You are on page 1of 47

Bechtel Generic ES&H Core Processes

ROOT CAUSE ANALYSIS

4SP-H01G-122, Rev. 0 Page 1 of 51 Dated 01Sep97 Supersedes CP-122, Rev. 0

TABLE OF CONTENTS
PAGE

1.0 PURPOSE 2.0 SCOPE 3.0 DEFINITIONS 4.0 REFERENCES 5.0 RESPONSIBILITY 6.0 REQUIREMENTS
6.1 Overview of Root Cause Analysis 6.2 RCA Application 6.3 Procedure 6.4 Phase I - Collect Data 6.5 Phase II - Assessment 6.6 Phase III - Corrective Actions 6.7 Phase IV - Communication 6.8 Phase V - Monitoring and Follow-Up

3 3 3 5 5 5
5 5 7 7 9 12 13 13

EXHIBITS Exhibit A Exhibit B Exhibit C Exhibit D Exhibit E Exhibit F Exhibit G Exhibit H Exhibit I RCA Methodology Event or Problem Causal Factor Categories Root Cause Interview Form Possible Documents to Use for RCA Summary of Root Cause Methods Event and Causal Factor Charting Change Analysis Barrier Analysis Typical Causal Factor Analysis Form

Bechtel Confidential ©1999 Bechtel Corp. All rights reserved. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission.

Bechtel Generic ES&H Core Processes

ROOT CAUSE ANALYSIS Exhibit J Exhibit K Corrective Action Example Contents for RCA Report

4SP-H01G-122, Rev. 0 Page 2 of 51 Dated 01Sep97 Supersedes CP-122, Rev. 0

Bechtel Confidential ©1999 Bechtel Corp. All rights reserved. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission.

Bechtel Generic ES&H Core Processes

ROOT CAUSE ANALYSIS

4SP-H01G-122, Rev. 0 Page 3 of 51 Dated 01Sep97 Supersedes CP-122, Rev. 0

1.0

PURPOSE
To provide: • A standard method of performing Root Cause Analysis (RCA) for both equipment and human performance problems and events. This includes identifying causal factors, root causes, contributing factors, and corrective actions to prevent problem or incident recurrence. Guidance on when and to what extent RCA should be used.

2.0

SCOPE
2.1 2.2 This procedure is applicable to Bechtel projects/facilities. RCA will be used when: • Performing investigations of events, especially investigations performed for or jointly with the customer. This includes plant and safety concerns. • Addressing problems with the effectiveness or efficiency of the way work is performed.

3.0

DEFINITIONS
3.1 3.2 Barrier - Something that acts to restrict or prevent the occurrence of an undesirable condition, action, behavior, or event. Cause (Causal Factor) - Anything that shapes or influences the outcome. This may be a human error, an administration weakness, or a management deficiency. Exhibit B provides a typical sample of major cause (causal factor) categories. Causal Factor Chain (Sequence of Events and Causal Factors) - A cause-and-effect sequence in which a specific action creates a condition that contributes to or results in an event. This creates new conditions that, in turn, result in another event. Earlier events or conditions in a sequence are called upstream factors. Condition - Related circumstances pertinent to the event or problem. Any as-found state that may have adverse safety, health, quality, security, operational, performance, or environmental implications. A condition is

3.3

3.4

Bechtel Confidential ©1999 Bechtel Corp. All rights reserved. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission.

Bechtel Generic ES&H Core Processes

ROOT CAUSE ANALYSIS

4SP-H01G-122, Rev. 0 Page 4 of 51 Dated 01Sep97 Supersedes CP-122, Rev. 0

usually programmatic in nature, for example, an (existing) error in analysis or calculation, an anomaly associated with (resulting from) design or performance, or an item indicating a weakness in the management process are all conditions. 3.5 3.6 Contributing Factor - A condition that may have affected the event. Contributing Cause - Causes that, if corrected, would not by themselves have prevented the event, but are important enough to be recognized as needing corrective action to improve the quality of the process or product. For example, in the case of a fluid system leak, a contributing cause could be lack of adequate operator training in leak detection and response, resulting in a more severe event than would have otherwise occurred. Corrective Action - Action taken to prevent recurrence of an identified adverse condition or trend. Direct (or Immediate) Cause - The cause that directly resulted in the event or problem. For example, in the case of a leak, the direct cause could have been the problem in the component or equipment that leaked. Effect - An undesirable result, namely an event or problem. Event - An undesirable occurrence. An incident. An event is also anything that could seriously impact the mission of the work being performed. NOTE: 3.11 For purposes of this procedure, “event” or “problem” can be used interchangeably.

