal
Management Procedures Factors Training Communications
Input/Output Records Program Implementation Supervision Performance
Systems Engineering
15 18 Design LTA 21 LTA 28 55 111 138 163 180 192 208

Corrective Preventive Predictive Proactive Failure Finding Routine

Design Input No Program Misleading/ Training Records Supervision
Maintenance Maintenance Maintenance Maintenance Maintenance Equipment Rounds Not Used Confusing Wrong/Incomplete No Training Training LTA Preparation
LTA Program LTA System LTA During Work
16 22 23 LTA 29 LTA 32 LTA 36 LTA 41 LTA 46 LTA 51 112 117 130 164 167 170 181 188

Not
Equipment Troubleshooting/ Event Available or Format Training
Design Output Analysis/Design Frequency Detection Frequency Frequency Typographical Decision Not to Job/Task
Design Records Corrective Action Specification Inconvenient Confusing Records No Preparation Supervision LTA
LTA Procedure LTA LTA LTA LTA LTA Error Train Analysis LTA
17 LTA 19 LTA LTA to Obtain or LTA Incorrect
24 30 33 37 42 47 52 113 118 131 165 168 171 182 189

Equipment Inappropriate More Than

Type of Repair Training Training Improper
Operating/ 20 Scope Monitoring Monitoring Scope Scope Procedure Sequence Program Design/ Job Plan
Maintenance Implementation One Action Requirements Not Records Not Performance
Maintenance LTA LTA LTA LTA LTA Difficult to Use Wrong Objectives LTA LTA
History LTA Assigned LTA per Step Identified Up-to-Date Not Corrected
25 31 34 38 43 48 53 114 120 132 166 169 172 183 190

Activity Troubleshooting/ Troubleshooting/ Activity Use Not No Checkoff Facts Wrong/

Risk Acceptance Scope Space Provided Requirements Not Lesson Instructions to
Implementation Corrective Action Corrective Action Implementation Required but Teamwork LTA
Criteria LTA LTA but Should Be Correct Content LTA Workers LTA
LTA LTA LTA LTA Should Be
26 35 39 44 49 54 115 121 133 174 184 191

Allocation Activity Activity Repair Wrong

of Resources No Procedure Inadequate Revision or Expired On-the-job Walkthrough
Implementation Implementation Implementation Procedure Revision
LTA for Task Checklist Training LTA LTA
LTA LTA LTA Used
27 40 45 50 116 122 134 175 185

Inconsistency
Graphics Qualification Scheduling
Between
LTA Testing LTA LTA
Requirements
123 135 176 186

Ambiguous or Incomplete/
Confusing Worker
Situation Not Continuing
Instructions/ Selection/
Covered Training LTA
Requirements Assignment LTA
124 136 177 187

Note: Node numbers correspond to Data/Computations

Overlap or
Training
Gaps Between
matching page in Appendix A of ABS Wrong/Incomplete
Procedures Resources LTA

Consulting's Root Cause Analysis 125 137 178

Handbook Insufficient or Abnormal

Excessive Events/Emergency
References Training LTA
126 179

Identification of
Revised Steps
LTA
127

Level of Detail
Level/Shape Description Standards, Standards,
Problem Document
LTA
No
Policies, or Policies, or Safety/Hazard/ Product/Material Procurement Customer Workplace Work Intolerant Misunderstood Wrong Job
Identification/ and 128 Communication
Administrative Controls Administrative Controls Identification/ and Configuration
Configuration Workload
[SPACs] LTA [SPACs] Not Used Risk Review Control Control Control Control Interface/Services Layout Environment System or Not Timely Communication Instructions Turnover LTA
72 Control78 85 93 Control
100 106 140 148 155 160 200 204 205
Primary Difficulty 57 67 194

Source Difficult to Identify

Problem Change Customer 129

Controls/ Excessive Method Standard Communication
Communication Review LTA or Handling Purchasing Housekeeping Errors Not
No SPACs Reporting Specifications Not Requirements Displays Control Action Unavailable or Terminology Not Within
of SPACs LTA Not Performed LTA LTA Detectable
LTA LTA Identified Not Identified LTA Requirements LTA Used Shifts LTA
59 69 74 80 87 95 102 108 141 149 156 161 195 201 206

Problem Category Recommendations

Problem
Control of
Changes to
Verification of
Design/Field
Control/Display Unrealistic Communication Verification/ Communication
Not Strict Recently Customer Needs Integration/ Errors Not
Not Yet Analysis Storage LTA Procurement Changes LTA Tools LTA Monitoring Between Work Repeat-back Not Between
Enough Changed Specifications Not Addressed Arrangement LTA Correctable
Implemented LTA (No PSSR) Requirements Groups LTA Used Shifts LTA
60 70 75 81 88
LTA 96 103 109 143 150 157 162 196 202 207

Material Documentation Location of Protective Knowledge- Communication

Major Root Cause Confusing,
Contradictory, or
Enforcement Risk Acceptance Audits Packaging/ Acceptance Content LTA Implementation LTA Controls/ Clothing/ based Decision Between Shifts and
Long
LTA Criteria LTA LTA Shipping LTA Requirements or Not Kept Message
Category Incomplete
LTA Up-to-Date Displays LTA Equipment LTA Required Management LTA
61 71 76 82 89 97 104 110 144 151 158 197 203

Corrective Unauthorized Control of Excessive Communication

Technical Review Material Conflicting Ambient Calculation or
Action Material Official Data Manipulation with Contractors
Error Procedure LTA Inspections LTA Layout Conditions LTA
Near Root Cause 62 77
LTA
83
Substitution
90 98
Documents LTA
105
Required LTA
145 152 159 198

Responsibility Corrective Product Other Communication

for Item/Activity Contractor Equipment Environmental
Not Adequately Actions Not Yet Acceptance Stresses with Customers
Selection LTA Location LTA
Defined Implemented Criteria LTA Excessive LTA
Root Cause 63 84 91 99 146 154 199

Planning, Product Labeling of

Scheduling, or
Note: LTA = Less Than Adequate Tracking of Work Inspections Equipment or
Activities LTA LTA Locations LTA
64 92 147

© 1995, 1997, 1999, 2000, 2001, 2003

ABSG Consulting Inc. Rewards/
Incentives LTA
All rights reserved 65

Rev. 10 (6/05)
Employee
Screening/Hiring Sensory/ Personal/
LTA Problem Perceptual Reasoning Motor/Physical Attitude/Attention Rest/Sleep Medication
66 Detection LTA Capabilities LTA* Capabilities LTA* Capabilities LTA* LTA* LTA (Fatigue)* Problems*
209 210 211 212 213 214 215

Available now!
Root Cause Analysis Handbook: *NOTE: Shaded nodes under Personal Performance are for descriptive purposes only. Code only to
Personal
Performance*
A Guide to Effective Incident Investigation
by ABS Consulting
ISBN #1-931332-30-4
See http://www.rothstein.com/data/dr388.htm for book details and ordering
Rothstein Associates Inc., Publisher
203.740.7444 or 1.888.ROTHSTEin (1.888.768.4783) www.absconsulting.com/knoxville
www.rothstein.com
info@rothstein.com (865) 966-5232