Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation

Root Cause Analysis Handbook

A Guide to Efficient and Effective Incident Investigation

Third Edition

By

Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney and David A. Walker

ROTHSTEIN ASSOCIATES INC., PUBLISHER

Brookfield, CONNECTICUT USA

www.rothstein.com

ISBN# 978-1-931332-51-4 (Paperback) ISBN# 978-1-931332-72-9 (PDF)

ISBN# 978-1-931332-82-8 (EPUB)

Copyright © 2008

ABSG Consulting Inc.

16855 Northchase Drive

Houston, TX 77060 USA

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior permission of the Publisher.

For permission to reproduce any portion of this handbook, contact the Publisher.

No responsibility is assumed by the Publisher or Author for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein.

ISBN# 978-1-931332-51-4 (Paperback)

ISBN# 978-1-931332-72-9 (PDF)

ISBN# 978-1-931332-82-8 (EPUB)

Library of Congress Control Number: 2008928960

Publisher:

Philip Jan Rothstein, FBCI

Rothstein Associates Inc.

The Rothstein Catalog On Service Level Management

4 Arapaho Road

Brookfield, Connecticut 06804-3104 U.S.A.

203.740.7444

203.740.7401 fax

www.rothstein.com

www.ServiceLevelBooks.com

info@rothstein.com

Thank You for Choosing ABS Consulting’s Root Cause Analysis Handbook as Your Root Cause Analysis and Incident Investigation Resource

ABS Consulting personnel have worked on all types of root cause analyses and incident investigations. These range from identifying human errors or component failures that contribute to simple system failures, to discovering the origins of catastrophic incidents by piecing together a complex chain of events through rigorous application of the root cause analysis techniques described in this handbook, to analyzing chronic problems at many facilities. Our techniques have been applied to personnel injuries and fatalities, environmental spills, scheduling issues, reliability problems, quality concerns, and financial issues.

ABS Consulting Investigation Assistance

If you need help investigating an accident or problems related to reliability, quality, production, security, or finances, ABS Consulting can be of assistance. Our investigators can lead a team of your personnel, advise your team, or provide an independent analysis, depending on your specific needs.

ABS Consulting Training Services

Based on our experience, we have trained thousands of individuals using the proven techniques outlined in this handbook. And because these training courses emphasize a workshop approach to learning, students gain valuable experience by practicing what they learn on realistic industry examples. We can even teach a course at your facility using workshops that have been customized to meet the needs of your company or organization. The courses can range from one to five days in duration. The following are summaries of just a couple of the 75+ public courses that we teach.

Incident Investigation/Root Cause Analysis (Course 106) — The focus of this course is on how to gather data, analyze data for causal factors, fill gaps in data, determine root causes, and write effective recommendations using ABS Consulting’s proven SOURCE™ (Seeking Out the Underlying Root Causes of Events) technique. You will learn and apply several systematic methods, such as causal factor charting, timelines, and cause and effect tree analysis, to uncover the root causes of system performance problems. You will also participate in several workshops, including one on the use of ABS Consulting’s Root Cause Map™ and another in which you will perform a complete root cause analysis of a realistic problem. You will also learn how to structure an effective incident investigation or root cause analysis program, which includes defining, classifying, and trending data on near misses and other incidents that need to be reported.

Preventing and Mitigating Human Errors (Course 124) — In this course you will learn how to examine human errors to identify the conditions and error-likely situations that contributed to mistakes. From this starting point, you will learn to recognize the true causes of most human errors, which are weaknesses in the management systems used to (1) design equipment and processes, (2) develop and use procedures and policies, and (3) select, train, supervise, and communicate with workers.

ABS Consulting Web-based Services

In addition to the guidance provided in this handbook and in our courses, ABS Consulting provides root cause analysis resources on our Web site. Up-to-date clarifications and guidance based on feedback from users of this handbook, as well as sample programs and reports, are all available at:

www.absconsulting.com/RCAHandbookResources

Contact Us for Information and Assistance

If you would like a copy of our training catalog or more information about how we can assist you, contact ABS Consulting.