3.7 3.8

3.9 3.10

Performance Problem - A situation where the performance of a system does not meet or exceed expectations. Also, the inability to fulfill a required function. Root Cause - The cause that, if corrected, would prevent recurrence of this and similar occurrences. It is the most fundamental aspect of the cause that can logically be identified and corrected. There may be a series of causes that can be fulfilled, one leading to another. This series should be pursued until the fundamental, correctable cause has been identified. For example, in the case of a leak, the root cause could be management not ensuring that maintenance is effectively managed and controlled. This cause could have led to the use of improper seal material or missed preventive maintenance on a component, which ultimately led to the leak. Root Cause Analysis (RCA) - The process or method by which the root causes of a performance problem or event and associated corrective

3.12

3.13

Bechtel Confidential ©1999 Bechtel Corp. All rights reserved. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission.

as follows: • Level 3 . Most of these events are caused by equipment malfunctions or human performance concerns. .1 Overview of Root Cause Analysis The reason for investigating and evaluating problems using RCA is to identify corrective actions that will prevent problem recurrence. Rev. or operation. 4SP-H01G-122.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS actions are determined. with Level 3 being the least significant and Level 1 being the most significant.0 REFERENCES INPO 90-004. January 1990.1 Events or problems can be categorized into one of three levels of significance. ⇒ The nature of the problem is so easily understood and straightforward that the causes are obvious and corrective action(s) can be taken without the need for a detailed investigation.1 Site Manager .2.The Site Manager is responsible for implementing this instruction at the construction site when root cause analysis is required.0 REQUIREMENTS 6. ⇒ Actions to permanently correct the problem are readily available and easily implemented. Management involvement and adequate allocation of resources are essential to successful execution of root cause investigations and reports. All rights reserved. A variety of events or problems can occur during engineering.2 RCA Application Events that require RCA should be selected based on severity of the event or worrisome performance trends. Institute of Nuclear Power Operations.RCA is not required. Rev.0 RESPONSIBILITY 5. construction. 0 Page 5 of 51 Dated 01Sep97 Supersedes CP-122. The following key issues may help in making this selection: 6. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. 0 4. 5. procurement. Root Cause Analysis. 6. 6. Each plant or work group must establish the required threshold for conducting root cause analyses. Bechtel Confidential ©1999 Bechtel Corp.

A formal RCA investigation is required. although a formal investigation is not required. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. during. The collection and review of data captures conditions before.RCA tools or techniques are required. . ⇒ Corrective action to prevent recurrence of the problem requires formal revision to existing procedures or other applicable documents. Although there may be overlap between phases. ⇒ The problem resulted in a condition so adverse to quality that corrective action may cause substantial revision to applicable procedures or work methods. ⇒ Determining the significance of the problem. formal documentation is not required.Data Collection. The problem significance is so complex or serious that a formal root cause analysis must be performed by an individual formally trained to perform RCA.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS • 4SP-H01G-122.Five Phases Every root cause evaluation or investigation includes performing five steps or phases of work. 0 Page 6 of 51 Dated 01Sep97 Supersedes CP-122. 6.2. 0 Level 2 . environmental factors. Rev. however. ⇒ The problem is significant or complex enough that. The following phases are briefly described.2 Standard RCA Method . All rights reserved. Phase II . and after the occurrence.Assessment ⇒ Identifying and understanding the problem. the phases should be separate and distinct to maintain the logical method in solving any problem or event encountered. or modification to the way work is conducted. or incidents which either caused severe consequences or have the potential to cause unacceptable conditions of quality. and other information having relevance to the occurrence. discrepancies. ⇒ Serious problems. • Phase I . ⇒ Identifying the causes (conditions or actions) immediately preceding and surrounding the problem. and • Bechtel Confidential ©1999 Bechtel Corp. ⇒ The problem affects the overall quality of services. • Level 1 . personnel involvement (including actions taken). Rev. a RCA investigation with supporting documentation is required.

blown fuses. partially completed work orders. RCA can be performed by an individual or by a team depending on the complexity of the problem and the time available to perform an evaluation. 6. during.3 Procedure RCA is a questioning process by which the root causes of a performance problem or event and associated corrective actions are determined. • Phase III . and other information relevant to the event or problem. Every effort should be made to preserve physical evidence such as failed components. Exhibit A provides a flow chart of the RCA methodology. The information collected should consist of conditions before. • • 6. personnel involvement (including actions taken). will prevent recurrence of these and similar occurrences). If the event involves equipment. Requires discussing and explaining the results of the analysis.Monitoring and Follow-up. This root cause is the stopping point in the assessment phase. Phase IV – Inform. with management and personnel involved in the occurrence. 0 Page 7 of 51 Dated 01Sep97 Supersedes CP-122. incorrect calculations. photographing the area of the event from several views may be useful in analyzing information developed during the investigation.Collect Data 6. 0 ⇒ Identifying the reasons why the causes in the preceding step existed. The following describes each phase of the RCA Methodology. Rev. spilled fluids. Phase V . including corrective actions. Event Bechtel Confidential ©1999 Bechtel Corp. Includes determining if corrective action has been effective in resolving problems. computer data. . incorrect work packages. information is given to other managers and personnel who may be able to use what was learned.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122. and misleading or faulty procedures. if corrected. and after the event. working back to the root causes (the fundamental reason which. Implementing effective corrective actions that target each cause which reduces the probability that a problem will recur and improves the way work is performed. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission.1 Data Collection Begin data collection immediately following the event or problem identification so data is not lost. environmental factors.4 Phase I . burned leads. In addition. etc. ruptured gaskets. All rights reserved. Rev.Corrective Actions.4.

