PRESENTED BY ABC TEXAS GULF COAST CHAPTER ROOT CAUSE ANALYSIS PRESENTED BY ABC TEXAS GULF COAST CHAPTER DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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 DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only Course Objective To provide the knowledge and skills necessary to participate in effective Root Cause Analysis. DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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 DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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 DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only ROOT CAUSE ANALYSIS DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

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? DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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 DOW RESTRICTED - For internal use only

CAUSE AND EFFECT PROCESS DIRECT CAUSE SUBSEQUENT EFFECT ROOT CONTRIBUTING CAUSE PRIMARY DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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. DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only ROOT CAUSE The cause that if removed or prevented from happening will prevent the primary effect from occurring. DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only ROOT CAUSE CATEGORIES Personnel performance problems Procedure problems Hardware problems DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only 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” DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only SUMMARY STATEMENT A good summary has this format Problem Definition with Primary Effect Caused by, or Why, ect.. Root Cause Stated Root Cause Categories DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

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 DOW RESTRICTED - For internal use only

DOW RESTRICTED - For internal use only PRACTICE DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only

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. DOW RESTRICTED - For internal use only