• By phone at 1-800-769-1199

• By fax at 1-281-673-2931

• By e-mail at training@absconsulting.com

• By mail at ABSG Consulting Inc., 16855 Northchase Drive, Houston, TX 77060, USA

• At www.absconsulting.com/training

What’s New in the 2008 Edition of the Root Cause Analysis Handbook

The 2008 edition of the Root Cause Analysis Handbook incorporates many updates and new features. ABS Consulting’s SOURCE™ incident investigation methodology continues to evolve based on the experience of ABS Consulting personnel using the technique, observation of customers using the tools we provide, and feedback from our customers. The changes incorporated into this edition make the use of the SOURCE™ methodology even more efficient and effective.

• More detail. The most visible change is that the handbook has much more detail on how to perform an analysis. It includes detailed steps, checklists, and forms used to perform an analysis. This should allow users to more effectively incorporate the methodology and apply it to a variety of situations.

• Changes to the Root Cause Map™. The Root Cause Map™ has changed significantly. For example:

– Two layers have been added. The two sections on Administrative/Management Systems related to Standards, Policies, and Administrative Controls (SPACs) have been moved off of the main Root Cause Map™ and are now used following identification of a near root cause. This should encourage users to dig deeper in finding underlying causes.

– It has been refined to more specifically address management of change. Because management of change is often a contributor to incidents, the steps involved in this process have been specifically addressed on the Root Cause Map™.

– There is additional focus on quality issues. The latest version of the Root Cause Map™ incorporates changes aimed at addressing issues frequently encountered during the analysis of product manufacturing and customer relations issues. In addition, the revised handbook places a greater emphasis on detecting and correcting human and equipment performance issues. As a result, quality activities that focus on this aspect of operations are now specifically addressed on the Root Cause Map™.

– It incorporates facility-specific procedures and policies. Facility-specific procedures and policies can be incorporated into the use of the Root Cause Map™ by adding that information to the coding of each root cause at the root cause level.

• New definitions. In the prior edition, we defined causal factors as human errors and equipment failures. As we continued to work with national and international organizations, we encountered difficulties in applying the definitions of error and failure. An error at one plant or facility was perfectly acceptable at another based on operating characteristics and requirements. We have adopted the use of front-line personnel performance gaps and equipment performance gaps to replace human errors and equipment failures. These new definitions force the user to specifically define both the actual and desired behavior of the people and equipment for any causal factor. These definitions integrate better with the concepts of human performance technology; antecedent, behavior, consequence (ABC) analysis; and behavior-based risk management programs that many organizations are already using. These changes should encourage users to more precisely define the performance gaps present in their organization.

• Online resources. ABS Consulting believes in providing the users of its SOURCE™ methodology with the best tools to deploy the approach in their facilities. To that end, ABS Consulting is providing an abundance of incident investigation resources on our Web site. The Root Cause Map™ guidance that was formerly included in the Root Cause Analysis Handbook is now available on our Web site with an application that allows users to rapidly access guidance on using the Root Cause Map™ as well as accessing numerous example analyses. The guidance still contains an explanation of the node, examples, and recommendations. Enhanced cross-referencing to other nodes has also been provided to allow users to more consistently code root causes. The online guidance will be updated based on feedback from users of the Root Cause Map™. Send us your examples and we will incorporate them into the online guidance.

• Resource CD. In addition to the resources available on the Web, ABS Consulting is providing much of the same information on a resource CD that accompanies this handbook. This should allow users without ready access to the Web to use much of the guidance contained on the Web site.

• SOURCE™ Investigator’s Toolkit . The SOURCE™ Investigator’s Toolkit has always been available for users to download from the ABS Consulting Web site. This addition to the handbook integrates the forms, checklists, and guidance from the toolkit into the handbook text.