Preparation of questions prior to the interview is essential to ensure that all necessary information is obtained. Establishing a quarantine area. it should not delay prompt contact with participants and witnesses. preferably in person. should be performed for failed equipment or components. Rev. more detailed interview can be arranged. ⇒ Hardware (equipment) or software (programmatic-type issues) associated with the event or problem. Individual statements could be obtained if time and/or the number of personnel involved make interviewing impractical. Interviews should be documented using any format desired by the interviewer. Interviews should be conducted. ⇒ Physical environment or circumstances.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122. Consider conducting a “walkthrough” as part of this interview.Interviews must be fact finding and not fault finding. Exhibit B can be used as a guide in developing questions that will cover all areas or aspects of a problem or incident. A second. if needed. Although preparing for the interview is important. All rights reserved. The first interview may consist solely of hearing their narrative. Flow charting how work is supposed to be performed can help in identifying what information should be collected. . Exhibit C is one type of documentation that can be used. 0 participants and other knowledgeable individuals should be identified. or the tagging and segregation of material. • Methods of Gathering Information ⇒ Interviews/Statements . it should be verified to ensure accuracy. ⇒ Recent program or equipment changes. 0 Page 8 of 51 Dated 01Sep97 Supersedes CP-122. Rev. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. ⇒ Initial or recurring problem. with those people who were involved or are most familiar with the problem. Once all the data associated with the event has been collected. The analyst should always consider the interviewee’s objectivity and frame of reference. Bechtel Confidential ©1999 Bechtel Corp. The investigation may be enhanced if some physical evidence is retained. • The following are some areas to be considered when determining what information is needed: ⇒ Activities related to the event or problem.

and taking photographs to better understand the condition.you may want to interview other personnel who have done the work in the past. Rev. developing layout sketches of the area. component. All rights reserved. Also. Record appropriate dates and times associated with the event on the documents reviewed. Rev.2 Data Review The primary objective of data review is to determine the significance of events and establish whether.5.4. or work area. 0 Page 9 of 51 Dated 01Sep97 Supersedes CP-122.1 above.Some additional information that an evaluator should consider when analyzing the cause(s) includes the following: ⇒ Viewing physical layout of system. ⇒ Review relevant documents or portions of documents as necessary and reference their use in support of the root cause analysis. Some key issues were listed in Section 6.5 Phase II . ⇒ Determining if industry experience information exists for similar events. the evaluator will develop a detailed sequence of facts and activities. prior to event analysis. • Acquiring related information . focus on key issues. Examples of documents that may be useful are listed in Exhibit D.4. 0 ⇒ Interview others . Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. During the analysis phase. 6. additional information is needed. . ⇒ Reviewing equipment supplier and manufacturer records to determine if correspondence has been received which addresses this problem if it involves equipment. Bechtel Confidential ©1999 Bechtel Corp.Assessment 6. 6. This can be accomplished by creating a flow chart of this sequence.1 Event Analysis (Equipment or Human Performance) The purpose of the analysis phase is to reconstruct how the event or problem occurred. make sure the RCA team completely understands how the work is supposed to be performed so as not to miss any necessary data. To effectively accomplish this. Consider using a “walk-through” as part of the interview.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122.

Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. such as technical failure. To obtain the most benefit. ⇒ Simplifies organization of the investigation report and provides an informative illustration that can be used in the investigation report to brief management. Examples of areas to be considered when evaluating the apparent cause and root cause are identified in the event causal factor categories listed in Exhibit B. The following techniques can be used to evaluate events. Each technique is summarized below. ⇒ Furnishes the investigator with a concise summary of what is known and unknown about the event. ⇒ Results in identification of causes and root causes. ⇒ Serves as a guide in directing the course of the investigation. .Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122. However. • Event and Causal Factor Charting . This technique is most effective for solving complicated problems. and identify possible solutions to prevent recurrence. ⇒ Results in a detailed sequence of facts and activities. A detailed description of how to prepare and use an events and causal factors chart is provided in Exhibit F. Guidance in using the techniques is found in the referenced exhibits. administrative/programmatic failure. Exhibit E. In some cases the various techniques can be used individually to identify the root cause(s). determine root cause(s). A block diagram is used to graphically display what is known and to identify the questions to ask. and equipment and human performance problems. The depth of this analysis should be commensurate with event significance/complexity. Bechtel Confidential ©1999 Bechtel Corp. These techniques represent proven methods for the general user to evaluate various types of problems. experience has shown that in most cases.” may be of assistance in determining when a particular technique is most effective. Rev. “Summary of Root Cause Methods.Cause-and-Effect (Walk-through) Task Analysis or Flow Charting. Rev. This is the most comprehensive method discussed. this technique should be applied early in the investigation. 0 Event analysis also identifies the apparent cause(s). The block diagram: ⇒ Provides a means for organizing the event data. more than one technique is required to identify the true root causes of the event. 0 Page 10 of 51 Dated 01Sep97 Supersedes CP-122. All rights reserved.

