Investigation File Table of Contents

25-Worksheets

Area Worksheet Description

Investigation Information Index This worksheet, which contains a table of contents for this file.
Versions Record for each meeting and conversation as the file progressed.
Contacts Names and contact info for those involved in the analysis.
CM Steps Cause Mapping method, steps and tools.
Cover Cover page for a final report or preliminary updates.
Description Text for a summary and detailed description of the incident.
Cause Mapping® Steps 1. Problem Capture specifics about the issue along with the consequences.
2. Cause Map Start with a single-path cause-and-effect diagram, expand as needed.
3. Solutions Action items showing corresponding cause, owner and due date.
Additional Information Tools Matrix Evaluation of possible solutions for implementation.
Timeline Sequence of events with date, time, description.
Photos Photographs and pictures.
Diagram Diagrams and drawings.
Process Map Steps of a work process or business operations documented in a flowchart.
Info To Get Information that needs to be collected during the investigation.
Notes Notes, emails, documents.
Resources Online resources related to this incident: web pages, video links.
END Previous versions and extras are located past this worksheet.
Extras Spare Parts Commonly used objects for building a complete Cause Map diagram.
Extra CM A copy of the Cause Map tab as backup.
Sols Expanded Solutions table with all columns unhidden.
Blank Extra worksheet.
Examples Example Cause Map diagrams for the relationship A contacted B.
Training Training videos for the Cause Mapping Method and Excel Tips.
Excel Tips Tip sheet for copying, making connectors and using the select objects cursor.

Version: 2022
Need Help? Copyright 2022 ThinkReliability, Novem, Inc.
info@thinkreliability.com www.thinkreliability.com
281-412-7766 phone
281-412-7761 fax

Index 1 of 25 ThinkReliability
 File Record Title
Client ID 0
TR Job ID Total Facilitation Hours 0.00 Total Contribution Hours 0.00

start end hours

Version Date (ctrl;) Type Description Time (ctrl:) optional Duration File Updated by Contributors Qty Hours
1

Versions 2 of 25 ThinkReliability
 Contacts

Organization Name Location Role Email Office Cell Note

Facilitation Help Desk (office) Houston, TX Incident Investigations info@thinkreliability.com 281-412-7766

www.thinkreliability.com

Contacts 3 of 25 ThinkReliability
 1. Problem Additional Tools - Use as needed to capture specific information during the
investigation.
Problem Outline
Capture specifics about the issue and the Timeline Photos Diagram Work Process
consequences. The sequence of events. Any photos or images. Any drawings or sketches. The work process(es)
What Problem(s)

When Date
Time
Timeline
Date Time Description
Diagram
Use the drawing tools to add any diagram to this work sheet.
Delete these objects if they are not needed.
Example objects
(industrial)
Cylinder Drum
relevant to the incident.
Different, unusual, unique
Pump

Where Facility, site

Process Map Decision point
Copy and use as needed

Unit, area, equipment Valve

Steps within a Task

YES
Task being performed

Impact to each GOAL Exchanger

Process

NO
Safety
Environmental
Expander,
Customer Turbine
Compressor

Production, Schedule
Equipment, Property
Labor, Time

This incident $0
Frequency

Annualized Cost $0

Add Enough Detail to Reduce Risk Sufficiently Info to Get

Information and evidence.
Detailed
Information to Collect

No. Investigation To Dos Owner Date Created Due Date Status Completed

2. Analysis
1

Notes Additional notes.

Notes

Text

Start a 5-Why Cause Map™ Diagram

Write down one of the goals that was impacted.
Start a 5-Why Cause Map diagram and expand as
necessary.
Basic
Why? Why? Why? Why? Why?
Resources
Impact to
Goal Related links and documents.
Resources

Title Source Format Note Link

3. Solutions
Evaluate Select Specific Each action item is essentially a project.
Follow up should evaluate its effectiveness.
Solution Options Best Solutions Action Plan Solutions may be a change in work process.
Propose Consider the effort IN to the Impact and risk to each
Possible Solutions solution versus the result goal should be reduced
to an acceptable level.
Measurable
OUT. Ref Possible Solution Cause Controlled Work Process
(process to be improved)
Implement?
(yes or no)
No. Specific Actions
(specific actions to be taken)
Owners
(names)
Due Date
.
(how will we verify completion

Capture ideas in a solution box

and effectiveness)

above the cause it controls.