• Use of timelines. This version of the handbook provides an additional tool for causal factor identification. In the past, SOURCE™ has used cause and effect trees (fault trees) and causal factor charts for identification of causal factors. Now, in addition to these two tools, graphical timelines have been included. Timelines share many of the same attributes as causal factor charts; however, they do not incorporate the logic tests that causal factor charts use. As a result, using timelines will not always result in identification of all of the causal factors for an incident. However, they can be used to quickly identify many of the causal factors. If the organization chooses not to invest heavily in an analysis of an incident, timelines may be the tool of choice. However, the user must keep in mind the limitation of the approach.

• Task triangle model. The task triangle model is used extensively to anchor the concepts of the SOURCE™ methodology. Depth of analysis, causal factors, root causes, and the scope of recommendations are all described in relationship to this model. This provides the user with an easy model to understand and use throughout the analysis.

We hope that these changes improve the usability and effectiveness of the methodology at each facility where it is applied. We welcome your feedback and continued assistance in improving our approach and our service to our customers. Use our Web site to ask questions, provide feedback, and submit examples for inclusion on our Web site.

Lee N. Vanden Heuvel

Manager – Incident Investigation and Root Cause Analysis Services

ABS Consulting

LNV@absconsulting.com

www.absconsulting.com/RCAHandbookResources

Table of Contents

List of Figures

List of Tables

List of Acronyms

Foreword

Background

The SOURCE™ Methodology

Scope of the Handbook

Contents of the Handbook

Section 1: Basics of Incident Investigation

1.1 The Need for Incident Investigation

1.1.1 Rational for Taking a Structured Approach to Incident Investigation

1.1.2 Depths of Analysis

1.1.3 Structured Analysis Process

1.2 Selecting Incidents to Investigate

1.3 The Investigation Thought Process

1.3.1 Differences Between Traditional Problem Solving and Structured RCA

1.3.2 The Typical Investigator

1.3.3 A Structured Approach to the Analysis

1.4 RCA Within a Business Context

1.5 The Elements of an Incident

1.6 Causal Factors and Root Causes

1.7 The Goal of the Incident Investigation Process

1.8 Overview of the SOURCE™ Methodology

1.9 The SOURCE™ Root Cause Analysis Process

1.9.1 Steps That Apply to Acute Incident Analyses

1.9.2 Steps That Apply to Chronic Incident Analysis

1.9.3 Steps That Apply When No Formal Analyses Are Performed

1.9.4 Steps That Apply to All Analyses

1.10 Levels of the Analysis: Root Cause Analysis and Apparent Cause Analysis

1.11 Definitions

1.12 Summary

Section 2: Initiating Investigations

2.1 Initiating the Investigation

2.2 Notification

2.3 Emergency Response Activities

2.4 Immediate Response Activities

2.5 Beginning the Investigation

2.6 Initial Incident Reports and Corrective Action Requests

2.6.1 Reasons to Generate an IIR or CAR

2.6.2 Typical Information Contained in an IIR or CAR

2.6.3 Using the IIR or CAR in the Incident Investigation Process

2.7 Incident Classification

2.8 Investigation Management Tasks

2.9 Assembling the Team

2.10 Briefing the Team

2.11 Restart Criteria

2.12 Gathering Investigation Resources

2.13 Summary

Section 3: Gathering and Preserving Data

3.1 Introduction