both physical and administrative. All rights reserved.5. These differences are then evaluated to see how they contributed to the event. Barrier Analysis . Change analysis compares the previous troublefree activity with the event to identify differences. A description of how to prepare and use this diagram is also included in Exhibit F. Exhibit H provides a description of this technique including the use of a convenient form for simple evaluations. It identifies physical. It is a simple. Rev.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS • 4SP-H01G-122. or how the event occurred. • • 6.2 Root Causes Determination Based on the above section. potential root and contributing causes should meet the following four criteria in relationship to the problem: • The particular problem would not have occurred had the Bechtel Confidential ©1999 Bechtel Corp. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. However.This technique identifies the root causes by evaluating the causal factor areas that are identified for the event. six-step process that is generally used for a single event and focuses on elements that have changed. .This approach is used when the problem is obvious. This technique should be used to assess why existing barriers. causal factor work sheets are provided as Exhibit I to aid in identifying additional root causes for simple evaluations.3 Validation of Root and Contributing Causes Once the causes of an event have been identified. Change Analysis . It is very effective to first reconstruct the sequence of events and causes by flow charting how the work was performed. failed and what additional barriers are needed to prevent recurrence. additional action should be taken to ensure that the correction of these causes will prevent recurrence. Rev. causes of the event should have been determined. 0 Cause and Effect Diagramming .5. 0 Page 11 of 51 Dated 01Sep97 Supersedes CP-122. administrative. To be validated. and other controls or barriers that should have prevented an event from happening.This is a systematic process that can be used especially when the problem appears to be programmatic. Exhibit G provides guidance in performing a change analysis. identify what barriers were in place that should have prevented the undesirable occurrence. Then. 6. A form is included which can be used with simpler evaluations. procedural controls.

Therefore. reevaluate and determine a better solution. • Will the corrective action prevent recurrence of the root cause? • Is the corrective action within our capability or the customer’s to implement? • • Will the corrective action allow meeting the primary objectives? Have assumed risks been clearly stated? In determining appropriate corrective actions. Bechtel Confidential ©1999 Bechtel Corp. • • Contributing causes also need to be validated. Correction or elimination of the cause(s) will prevent recurrence of similar conditions. “The condition would not have occurred to the degree it did had the contributing causes not been present. . For example.Corrective Actions Identify corrective action for each root cause. If they are not. and others like it.6 Phase III . All rights reserved.” 6. The root causes identified are consistent with the data and interviews obtained.” i. Therefore.e. Other contributing causes may need to be validated with “tempered criteria. Rev. also evaluate the impact they will have on other organizations.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS causes not been present. Based on the severity of the condition it created. may be validated with the above criteria. • 4SP-H01G-122. a plan for corrective action implementation should be described in the report which addresses this urgency. if they are important enough. 0 Page 12 of 51 Dated 01Sep97 Supersedes CP-122. each specific root cause will have a relative importance and urgency associated with it. Apply the following criteria to the corrective action to ensure they are acceptable. the group(s) required to implement the corrective action(s) should be involved in this process.. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. Some. Rev. Experience has shown that the root causes of events can involve management issues. management must be involved and willing to take responsibility for corrective actions related to management issues. will not recur due to the same root causes or causal factors if the causes are corrected or eliminated. 0 The problem.

NOTE: Specialized training directed at the root cause analysis process will make the event analysis effort less time-consuming and the end result more useful. If an event recurs.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122.Communication The results of the root cause analysis should be presented in a report to management and the customer if appropriate. Rev. its root cause(s). reevaluate the original condition or event in addition to evaluating the new condition or event.Monitoring and Follow-Up An effectiveness review is essential to ensure that the corrective actions are preventing recurrence of the condition or event. 0 Proposed corrective actions should be reviewed to ensure that they are compatible with other commitments and what effect proposed changes will have on performance. Sufficient information should be provided to allow an understanding of the event. Contains confidential information proprietary to Bechtel not to be disclosed to third parties without Bechtel's prior written permission. .7 Phase IV . Rev. Determine why the corrective actions being taken are not effective and take further action to correct.) Bechtel Confidential ©1999 Bechtel Corp. The results should be given to personnel involved in the event and other personnel as necessary to prevent recurrence. All rights reserved. 0 Page 13 of 51 Dated 01Sep97 Supersedes CP-122. its significance. Exhibit J provides additional information to be considered when developing corrective actions.8 Phase V . as well as to justify recommended corrective actions. Sharing of root cause information with other departments or offices is desirable if this information may help to prevent similar problems or resolve long-standing problems. An example of report contents is shown in Exhibit K. A database to track and trend root cause analyses can be developed using the event causal factor categories identified in Exhibit B. 6. (Training and Training Material for root cause methodology is available from Quality Services. 6.

