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Root Cause Analysis Tool (RCAT)
Root Cause Analysis Tool (RCAT)
Agenda:
• Assumptions
• Root Cause Analysis Tool (RCAT)
• Definitions
• Process
• Considering the “Influencers”: What People Know,
See and Feel
• Root Cause Chart
• Tips and Traps
• Practical Application
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Assumptions
• An underlying root cause and other contributory causes
American Standard Incident Investigation Procedure Develop Local Incident investigation Procedure Local Incident investigation procedure
Local Regulatory requirements
Site employee listing Select possible incident investigation Team members listing with incident investigation team members
Management decision
Incident investigation procedure Prepare team members through training and exercise members trained, ready to deploy procedure
Identified team members
Broken Process Unsafe Acts INCIDENT Fatality, Injury, First aid, Near miss
Unsafe Conditions Environmental Spill
Questions : Who ? What? When? Where? Incident notification Problem Statement (concise event description)
Incident investigation procedure Appoint team leader and activate team Incident investigation start
Problem Statement
6 hours
Interviews Observation Collect evidence - Documented direct evidence (scene, witnesses)
Photo's - Indirect evidence (written sources)
Direct/Indirect evidence 5 Why Organize evidence for immediate cause identification Fishbone with 6 M's
RCAT Excell tab Immediate cause listing 24 hours Answer on "How the accident happened"
Fishbone with immediate causes 5 Why Identify System Root cause for each immediate Root cause and contributory cause listing
Excell tab Potential system cause listing cause 48 hours
Root cause and contributory cause listing Develop proposal for corrective action that eliminate 72 hours Corrective action plan with responsible person and target date
identified root causes Preventive action plan with responsible person and target date
Root cause listing Prepare report for management approval Report and actions approved by management
Action plan
Action plan - action steps Implement corrective actions and check effectiveness Corrected work environment
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Definitions
• Problem – Obstacle to safety. The “effect” of an incident
• Root Cause – Basic, underlying reason for an undesirable condition or problem
which, if eliminated or corrected, would have prevented the problem from existing
or occurring. Systemic, process, long‐term
• Causes:
• Immediate – “seen” ; short‐term
• Contributory ‐ worsens effect, severity and frequency of problem; short‐term
• Solution ‐ Permanent elimination of the problem and root cause.
• Implementation – Action plan: documentation; introduction; training, tracking and
auditing.
Process
UNDERSTAND THE WORK PROCESS AND INFLUENCERS
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4. Personal Factors
Work history, physical condition
Effect
Suggested format –
(Injury/Illness) from
(Event or Task)
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5 Why Example
1. Why did the shipment arrive late?
The driver did not get to work on time blame the driver
2. Why did the driver not get to work on time?
He over slept blame the driver
3. Why did he oversleep?
He was working too much overtime blame the driver
4. Why was he working too much overtime?
There weren’t enough drivers available System problem
5. Why weren’t there enough drivers available?
Because three drivers quit last week System problem
1. Use a fishbone chart to identify immediate causes. Consider these the 1st why of
“5 whys”
2. Brainstorm possible causes from these first immediate causes. These will be the
2nd why of the “5 whys”.
3. Select a target for deeper root cause evaluation: Look for reoccurring pattern of
causes; or an issue, which if solved, would remove all others causes.
4. Brainstorm possible deeper causes…3rd, 4th and 5th whys
5. Selecting the root cause – by definition: Basic reason for an undesirable condition or
problem which, if eliminated or corrected, would have prevented the problem from existing
or occurring.
A good root cause is one where we can change or influence a process or system to
remove the reason or influence for an unsafe act or condition…for good.
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A good root cause is one where we can change or influence a process or system to
remove the reason or influence for an unsafe act or condition…for good.
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Associate 8.02 Inadequate leadership 9.02 Inadequate contractor pre- 10.01.01 Inadequate technical design: 11.02 Inadequate Preventive
Involvement (B) (A) (C) qualification (C) design input obsolete (E) maintenance
American Standard Maturity Path
8.03 Inadequate correction of 9.03 Inadequate contractor selection 10.01.02 Inadequate technical design: 11.02.01 Inadequate Preventive
S&H Business
(E) worksite/job hazards (C) (C) design input not correct (D) maintenance: assessment of
Integration (C)
needs
S&H Risk
Identification and 8.04 Inadequate identification of 9.04 Use of non-approved contractor 10.01.03 Inadequate technical design: 11.02.02 Inadequate Preventive
Exposure (D) worksite/job hazards (A) (C) design input not available (E) maintenance: lubrication/servicing
Assessment (D)
KEY:
S&H Risk
Reduction and 8.05 Inadequate management of 9.05 Lack of job oversight 10.01.04 Inadequate technical design: 11.02.03 Inadequate Preventive
Management (E) (C) change system (D) (C) design input infeasible (E) maintenance:
adjustment/assembly
S&H Procedures
(F) 8.06 Inadequate incident 9.06 Inadequate oversight 10.01.05 Inadequate technical design: 11.02.04 Inadequate Preventive
(E) reporting/investigation system (D) (C) design output inadequate (E) maintenance: cleaning/resurfacing
S&H Resources
(H) Inadequate performance 10.01.07 Inadequate technical design: 11.03.01 Inadequate repair maintenance:
8.08
(C) measurement and assessment (C) design output not correct (E) communication of needed repair
S&H Metrics and
Data Analysis (I)
o Safety impacts o MOC process, including o The MOC process, o MOC process best practices are shared
are considered in noting and addressing including noting and across all sites.