3.2 General Data-gathering and Preservation Issues

3.2.1 Importance of Data-gathering

3.2.2 Types of Data

3.2.3 Prioritizing Data-gathering Efforts

3.2.3.1 People Data Fragility Issues

3.2.3.2 Electronic Data Fragility Issues

3.2.3.3 Physical/Position Data Fragility Issues

3.2.3.4 Paper Data Fragility Issues

3.3 Gathering Data

3.4 Gathering Data from People

3.4.1 Factors to Assess the Credibility of People Data

3.4.2 Initial Witness Statements

3.4.3 The Interview Process

3.4.3.1 Before the Interviews

3.4.3.2 Beginning the Interview

3.4.3.3 Conducting the Interview

3.4.3.4 Concluding the Interview

3.4.3.5 Follow-up Interviews

3.5 Physical Data

3.5.1 Sources of Physical Data

3.5.2 Types and Nature of Physical Data Analysis Questions

3.5.3 Basic Steps in Failure Analysis

3.5.4 Use of Physical Data Analysis Plans

3.5.5 Chain of Custody for Physical Data

3.5.6 Use of Outside Experts

3.6 Paper Data

3.7 Electronic Data

3.8 Position Data

3.8.1 Unique Aspects of Position Data

3.8.2 Collection of Position Data

3.8.3 Documentation of Photos and Videos

3.8.4 Alternative Sources of Position Data

3.9 Overall Data-collection Plan

3.10 Application to Apparent Cause Analyses and Root Cause Analyses

3.11 Summary

Section 4: Analyzing Data

4.1 Introduction

4.2 Overview of Primary Techniques

4.3 Cause and Effect Tree Analysis

4.4 Timelines

4.5 Causal Factor Charts

4.6 Using Causal Factor Charts, Timelines, and Cause and Effect Trees Together During an Investigation

4.7 Application to Apparent Cause Analyses and Root Cause Analyses

4.8 Summary

Section 5: Identifying Root Causes

5.1 Introduction

5.2 Root Cause Analysis Traps

5.2.1 Trap 1 – Equipment Issues

5.2.2 Trap 2 – Human Performance Issues

5.2.3 Trap 3 – External Event Issues

5.3 Procedure for Identifying Root Causes

5.4 ABS Consulting’s Root Cause Map™

5.5 Observations About the Structure of the Root Cause Map™

5.6 Using the Root Cause Map™

5.6.1 The Five Steps

5.6.2 Multiple Coding

5.6.3 Incorporating Organizational Standards, Policies, and Administrative Controls

5.6.4 Using the Root Cause Map™ Guidance During an Investigation

5.6.5 Typical Problems Encountered When Using the Root Cause Map™

5.6.6 Advantages and Disadvantage of Using the Root Cause Map™

5.7 Documenting the Root Cause Analysis Process

5.8 Application to Apparent Cause Analyses and Root Cause Analyses

5.9 Summary

Section 6: Developing Recommendations

6.1 Introduction

6.2 Timing of Recommendations

6.3 Levels of Recommendations

6.3.1 Level 1 – Address the Causal Factor

6.3.2 Level 2 – Address the Intermediate Causes of the Specific Problem

6.3.3 Level 3 – Fix Similar Problems

6.3.4 Level 4 – Correct the Process That Creates These Problems

6.4 Types of Recommendations

6.4.1 Eliminate the Hazard

6.4.2 Make the System Inherently Safer or More Reliable

6.4.3 Prevent Occurrence of the Incident

6.4.4 Detect and Mitigate the Loss

6.4.5 Implementing Multiple Types of Recommendations

6.5 Suggested Format for Recommendations

6.6 Special Recommendation Issues

6.7 Management Responsibilities

6.8 Examples of Reasons to Reject Recommendations

6.9 Assessing Benefit/Cost Ratios

6.9.1 Estimating the Benefits of Implementing a Recommendation

6.9.2 Estimating the Costs of Implementing a Recommendation

6.9.3 Benefit/Cost Ratios

6.10 Assessing Recommendation Effectiveness

6.11 Application to Apparent Cause Analyses and Root Cause Analyses

6.12 Summary

Section 7: Completing the Investigation

7.1 Introduction

7.2 Writing Investigation Reports