0 Exhibit A RCA METHODOLOGY /opt/scribd/conversion/tmp/scratch6309/83848192. Rev. Rev.doc Page 1 . 0 Page 1 of 51 Dated 01Sep97 Supersedes CP-122.Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS 4SP-H01G-122.

Bechtel Generic ES&H Core Processes ROOT CAUSE ANALYSIS Exhibit A RCA METHODOLOGY 4SP-H01G-122. Rev.doc Page 2 . 0 Page 2 of 51 Dated 01Sep97 Supersedes CP-122. Rev. 0 Collect Data Conduct Assessment Develop Corrective Actions Communicate Analysis Results Monitor Results • Determine how work is supposed to be performed • Conduct interviews/ statements • Observe site • Gather applicable documents • Determine sequence of events • Identify causes • Identify and evaluate barriers • Identify and evaluate changes • Determine root causes • Identify solutions for each root cause • Select solutions that satisfy criteria • Implement solutions using barriers and aids • Produce report • Distribute information • Determine success of corrective actions • Reevaluate if event occurs /opt/scribd/conversion/tmp/scratch6309/83848192.

Exhibit B EVENT OR PROBLEM CAUSAL FACTOR CATEGORIES /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Excessive overtime. equipment/material use. • Supervisory Method: A technique used to directly control work-related tasks. scoping.The physical configuration of equipment affects the accessibility of the equipment. The effectiveness of the training is affected by both the method and content of the training. also. • Man-Machine Interface: The design and maintenance of equipment used to communicate information to a person (displays/labels) or from a person to the equipment (controls). a method used to direct and monitor workers in the accomplishment of tasks. • Work Practice: A method a worker routinely uses to ensure the safe and successful performance of a task -. • Work Organization/Planning: The work-related task -. and the condition of the physical surroundings or environment can affect maintainability or aging of the component. in particular. Additionally. and work preparation.Included are the planning.Exhibit B EVENT OR PROBLEM CAUSAL FACTOR CATEGORIES • Verbal Communications: The spoken presentation or exchange of information -. understanding component/system interfaces. this includes the actual performance of on-the-job training. rotating shift work.The effectiveness of the presentation is affected by the method used to present the information.The effectiveness of written communication is affected by the content of the document and the method used to present the information within the document.doc Page 2 . How well a job is planned and organized plays an important role in getting the job completed on time and error-free. and the relationship of the task to performance. • Written Procedure and Documents: The written presentation or exchange of information -. the design considerations for equipment reliability. • Training/Qualification: The process of presenting information on how a task is to be performed prior to the accomplishment of the task and how the training program was developed and the adequacy of program content -.Included are the worker’s practices for error detection. and assignment of the task to be performed.Based on task frequency. • Work Schedule: Those time-related factors that contribute to the ability of the worker to perform his assigned tasks in an effective manner -. this includes periodic refresher training to determine proficiency and actions taken to correct training deficiencies. /opt/scribd/conversion/tmp/scratch6309/83848192. document use. and working on the job for extended periods of time have an influence on how well an individual will be able to perform a task. • Environmental Conditions: The physical conditions encountered in the work area -.

monitor. or exercise accountability relative to the performance of activities.doc Page 3 . • Maintenance/Testing: The process of ensuring that components/systems are maintained in the optimum condition and tested on operability. • External: Influence outside the usual control of the utility. modify. materials selection. technique. assess. • Resource Management: The process whereby manpower and material are allocated for a particular task/objective. and control of subsequent design changes. This includes initial design specification. Event causal factors for equipment performance problems are as follows: • Design Configuration and Analysis: The design and layout of systems or subsystems needed to support plant operations and maintenance. Manufacturer. • Equipment Specification. • Plant/System Operation: Reflects the actual performance of the system or component when performing its intended function.Exhibit B EVENT OR PROBLEM CAUSAL FACTOR CATEGORIES (Cont’d) • Change Management: The process whereby the hardware or software associated with a particular operation. /opt/scribd/conversion/tmp/scratch6309/83848192. or system is modified. design calculations and analyses. Construction: The process that includes the manufacture and installation of equipment in the plant. • Managerial Method: Techniques used to direct.

