Root Cause Analysis

for Effective Incident Investigation

Christy Wolter, CIH

Principal Consultant
Environmental and Occupational Risk Management (EORM®)
April 7, 2005
 Outline
 Introduction
 What is Root Cause Analysis (RCA)?
 How does RCA work?
 Tips to make your RCA more effective
 Interviewing techniques

© 2005 EORM, Inc. 2

 What is Root Cause
Analysis (RCA)?
 One of several tools suitable for after
the fact investigations
 Most straightforward method
sufficiently structured to identify, and
determine relationships between,
various events and issues that may
have combined to produce the
incident

© 2005 EORM, Inc. 3

 How Does RCA Work?
 Employee fell down Symptoms vs. Roots
 Employee was careless
 Employee under time
pressure
 Under time pressure
because of overlapping
delivery dates
 Delivery dates overlap
because of poor
communication
between teams
 Poor communication Keep going further
exists because… by asking “why?”

© 2005 EORM, Inc. 4

 The Root
 The root cause is typically not
simply machine failure
 The root cause is more typically:
– Machine failure due to improper
maintenance, contributed to by
both difficulty of maintenance
access and unclear procedures,
each exacerbated by lack of
procedure review because no
management of change
process….(can we go further?)

© 2005 EORM, Inc. 5

 Has a Root Cause Been
Identified?
 Thermocouple probe reading high
 Wrong manual valve opened
 Pressure set point incorrect
 Object lifted was too heavy
 Procedural step performed out of
order

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 How Does RCA Work?
1. Start with a descriptive statement of the
incident/near miss
2. Determine what conditions, events, and/or
factors might have caused (alone) or
contributed to (in combination with other
conditions) the incident. These are your
primary (1o) factors (i.e., Why?)
3. Determine conditions/events/factors that
may have caused or contributed to the
primary factors. These are your secondary
(2o) factors (i.e., Why?)

© 2005 EORM, Inc. 7

 Examples of RCA
Documentation
 Fishbone (cause and effect) diagram

 Simplified logic diagram

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 Example Fishbone Diagram
Fishbone Diagram
Example

Methods
Machines
Written checklist did not
New valve access
include warnings re safe
requires ladder
ladder use
No Mgt of No hazard
Change analysis analysis of
Ladder legs uneven procedure
Lack of
Maintenance
No Trng Operator
Mgt broke wrist on
System fall from
Operator not trained ladder
Steps wet and slippery
Operator did not heed ladder Lack of
warning label Housekeeping

No discipline for People Material

previous safety
violations

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 Example Root Cause
Diagram
Example Root Cause
Diagram
Operator suffers
chemical burn on hand

"AND"

PPE did not prevent

Chemical splashed when 1o
it was manually added to
exposure
tank

"OR" "OR"

Procedure does not

PPE not used
PPE wrong for this
prevent
Procedure not 2o
service followed correctly
splashing

Operator did not

3o
PPE not available
don available PPE Chemical changed PPE assessment poor/
since initial PPE omitted
assessment Procedure unclear Deviations
not
considered
important

No PPE inventory
management system
No procedural HAZOP
PPE performed
PPE was Change review
hinders
not didn't consider PPE
work
considered issues
progress
important 4o

No Management of
Change process in place 5o

Low accountability for

safety issues

PPE assessment
poor/omitted

KEY:

"OR" Cause Factor/

Contributor

"AND" "Root"

© 2005 EORM, Inc. 10

 Chronology of an Incident
Investigation
1. Event occurs
2. Collect information from the scene of
the event
3. Gather more information (witnesses,
system information, etc.)
4. Conduct detailed RCA
5. Write an Action Plan
6. Implement the Action Plan
7. Review results
8. Modify Action Plan as necessary

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 Tips For More Effective
RCAs
 Factors concisely written yet
sufficiently descriptive
– Will the logic be understandable to
persons not in the session, or to you a
few years from now?
 Speculation is clearly identified as
such
 Actionable items are clearly defined
 Conduct analysis as soon as possible
after data have been gathered
 Disallow blame
© 2005 EORM, Inc. 12
 Tips For More Effective
RCAs
 Assemble a knowledgeable team
 Use the 80/20 Rule
 Tackle one branch at a time….
this helps keep team’s thoughts organized
 Use brainstorming techniques
 Don’t disrupt the brainstorm by trying to
perfect the flow/diagram!
– Stay ½-step ahead of your team when
diagramming
 Prevent skipping levels or jumping to
conclusions

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 Focusing the Analysis
 Consider the likelihood and magnitude
of impact of each potential cause, and
assess most deeply (i.e., spend the
most time on) those most likely or
that may contribute most impact.
 Although the team may brainstorm
20+ potential causes, they vary in
placement along the continuum…

Defies the laws Happens every day

of physics everywhere

© 2005 EORM, Inc. 14

 Conducting RCA
Interviews
 Create a list of
questions to ask in
advance
 Avoid conducting a
Root Blame
interview
 Ask how injured
employees are
doing

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 Examples Of Questions To Ask
 Process Equipment Questions
– Were any operating parameters (e.g., temperature,
pressure, flow rates) changed just prior to the
incident (preceding minutes, hours, or days,
depending on length of operation)?
– Were operating conditions leading up to the incident
recorded (e.g., strip charts, process control system
print outs, instrumentation )?
– Were any reactants changed just prior to the incident
(e.g., new chemical used, change in chemical
concentration, change in chemical vendor)?
 Employee Interaction
– Was the employee involved in the incident interacting
with the process equipment at the time (e.g.,
adjusting valves, performing a manual procedure,
servicing, troubleshooting, calibrating)?
– Was the employee involved in the incident using
support equipment at the time (e.g., ladder,
extension cord, lift devices, portable pumps for
maintenance)?
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 Examples Of Questions To Ask
 Documentation
– Do written procedures exist for the
operation/activity performed at the time of the
incident?
– Do written maintenance procedures exist for the
equipment involved in the incident?
– Was maintenance performed on the equipment
involved in the incident?
– Did clearly-written procedures exist for all tasks
required for this process/equipment?
– Do written procedures describe the potential
consequences of deviations?
– Do written procedures describe the PPE required?
 Systems Review
– Was the appropriate PPE available and worn?
– Have you received training on this process
and equipment?

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 Focusing the Analysis
 Consider the likelihood and magnitude of
impact of each potential cause, and assess
most deeply (i.e., spend the most time on)
those which are most likely or which may
contribute most of the impact. Although the
team may brainstorm 20+ potential causes,
they vary in their placement along the
continuum…

Defies the laws of physics Happens every day everywhere

© 2005 EORM, Inc. 18

 Summary
 Use Root Cause Analysis for actual or
near miss incidents, to prevent
recurrence
 Maximize effectiveness by gathering
the right data and following the
approach outlined in this course
 Keep the analysis and its
documentation as straightforward as
possible, to enhance the probability
you will continue to use it in the
future!

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