7.2.1 Typical Items to Be Included in an Investigation Report

7.2.2 Tips for Writing Reports

7.3 Communicating Investigation Results

7.3.1 Decide to Whom the Results Should Be Communicated

7.3.2 Decide How to Distribute the Report

7.3.3 Document the Communication

7.4 Resolving Recommendations and Communicating Resolutions

7.4.1 Tracking Recommendations

7.4.2 Report Resolution Phase and Closure of Files

7.5 Addressing Final Issues

7.5.1 Enter Trending Data

7.5.2 Evaluate the Investigation Process

7.6 Application to Apparent Cause Analyses and Root Cause Analyses

7.7 Summary

Section 8: Selecting Incidents for Analysis

8.1 Introduction

8.2 Why Be Careful When Selecting Incidents for Investigation?

8.3 Some General Guidance

8.3.1 Incidents to Investigate (High Potential Learning Value)

8.3.2 Incidents to Trend (Low to Moderate Potential Learning Value)

8.3.3 No Investigation (Low Potential Learning Value)

8.4 Performing the Investigation

8.4.1 Incidents to Investigate Immediately (Acute Incidents)

8.4.2 Incidents to Trend (Potentially Chronic Incidents)

8.5 Near Misses

8.5.1 Factors to Consider When Defining Near Misses

8.5.2 Reasons Why Near Misses Should Be Investigated

8.5.3 Barriers to Getting Near Misses Reported

8.5.4 Overcoming the Barriers

8.6 Acute Analysis Versus Chronic Analysis

8.7 Identifying Chronic Incidents That Should Be Analyzed

8.7.1 Using Pareto Analysis for Environmental, Health, and Safety Incidents

8.7.1.1 Examples of Pareto Analysis

8.7.1.2 Weaknesses of Pareto Analysis

8.7.2 Chronic Analysis of Reliability Problems

8.7.2.1 Prioritizing the RCA Efforts

8.7.2.2 Repeating the Process

8.7.3 Chronic Analysis for Quality Incidents

8.7.3.1 Prioritizing the RCA Efforts

8.7.3.2 Repeating the Process

8.7.4 Other Data Analysis Tools 8.8 Summary

Section 9: Data and Results Trending

9.1 Introduction

9.2 Benefits of a Trending Program

9.3 Determining the Data to Collect

9.3.1 Deciding What Data to Collect

9.3.2 Defining the Data to Collect

9.3.3 Other Data-collection Guidance

9.4 Data Analysis

9.4.1 Interpreting Data Trends

9.5 Application to Apparent Cause Analyses and Root Cause Analyses

9.6 Summary

Section 10: Program Development

10.1 Introduction

10.2 Program Implementation Process

10.2.1 Design the Program

10.2.2 Develop the Program

10.2.3 Implement the Program

10.2.4 Monitor the Program’s Performance

10.2.5 Improve the Program

10.3 Key Considerations

10.3.1 Legal Considerations and Guidelines

10.3.2 Media Considerations

10.3.3 Some Regulatory Requirements and Industry Standards

10.3.4 Training

10.4 Management Influence on the Program

10.5 Common Investigation Problems and Solutions

10.5.1 There Is No Business Driver to Change

10.5.2 There Is No Organizational Champion for the Program

10.5.3 The Organization Never Leaves the Reactive Mode

10.5.4 The Organization Must Find an Individual to Blame

10.5.5 Personnel Are Unwilling to Critique Management Systems

10.5.6 Reward Implementation of Recommendations

10.5.7 The Organization Tries to Investigate Everything

10.5.8 The Organization Only Performs Incident Investigations on Large Incidents

10.5.9 Recommendations Are Never Implemented

10.6 Summary

Section 11: Contents of the Companion CD and Downloadable Resources

11.1 Introduction

11.2 Resources Available on the Companion CD and at www.absconsulting.com/RCAHandbookResources

11.2.1 SOURCE™ Investigator’s Toolkit

11.2.2 Updates and Modifications to the Root Cause Map™ Guidance