Exhibit C ROOT CAUSE INTERVIEW FORM /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Exhibit C ROOT CAUSE INTERVIEW FORM NAME: _____________________ POSITION/TITLE: ______________________ The purpose of soliciting your input is to assist in determining the sequence of events and root cause(s) of an event or problem that occurred. your input is crucial in determining the root cause(s). DATE /opt/scribd/conversion/tmp/scratch6309/83848192. What did you observe at the time of the event or problem? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4. What were you doing when the event occurred? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2. How did this contribute to the event? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3. Please answer the following questions to the best of your recollection.doc Page 2 . What do you think can be done to prevent it from happening again? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ NAME: _______________________________________________________________ PRINT SIGNATURE DEPT. Since you have some knowledge or involvement relative to what occurred. what are the root cause(s) of this event? Why did it happen? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5. 1. In your opinion.

doc Page 1 .Exhibit D POSSIBLE DOCUMENTS TO USE FOR RCA /opt/scribd/conversion/tmp/scratch6309/83848192.

etc.Exhibit D POSSIBLE DOCUMENTS TO USE FOR RCA • • • • • • • • • • • • • • • • • • • • • • • • Operating Logs Tagging Logs Correspondence Inspection/Surveillance Records Maintenance Records Meeting Minutes Computer Process Data Procedures and Instructions Vendor Manuals Drawings and Specifications Functional Retest Specification and Results Equipment History Records Design Basis Information Technical Specifications Related Quality Evaluation Reports Reliability Data System Reports Surveys Trend Charts and Graphs Plant Parameter Readings Sample Analysis and Results (Chemistry. Radiological. Air.doc Page 2 .) Work Order and Work Packages Functional Retest Specification and Results Pre-Job Briefings Shift Turnovers /opt/scribd/conversion/tmp/scratch6309/83848192.

Exhibit E SUMMARY OF ROOT CAUSE METHODS /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Barrier Analysis Use for procedural or administrative problems. Use for complex problems having multiple causes and contributing causes.Exhibit E SUMMARY OF ROOT CAUSE METHODS Method Cause-and-Effect Analysis (Event and Casual Factor Charting or Walk-Through Task Analysis) When to Use Use for multi-faceted problems such as plant trips or transients. Change Analysis Use on singular problems. Requires a broad perspective of the event to identify unrelated problems.doc Page 2 . Provides a systematic approach. Useful with cause-and-effect analysis. A singular problem technique that can be used in support of a larger investigation. Simple process. Also good for evaluating equipment failures. Identifies probable contributors to the condition. Also good for human performance problems. Helps to identify where deviations occurred from acceptable methods. Especially useful in evaluating equipment failures. May also be used for equipment failures. All root causes may not be identified. Provides an organized way to evaluate causes by a team. Remarks Provides visual display of analysis process. Cause-and-Effect Diagramming /opt/scribd/conversion/tmp/scratch6309/83848192.

Exhibit F EVENT AND CAUSAL FACTOR CHARTING /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Identify the cause and effect with the primary effect. How do you know this. * Primary effect is the effect or problem you are trying to prevent from recurring /opt/scribd/conversion/tmp/scratch6309/83848192. list in a block just below the cause two ways which lead you to know it to be true. If only one way is known.Exhibit F EVENT AND CAUSAL FACTOR CHARTING Cause-and-Effect Chart Conceptual Process of Cause-and-Effect Charting Primary Effect* Caused by Effect Caused by Effect. For each cause.doc Page 2 . which is(are) the root cause(s). and the last block(s) in the series. For each effect there is a cause that then becomes the next effect for which you need to identify the cause. or not firm. and is within our control. alarm type. etc. When this process gets to the point where a cause(s) can be corrected to prevent recurrence in a way that allows us to meet our objectives. personnel statement. then all possible causes should be evaluated as potential causes. etc. 3. 2. transient data acquisition system. except for the first block.g. How do you know this? e. which is the primary effect.? 1. Each block is an effect and a cause. etc. then we have found the root cause or causes. and the bases for rejected and accepted causes stated. List two or more ways that explain how you know each cause.

doc Page 1 .Exhibit G CHANGE ANALYSIS /opt/scribd/conversion/tmp/scratch6309/83848192.

6. Not recognizing the introduction of gradual change as compared with immediate change also is possible. though.g. a change in color or finish may change the heat transfer and consequently affect system temperature). the undesirable consequences. or the contributors to. /opt/scribd/conversion/tmp/scratch6309/83848192. Analyze the differences for their effects in producing the undesirable consequences. This technique consists of asking the questions: What? When? Where? Who? How? Answering these questions should provide direction toward answering the root cause determination question. combined with a change made recently) is a potential shortcoming of change and situation analysis. Not recognizing the compounding of change (e.. Several key elements include the following: 1. Integrate information into the investigative process relevant to the causes of. Compare the condition containing the undesirable consequences with the reference activity. 3. 5. a change made five years previously. Why? Primary and secondary questions included within each category will provide the prompting necessary to thoroughly answer the overall question.g. In general. 2. or you suspect a change may have contributed to the condition. you don’t know where to start. This must be done with careful attention to detail. Some amount of redundancy exists in the questions to ensure that all items are addressed. This technique may be adequate to determine the root causes of a relatively simple condition. Consider a comparable activity that did not have the undesirable consequences.Exhibit G CHANGE ANALYSIS Change Analysis looks at a problem by analyzing the deviation between what is expected and what actually happened.doc Page 2 . 4.. ensuring that obscure and indirect relationships are identified (e. The evaluator essentially asks what differences occurred to make the outcome of this task or activity different from all other times this task or activity was successfully completed. Set down all known differences whether they appear to be relevant or not. Change situation analysis is a good technique to use whenever the causes of the condition are obscure. Some of the questions will not be applicable to any given condition. Consider the event containing the undesirable consequences. it is not thorough enough to determine all the root causes of more complex conditions.