High

Risk Curve
C

A
B

F
Payback
Medium
Risk

Benefit

G H

Low Medium High

Effort
Cost
Effectiveness of Solution(s)

Need Help 281-412-7766, Copyright 2022 ThinkReliability, Novem, Inc.

info@thinkreliability.com
CM-Steps 4 of 25 ThinkReliability
 Replace this box with
your company logo. Title
Location of Incident 0
Date of Incident
Date of Final Report

Preliminary update as of September 27, 2024

Version 1

SUMMARY FILE - Contents Page

Incident Description (optional) 2

Problem Definition 3
Timeline (Sequence of Events) 4
Photos 5
Diagram 6
Cause-and-Effect Analysis (5-, 7-, 10-, 25-Why) 7
Solutions 10
Resources
Contacts
Versions

Cover 5 of 25 ThinkReliability
 Summary of Incident
1-2 sentences.

Incident Description
For a more detailed sequence of events, see Timeline.

At this time, on this date.

Description 6 of 25 ThinkReliability
 1. Problem Outline

Title

Summary Description
(Optional)

What Problem(s) Lote "…." de Salsa para Pizza Sigma desviada en ph y acidez ooe

When Date
Time
Different, unique, changed
Where Facility, site
Unit, area
Equipment
Task(s) being performed
GOALS Negative effect to each item below:

Safety N/A
Environmental N/A
Customer
Production, Schedule
Equipment, Property
Labor, Time
This incident $0
Frequency
Annualized cost $0

Problem 7 of 25 ThinkReliability
 Title

Analysis AND/OR Possible Solution:

Idea, suggestion.
OR
?
Evidence:
AND Info, Facts
Area Label

Cause Map™ Diagram

pH

Why? Why?

Impact to
Acidez y pH
fuera de
Quality
espacificación

Cause Map 8 of 25 ThinkReliability

 Solutions - Action Items, Recommendations

Recommendation, action, control, idea Cause to be controlled Task to be improved Why or why not it was selected Solution details if needed Evidence it was effective

Ref. Possible Solution Cause Work Process Rationale Specific Action Owner(s) Due Date Status Measurement

Solutions 9 of 25 ThinkReliability
 Solutions Matrix

Evaluate the Different Possible Solutions

High
Use either solution boxes, letters or numbers to
place the possible solutions relative to one
another.

Great Idea Long Term Solution

Possible Solution:
Works Well Permanent Solution
Idea, suggestion. Low Hanging Fruit Design Change
No Brainer Capital Project
Slam Dunk

A B C D
Estimated
E F G H BENEFIT of Solution
Expected Result Out

Works OK for Now Not Good

1 2 3 4 Short Term Too Expensive
Quick Fix Not Enough Benefit
5 6 7 8 Work Around Diminishing Return
Get By

Low High

Estimated COST of Solution

Expected Effort In
- Scope-Function-
Quality
- Time-Schedule
- Cost-Budget
- Resources

Matrix 10 of 25 ThinkReliability
 Timeline

Date Time Description Source, Reference, Note

Timeline 11 of 25 ThinkReliability
 Photos
Black text, white glow

White text, black glow

Description

Description

Photos 12 of 25 ThinkReliability
. Diagrams

Diagrams 13 of 25 ThinkReliability
 Process Map
Steps of a Task, Job A
Steps of an Operation YES Top left

Decision
Top centered

Basic NO Middle centered

Process Map

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Process Map 14 of 25 ThinkReliability

 Information to Get

No. Information and Evidence to Collect Owner Date Created Due Date Status Completed
1

Info to Get 15 of 25 ThinkReliability

 Notes

Text

Notes 16 of 25 ThinkReliability
 Resources

Title Source Format Note Link

Resources 17 of 25 ThinkReliability
 END

END 18 of 25 ThinkReliability
 Spare Parts Text 12 Text 10
(use as needed)
Text 14 Black text, white glow

Figure 14 Figure 12 Figure 10

White text, black glow

Cause Map Diagram

™
Optional Grouped Ungrouped
Description
Negative Impact to
Process
Safety Formats Description

5-Why Cause Map™ Diagram Step Step

Negative Impact to QUESTION ANSWER

Environmental Role Role
Why ? Because...