11.2.3 Examples Specific to Handbook Sections

11.3 Download Instructions

Appendix A: Glossary

Appendix B: Cause and Effect Tree Details

B.1 Introduction to Cause and Effect Tree Analysis

B.1.1 The Basic Structure of Cause and Effect Trees

B.2 Cause and Effect Tree Examples

B.2.1 Example 1: Spill from a Tank

B.2.2 Example 2: Lighting Failure

B.2.3 Example 3: Hand Injury During Sandblasting

B.3 Cause and Effect Tree Symbols

B.4 Using AND Gates

B.4.1 Multiple Elements Required

B.4.2 Multiple Pathways Required

B.4.3 Redundant Equipment Must Fail

B.4.4 Initial Event Combined with a Safeguard Failure

B.5 Using OR Gates

B.5.1 One of More of Multiple Elements Fail

B.5.2 Component Failures

B.5.3 Inadvertent Actuation of Safeguards

B.6 Example Cause and Effect Tree Structures

B.7 Procedure for Creating a Cause and Effect Tree

B.7.1 Step 1 – Define an Event of Interest as the Top Event of the Cause and Effect Tree

B.7.2 Step 2 – Define the Next Level of the Tree

B.7.3 Step 3 – Develop Questions to Examine the Credibility of Branches

B.7.4 Step 4 – Gather Data to Answer Questions

B.7.5 Step 5 – Determine Whether the Branch Is Credible

B.7.6 Step 6 – Determine Whether the Branch Is Sufficiently Developed

B.7.7 Step 7 – Stop Branch Development

B.7.8 Step 8 – Stop When the Scenario Model Is Complete

B.7.9 Step 9 – Identify Causal Factors

B.8 Drawing the Cause and Effect Tree

B.9 Additional Examples of Cause and Effect Trees

Appendix C: Timeline Details

C.1 Introduction

C.2 Timeline Example

C.3 Overall Timeline Guidance

C.3.1 Use Different Colors of Post-it® Notes for Different Types of Data

C.3.2 Use a Simple, Flexible Format

C.3.3 Keep the Level of Detail Manageable

C.4 Rules for Building Blocks

C.4.1 Use Complete Sentences

C.4.2 Use Only One Idea Per Building Block

C.4.3 Be as Specific as Possible

C.4.4 Document the Source for Each Event and Condition

C.5 Rules for Questions

C.6 Timeline Construction

C.6.1 Step 1 – Identify the Loss Events

C.6.2 Step 2 – Identify the Actors

C.6.3 Step 3 – Develop Building Blocks and Add Them to the Timeline

C.6.4 Step 4 – Generate Questions and Identify Data Sources to Fill in Gaps

C.6.5 Step 5 – Gather Data

C.6.6 Step 6 – Add Additional Building Blocks to the Timeline

C.6.7 Step 7 – Determine Whether the Sequence of Events Is Complete

C.6.8 Step 8 – Identify Causal Factors and Items of Note

C.7 Example Timeline Development

C.7.1 Step 1 – Identify the Loss Events

C.7.2 Step 2 – Identify the Actors

C.7.3 Step 3 – Develop Building Blocks and Add Them to the Timeline

C.7.4 Step 4 – Generate Questions and Identify Data Sources to Fill in Gaps

C.7.5 Step 5 – Gather Data

C.7.6 Step 6 – Add Additional Building Blocks to the Timeline

C.7.7 Step 7 – Determine Whether the Sequence of Events Is Complete

C.7.8 Step 8 – Identify Causal Factors and Items of Note

Appendix D: Causal Factor Charting Details

D.1 Introduction

D.2 Causal Factor Chart Example

D.3 Overall Causal Factor Chart Guidance

D.3.1 Use Different Colors of Post-it® Notes for Different Types of Data

D.3.2 Use a Simple, Flexible Format

D.3.3 Keep the Level of Detail Manageable

D.4 Rules for Building Blocks

D.4.1 Use Complete Sentences

D.4.2 Use Only One Idea Per Building Block

D.4.3 Be as Specific as Possible

D.4.4 Document the Source for Each Event and Condition

D.5 Rules for Questions

D.6 Causal Factor Chart Construction

D.6.1 Step 1 – Identify the Loss Event(s)

D.6.2 Step 2 – Take a Small Step Back in Time and Add a Building Block to the Chart