Compare 3. Comparable activity without undesirable consequence 3.Exhibit G CHANGE ANALYSIS (Cont'd) Six Steps Involved in Change Analysis 1. Event with undesirable consequence 3.doc Page 3 . Integrate information relevant to the causes of the undesirable consequence /opt/scribd/conversion/tmp/scratch6309/83848192. Set down differences 3. Analyze differences for effect on undesirable consequence 2.

plant status. occurrence. out of sequence. schedule) Where (physical location. identified.doc Page 4 . omission. training qualification. supervision) Effect Questions to Answer /opt/scribd/conversion/tmp/scratch6309/83848192. extraneous action. activity. equipment When (occurred. environmental conditions) How (work practice. procedure) Who (personnel involved.Exhibit G CHANGE ANALYSIS (Cont'd) CHANGE ANALYSIS WORK SHEET Difference/ Change What (conditions.

Were any changes in plant conditions noted which could have contributed to the event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3.Exhibit G CHANGE ANALYSIS (Cont'd) CHANGE ANALYSIS FORM ROOT CAUSE INVESTIGATION .doc Page 5 . Were procedures or work practices revised which resulted in the undesirable consequence? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2.CHANGE ANALYSIS 1. Were other activities being performed which are normally not performed in conjunction with the activity? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. temperature. weather or time of day different than when previously performed? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Were any other changes or differences noted which could have caused the undesirable results? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ INVESTIGATOR SIGNATURE DATE /opt/scribd/conversion/tmp/scratch6309/83848192. Were conditions such as lighting.

doc Page 1 .Exhibit H BARRIER ANALYSIS /opt/scribd/conversion/tmp/scratch6309/83848192.

4. 5. 6. 22. did they perform their functions. operators. considering all economic concerns (as regards operation. managers. 1. If there were barriers. 12. design. supervision. anyone? Is it possible to have foreseen the event? Why? Is it practical to have taken further steps to have reduced the risk of the event occurring? Can this reasoning be extended to other similar systems/components? Were adequate human factors considered in the design of the equipment? What additional human factors could be added? Should be added? Is the system/component user-friendly and logical? Is the system/component adequately labeled for ease of operation? Is there sufficient technical information for operating the component properly? How do you know? Is there sufficient technical information for maintaining the component properly? How do you know? What would you have done differently to have prevented the event. maintainers. 7. 8. 14. 13. The questions below are to aid in determining what barrier failed that resulted in the event or problem. 18. 15. 19.Exhibit H BARRIER ANALYSIS There are many things that should be addressed during the performance of a Barrier Analysis. 2.doc Page 2 . 10. 23. maintenance. 3. 16. 17. 21. and management)? /opt/scribd/conversion/tmp/scratch6309/83848192. Why? Did the presence of any barriers mitigate or increase the event or problem severity? Why? Were any barriers not functioning as intended? Why? Was the barrier design adequate? Why? Were the barriers adequately maintained or adhered to? Were the barriers inspected or evaluated prior to expected use? Why were any unwanted energies present? What management changes could have prevented the unwanted flow of energy? Why? What design changes could have prevented the unwanted flow of energy? Why? What operating changes could have prevented the unwanted flow of energy? Why? What maintenance changes could have prevented the unwanted flow of energy? Why? What other controls are the barriers subject to? Why? Was this event foreseen by the designers. 9. 20. 11.

Exhibit H BARRIER ANALYSIS (Cont'd) Example Barriers Assessment Procedures None used Adequate Turnover Not performed Log Books Log entries not made Tag Report Not noted Tag Log No tags hung Walkdown Not performed prior to energization Undesirable Event /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 3 .

Did the barriers perform their function? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3.doc Page 4 . Were the barrier adequately maintained? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Can additional barriers be created to prevent this type of event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ /opt/scribd/conversion/tmp/scratch6309/83848192.Exhibit H BARRIER ANALYSIS (Cont'd) BARRIER ANALYSIS FORM 1. Did the barrier increase or decrease the severity of the event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6. Were the barriers in place or inspected prior to the event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. What barriers are in place to prevent this type of event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Was the design of the barrier adequate to prevent the event? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 7.

Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Was the equipment properly labeled? Field identification.Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM Procedures: 1. heat stress area. Was the work environment acceptable? Adequate lighting. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Were procedures followed/completed correctly? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. etc. Was the task interrupted? ________________________________________________________________ ________________________________________________________________ Exhibit I /opt/scribd/conversion/tmp/scratch6309/83848192. Were procedures correct? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. list procedures) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. matched design drawings and procedure ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Were procedures used? (if YES. Was the procedure/document/work order appropriately reviewed prior to use? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Human Factors: 1.doc Page 2 .

