1. PRESENTED BY ABC TEXAS GULF COAST CHAPTER
ROOT CAUSE ANALYSIS
PRESENTED BY
ABC
TEXAS GULF COAST CHAPTER
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TRAINING AGENDA
1. Introduction to RCA
2. RCA Problem Solving
A. Problem Solving Flow Chart
B. Cause and Effect Chain
C. Primary Effect Definition
D. Root Cause Definition
E. Cause and Effect Chart Process
F. Root Cause Analysis Example
G. Cause/Effect Flow Chart Example
H. Summary Report Example
3. Skills Exercises
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Course Objective
To provide the knowledge and skills necessary to participate in effective Root Cause Analysis.
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LEARNING OBJECTIVES
State the definition of Root Cause
State the purpose of Root Cause Analysis
State the three elements of problem analysis
Explain the cause and effect principle
Be able to identify the three basic root cause categories and know their basis
State the four root cause criteria
Given and example, be able to recognize a root cause summary statement
Given a sample scenario demonstrate competence in the use of the Cause and Effect charting technique
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ROOT CAUSE ANALYSIS
A tool that helps find a way to prevent problem recurrence
Main intent of process is not to place blame
Starts out as a reactive process and after it is full understood, it’s use becomes more proactive
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6. WHY USE THE ROOT CAUSE ANALYSIS PROCESS?
Provides and orderly approach to problem solving
Avoids opinion and forces the use of facts
Helps find a root cause or admit a root cause is not clear
Leads to true solution that will prevent recurrence of the problem
Documents your thinking in the form of a cause and effect diagram.
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ROOT CAUSE ANALYSIS
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8. DEFINE THE PROBLEM Perform Analysis
Gather Information
When did it happen?
What is the problem?
Where did it happen?
What is the significance?
Write the Problem
Perform Analysis
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9. Perform Analysis Verify Solution
Prepare Cause and Effect Chart
Define the Problem
Identify Root Cause(s)
Write Cause and Effect Summary
Identify Associated Solutions
Verify Solution
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10. VERIFY SOLUTION Perform Analysis
Does the Solution prevent recurrence?
Perform Analysis
Is the solution within your control?
Does the solution meet your goals?
Does the solution cause other problems?
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CAUSE AND EFFECT CHAIN
All events are a result of a chain of causes and effects; starting with the primary effect, and ending with the root cause or causes
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12. CAUSE AND EFFECT PROCESS
DIRECT
CAUSE
SUBSEQUENT
EFFECT
ROOT
CONTRIBUTING CAUSE
PRIMARY
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PRIMARY EFFECT
The effect or problem you are trying to prevent from recurring is the primary effect. It is singular with one or more root causes.
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ROOT CAUSE
The cause that if removed or prevented from happening will prevent the primary effect from occurring.
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ROOT CAUSE CATEGORIES
Personnel performance problems
Procedure problems
Hardware problems
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ROOT CAUSE CRITERIA
The Root Cause has a solution that:
Prevents recurrence
Is within your control
Allows you to meet your goals and objectives
Does not cause other issues. No “side effects”
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17. CAUSE AND EFFECT CHART PROCESS
Step 1. Write down the primary effect
Step 2. Ask why this happened
Step 3. After you have found the answer
write it down as the cause
Step 4. Ask how it is that you know this to be the
cause, and write down at least two ways
you know it to be true
Step 5. Repeat steps 2, 3, and 4 until the root causes are
found.
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18. ROOT CAUSE ANALYSIS EXAMPLE
Incident Report 4/1/1994
Description of Occurrence:
On March 21, 1991 at PF-41, hazardous material was released which contaminated
several workers and the immediate area.
Immediate Actions Taken and Results:
Several workers went to Industrial Medicine, and received first aid. The effects were not
serious, but the employees were shaken up by the unexpected event.
Investigation:
A system improvement project for the TBA plant was being undertaken. The project consisted
of installing a pump and a new piping system. The block machinists and pipefitters were utilized
for all the required work. After all the work was completed, operations was asked to test the
system. An operator started the pump while a machinist and pipefitter stood by observing the
start-up of the system. After a few minutes, a leak occurred at one of the flanged connections
by the pump and sprayed the operator, machinist and pipefitter. The operator immediately
shutdown the pump and called the board operator for assistance. All three worked went to
the safety showers and stayed there until the ambulance arrived.
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19. SIMPLIFIED CAUSE AND EFFECT CHART
Personnel /area contamination with hazardous material
Flange seal failure
O-Ring Blowout
O-Ring misalignment with flange
Wrong O-ring installed
Maintenance Procedures not adequate
Root Cause
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20. CAUSE AND EFFECT CHART DOW RESTRICTED - For internal use only A
Recorded at 100psig
O-ring separated & sticking out of flange
Observed by Mechanics
Observation
Reportable Event
Standard Operating Practice
Personnel /area contamination with hazardous material
Hazardous Material in System
Flange Seal Failure
O-Ring Blew Out
O-Ring Misaligned with Flange
System Pressure Runs High
Wrong O-Ring Installed
Maintenance Procedures less than adequate
ROOT CAUSE
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SUMMARY STATEMENT
A good summary has this format
Problem Definition with Primary Effect
Caused by, or Why, ect..
Root Cause Stated
Root Cause Categories
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22. Root Cause Analysis Report
Things to include in RCA Report:
Goal
Report Writer
Report Date
Significance
Cause and Effect Summary Statement
Root Cause
Root Cause Category
Corrective Action and Those Responsible
Example Report in Packet
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23. Goal: Prevention, Not Blame
ROOT CAUSE ANALYSIS
Goal: Prevention, Not Blame
Define the Problem: What?
When?
Where?
Significance?
Perform Analysis: Create C&E Chart
Identify Root Cause(s)
Identify Associated Solutions
Verify Solutions Prevents Recurrence
Within Your Contol
Meets Goals and Objectives
Does Not Create New Problems
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PRACTICE
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25. ROOT CAUSE ANALYSIS CAUSE AND EFFECT CHART-SIMPLE
Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise it is not necessary to include the evidence portion
Use the Checklist in your book to keep you on track.
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26. ROOT CAUSE ANALYSIS Cause and Effect Chart w/ Evidence
Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise you will need to include the evidence portion
Use the Checklist in your book to keep you on track.
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27. ROOT CAUSE ANALYSIS Cause and Effect Chart w/ Evidence and RCA Report
Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise you will need to include the evidence portion and complete a Root Cause Analysis Report
Use the Checklist in your book to keep you on track.
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