D.6.3 Step 3 – Perform Sufficiency Testing

D.6.4 Step 4 – Gather Data to Answer Questions Developed in Step 3

D.6.5 Step 5 – Add Building Blocks to the Chart

D.6.6 Step 6 – Determine Whether the Sequence of Events Is Complete

D.6.7 Step 7 – Repeat Sufficiency Testing for All Items on the Chart

D.6.8 Step 8 – Perform Necessity Testing

D.6.9 Step 9 – Identify Causal Factors and Items of Note

D.7 Example Development of A Causal Factor Chart

D.7.1 Step 1 – Identify the Loss Event(s)

D.7.2 Step 2 – Take a Small Step Back in Time and Add a Building Block to the Chart

D.7.3 Step 3 – Perform Sufficiency Testing

D.7.4 Step 4 – Gather Data to Answer Questions Developed in Step 3

D.7.5 Step 5 – Add Building Blocks to the Chart

D.7.6 Step 6 – Determine Whether the Sequence of Events Is Complete

D.7.7 Step 7 – Repeat Sufficiency Testing for All Items on the Chart

D.7.8 Step 8 – Perform Necessity Testing

D.7.9 Step 9 – Identify Causal Factors and Items of Note

Appendix E: Root Cause Map™ Guidance

E.1 Instructions for Using This Appendix with the Root Cause Map ™

E.1.1 Types of Information Provided

E.1.2 Online Documentation

E.1.3 Working Your Way Through the Root Cause Map ™

E.1.4 Special Considerations

E.2 Clarifications and Updated Guidance

Appendix F: SOURCE™ Investigator’s Toolkit

Table of Contents

Pocket Guide to Incident Investigation/Root Cause Analysis

Index of Incident Investigation Forms, Checklists, and Support Materials

Responsibilities of the Team Leader

Investigator’s Log

Simple Investigation Plan

Detailed Investigation Plan

Investigation Data Needs Form

Investigation Data Needs Checklist

Initial Incident Scene Tour Checklist

List of Contacts

List of Meeting Attendees

Interview Scheduling Form

Initial Witness Statement

Interview Preparation and Documentation Form

Interview Documentation Form

Physical Data Analysis Plan - Parts Analysis

Physical Data Analysis Plan - Sample/Chemical Analysis

Guidelines for Collecting Paper Chart Data

Photography Guidelines

Photographic Record

Position Data Form

Data Log Form

Data Correspondence Log

Data Tracking Form

Procedure for Creating a Cause and Effect Tree

Testing an OR Gate

Testing an AND Gate

Procedure for Creating a Timeline

Building a Timeline from Witness Statements

Procedure for Creating a Causal Factor Chart

Building a Causal Factor Chart from Witness Statements

Root Cause Map™

Causal Factor, Root Cause, and Recommendation Checklist

Root Cause Summary Table Form

Instructions for Completing the Incident Investigation Report Form

Incident Investigation Report Form

Report and Investigation Checklist

Open Issues Log

List of Figures

F.1: ABS Consulting’s SOURCE™ Incident Investigation Model

1.1: Task Triangle Showing Possible Depths of Analyses

1.2: Overlap of Multiple Task Triangles

1.3: Differences Between Traditional Problem Solving and Structured Root Cause Analysis

1.4: Relationship Among Proactive Analysis, Reactive Analysis, and Management Systems

1.5: Idealized Operation

1.6: Realistic Operation

1.7: Steps in the SOURCE™ Methodology

1.8: Steps That Apply to Acute Incident Analyses

1.9: Steps That Apply to Chronic Incident Analyses

1.10: Steps That Apply When No Formal Analyses Are Performed

1.11: Levels of Analysis

1.12: Connection Between Causal Factors and Root Causes

2.1: Initiating Investigations Within the Context of the Overall Incident Investigation Process

3.1: Gathering Data Within the Context of the Overall Incident Investigation Process

3.2: Types of Data