Was worker fatigue or excessive overtime a factor? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Communications: 1. Were verbal commands misunderstood? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Were equipment noun names and system used? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4.TYPICAL CAUSAL FACTOR ANALYSIS FORM (Cont'd) 4. Was excessive use of radio or page system required? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Were complicated instructions involving more than one or two components written down? ________________________________________________________________ Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM (Cont'd) Planning/Scheduling: /opt/scribd/conversion/tmp/scratch6309/83848192. Was training adequate to assure successful performance of the task? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6. Were proper self check techniques used? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5.doc Page 3 .

Could the cause be attributed to misapplication of the type of equipment involved in the failure? ________________________________________________________________ Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM (Cont'd) 3. Were proper spare parts or consumables identified and available? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Could the cause be attributed to a manufacturing defect? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ /opt/scribd/conversion/tmp/scratch6309/83848192. Was proper retest specified in the work package? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Did planning identify special conditions? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Equipment Reliability/Design: 1. etc. tagouts. RWPs.doc Page 4 . procedures. Was the activity delayed or interrupted? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Could the cause be attributed to improper design? ________________________________________________________________ ________________________________________________________________ 2. Did the work package include all information required to perform the task? Drawings.1.

Could the failure be attributed to inadequate preventive maintenance? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6. Could the cause be attributed to improper installation? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Natural Phenomenon: 1.4. Could the failure be attributed to improper storage? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 7. Could the cause be attributed to flooding. earthquake or fire? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ /opt/scribd/conversion/tmp/scratch6309/83848192. Could the cause be attributed to extreme weather conditions? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2.doc Page 5 . Were defective or worn parts found? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5.

Other? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Supervision: 1.Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM (Cont'd) 3. Did the job supervisor perform a prestart inspection on the work package and job site? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Did the supervisor visit the job site during the activity? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2.doc Page 6 . Did administrative duties interfere with supervisor’s ability to observe the work activity? ________________________________________________________________ Exhibit I TYPICAL CAUSAL FACTOR ANALYSIS FORM (Cont'd) /opt/scribd/conversion/tmp/scratch6309/83848192. Was shift turnover involved? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Did emphasis on meeting schedule exceed that on workmanship? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6. Was a prejob briefing performed? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4.

Did existing job performance standards adequately cover the task/job? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2.doc Page 7 . Did previously identified corrective actions fail to resolve the problem? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Did the management review process fail to identify the problem? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Did management fail to implement corrective actions in a timely manner? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ INVESTIGATOR SIGNATURE DATE /opt/scribd/conversion/tmp/scratch6309/83848192.Management Deficiency: 1.

Exhibit J CORRECTIVE ACTION /opt/scribd/conversion/tmp/scratch6309/83848192.doc Page 1 .

Exhibit J CORRECTIVE ACTION In developing and implementing corrective action.doc Page 2 . the following questions can help to ensure success: • • • • • Do the corrective actions address all the root causes? Will the corrective actions cause detrimental effects to this or other processes? What are the consequences of implementing the corrective actions? What are the consequences of not implementing the corrective actions? What is the cost of implementing the corrective actions? ⇒ ⇒ ⇒ • • • • • Capital Costs? O&M Costs? Time? Will training be required as part of the implementation? In what time frame can the corrective actions reasonably be implemented? What resources are required for successful development of the corrective actions? What resources are required for successful implementation and continued effectiveness of the corrective actions? What impact will the development and implementation of the corrective actions have on other work groups? For example: Plant Engineering? Quality Control? Security? Operations? Drafting? Materials Management? Safety Reviews? Design Engineering? Maintenance? Training? Drawing Control? Document Control? Computer Support? Plant Modifications? Configuration Management? • Is the implementation of the corrective actions measurable? /opt/scribd/conversion/tmp/scratch6309/83848192.

doc Page 1 .Exhibit K EXAMPLE CONTENTS FOR RCA REPORT /opt/scribd/conversion/tmp/scratch6309/83848192.

doc Page 2 .Exhibit K EXAMPLE CONTENTS FOR RCA REPORT Root Cause Analysis Report # _____ Event/Problem Description: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Location: _____________________________________________________________________ Date and Time: _____________________________________________________________________ Work Involved: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Team Members Conducting RCA: _____________________________________________________________________ Narrative of Event/Problem Sequence: (Attach Sequence Flow Chart) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Data Collected (Attach Documents/Facts and Interview Results) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ /opt/scribd/conversion/tmp/scratch6309/83848192.

doc Page 3 .Exhibit K EXAMPLE CONTENTS FOR RCA REPORT (Cont'd) Assessment of the Event or Problem: • • • • Reconstruction of the Event or Problem Root Causes Contributing Factors Validation of Root Causes _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Corrective Actions: • • Immediate Actions Long-term Actions _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Communication and Monitoring: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ /opt/scribd/conversion/tmp/scratch6309/83848192.