Negative Impact to Negative Impact to Not Supported with Evidience

Effect Cause
Goal Compliance
A B C

After Before 1 2 3
Negative Impact to
Near-Miss,
Potential Impact to
Potential for Customer
cause Area Label
Safety
AND/OR
Possible Solution:
Negative Impact to Idea, suggestion.
Production, OR
Schedule
Evidence: AND
Positive Impact to
Info, Facts
Safety
Negative Impact to
Property Info to Get:

Negative Impact to
Labor, Time ? ?
File Name
File Name Convention:
CM - Client - Description - MMDDYY ID - v1JH
Cause Map - Client - Incident Name - MMDDYY - v1JH

Spare Parts 19 of 25 ThinkReliability

 Title

Analysis AND/OR Possible Solution:

Idea, suggestion.
OR
?
Evidence:
AND Info, Facts
Area Label

Cause Map™ Diagram

Why? Why? Why? Why? Why?

Impact to
GOAL

Extra CM 20 of 25 ThinkReliability
 Solutions - Action Items, Recommendations

Recommendation, action, control, idea Cause to be controlled Task to be improved Why or why not it was selected Solution details if needed Evidence it was effective

Ref. Possible Solution Cause Work Process Rationale Specific Action Owner(s) Due Date Status Measurement

Sols 21 of 25 ThinkReliability
 Extra Worksheet

Blank 22 of 25 ThinkReliability
 Examples

CONTACT Contact Contact

Cause-and-Effect Fundamental Relationship

A A
Incidents of this type occur when two things location, location,
Because.. Why? Why? Why? Why? Why?
come in contact resulting in a negative Why? position, position,
. time
outcome. time
A A A
Applies to: B was in the Impact to Consequences,
contacted contacted contacted
"Line of Fire" Incidents path Safety outcome
B B AND B AND
Hand Injuries
Eye Injuries
Chemical Exposure EFFECT CAUSE
Contamination B B
Electric Shock After Before location, location, Why?
Vehicle Accidents position, time position, time

5-Why Cause Map™ Diagram 6-Why Cause Map™ Diagram 10-Why Cause Map™ Diagram
Contact
Normal valve
operation

Valve
Contact rotated, AND
Driver looked actuated
Contact away from Energy
Valve
route isolation not
energized,
Dust part of job
not isolated
Dust particles collection not plan
location, area working Forklift at Valve
AND Serious hand
optimally location, pinched, cut AND
injury
off route fingers

Person Transporting
inhaled dust AND product Technician
Damage to Forklift hit
particles pickup pickup AND was checking
Work in area for debris
?

Fingers
Unprotected on edge of
person in Pickup valve
AND AND
area parked on Valve was
housing
pad silent, no
noise

No PPE Tech was

unaware
valve was AND
operational

No
confirmation,
check if valve
in service

Examples 23 of 25 ThinkReliability
 Training Videos

Top 3 Excel Tips 5-Why How To Video

https://www.youtube.com/watch?v=GJHm9CMYOq0 How to Conduct a 5-Why - Titanic Example - YouTube

Attend a FREE, 45-

minute webinar
(click to save your seat for an
upcoming webinar)

Attend a two-hour online

short course
(click to see the list of upcoming topics)

Attend a Cause Mapping®

Workshop
(click to see upcoming workshops)

Training 24 of 25 ThinkReliability
 Tips for Using the Cause Mapping®
Template
in Microsoft Excel®

Excel Tips 25 of 25 ThinkReliability