ESSH the management safety impacts, is addressing safety o Leadership ensures that safety
Integration of change understood and impacts, is common at all considerations are properly integrated
into all ISC process, but not documented in all sites with identical into all business processes, tools and
Processes on a routine regulated change terminology. decisions.
(ops, basis and not management events o A safety review is o Leadership ensures that environmental,
engineering, always early o Other ISC processes and documented for all security and health (ESH) considerations
maintenance, enough in the Commercial decisions projects & major are also properly integrated into all
procurement, process. incorporate ESSH issues maintenance events business processes, tools and decisions.
etc…) o Safety issues are timely in the process (overhauls, turnarounds) o Safety and ESH are considered a
not incorporated o Most operational work o Commercial planning strategic component of business and
at all or timely practices and (new product workforce planning.
enough into procedures include a development, etc…) o Business processes effectively work
other ISC description of the includes a documented together to reduce risks and exposure to
operational, safety hazards, and safety review early in the hazards and make sound safety and ESH
planning, or precautions of doing decision‐making process. decisions, as early as possible.
decision the prescribed work. o All ISC and Commercial o A process is in place to benchmark
processes. processes facilitate safety operational work practices and
o Operational risk reduction strategies procedures with all five plants and with
work practices in all decisions made. best in class companies from safety and
and procedures o Operational work ESH perspectives.
are documented practices and procedures
for all significant are periodically reviewed
work done on for changes from actual
the site. practice, procedures are
updated as needed, and
“gap” training is
completed to ensure all
employees know the
best, current procedures,
safety risks and
safeguards. .
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A good root cause is one where we can change or influence a process or system to
remove the reason or influence for an unsafe act or condition…for good.
• Uses of RCAT
• Accident
• Incidents
• Risk Analysis—hazards and exposures
• Current Safety Programs
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Tips
Preparation :
1. Maturity path or management system
2. Education…bust old myths
3. Templates…make it easy
4. Review and monitor the process
5. Track closure of corrective actions
6. Track effectiveness of corrective actions
Tips
Usually a Culture‐Business integration root cause …
1. Unplanned events or tasks
2. Not do a pre‐job or pre‐task review
3. Insufficient manning, equipment, time,
4. Job design with inherent hazards or risks not removed or not mitigated
5. Routine job turns non‐routine and no MOC done
6. Unit or plant does not see the risk‐‐‐work is routine, usual way…this leads to no
procedures, no training, no enforced pre‐job reviews, undefined ppe, different ways
to do the job
Cultural Leadership
1. Unsafe acts condoned
2. Unsafe tools, equipment and processes condoned
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Tips
Motivations...strong influences, as contributing factors,
but are usually not root causes:
1. Not ask for help
2. Rushed
3. New‐reluctant to ask for help
4. Seasoned vet‐complacent with long‐standing work
tasks and inherent risks; established work‐arounds
5. Unsafe Peers actions or coaching
6. Unsafe Supervisor actions
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Case Study
Machine was
recently
moved from
one
building to
another
On completion of her work, the employee intended to shut down the machine.
For this purpose she climbed on the rear side of the system. In the process
she placed her foot on a bundle of cables that was fastened to the middle
of the control cabinet. After a short moment, the control cabinet tilted toward the
system’s access staircase and hit the employee in the back.
Root Cause
Dept. did not issue work order
Machine move was performed by
Dept.
Dept did not follow process change
procedure (MOC)
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Root Cause Analysis Tool (RCAT) ‐ Chart, How does that work?
Under “Job Factors” categories:
7. Training / Knowledge transfer
8.05 Management
8. Management/Employee Leadership of Change (C)
9. Contractor selection and oversight
10. Engineering design
11. Work planning
12. Purchasing, Material handling and Control
13. Tools and equipment (ergonomics)
14. Procedures, policies, rules,
15. Communication
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6
6 NOTE: ESSH
Integration (56%)
13 combines ESSH
56% included in work
tasks and design,
AND work support,
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like planning, pre‐
job reviews,
scheduling and
manning
ESSH Integration Risk assessment Employee decision/action
Inadequate Procedure Inadequate Training
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