A Cuide to Effective Incident Investigation

eellS... ~.stDr
Cherting

Recommendation
Generation and
Implementation

~ABS Consulting
RISK CONSULTING DIVISION

2005 Edition

 Root Causl!
Analysis Handbook
A CuIde to Effectfve Inddent Invest/gat/on

2005 Edition

By

~ABS Consulting
RlSK CONSULnNO DMSION

Lee N. Vanden Heuvel. Donald K. Lorenzo.

Randal L. Montgomery. Walter E. Hanson.
and James R. Rooney

ROTHSTEIN AsSOCIATES INC., Publisher

Brookfield, Connecticut USA
www.rothstein.com

ISBN # 1-931332-30-4
Copyright () 2005, ABSG Consulting. Ine. A11 rights reserved.

A11 rights reserved. No part of this publieation m2ly be reprodueed, slored in a retrieval syslem, or
tTansmitted in any fonn by any means, electronic, mechanical, photocopying, recording or o1heJWise,
without prior permission of !he Publisher.

No responsibility is assumed by the Publisher or Author tor any injury andJor damagE! to persens or
property as a maner of produel liability, negligence or otherwise. or from any use or operation of
any methods, products, instnJctions or ideas contained in the material herein.

ISBN #193133230-4

PUBLlSHER,
Philip Jan Rothstein, FBCI
Rothsteln Assoclates Ine.
The Rothsteln Catalog On Servlce Leve' Management
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-------------_ ..........
Introduction lo the 200S Edition

This editioo of the Roor Cause Ano/vsis Handbook is a reprinting of Ihe version originally published in
1999. In he six years since Ihe original book W2IS published, organizations have come under increasing
pressure to produce more with less and lo produce higher quality outcomes (products and services).
Organizations aTe conslantly slriving to mee! hese demands through Ihe implemenlation o a variety of
different strategies. such as:
Lean stralegies (sharing of work berween operalions and maintenance)
Reliabilily improvements (reliabilitycentered maintenance. predietive maintenance. and improved
use of maintenance resources)
Quality iniliatives (ISO certiflcation, setting up critical variables lo monitor and adjust. quality cireJes
and leams, and six-sigmal
Improved data collection and analysis (bolh inlemal and extemalto Ihe business uni!)
Workplace culture improvements (behavior-based safety and risk management)
Staff reduetions, both in central corporale suppon and resources at production facilities.

However, cerlain issues remain conslant: soc.ielal and management demands far continuous improvemenl in
safety, reliability, environmental stewardship, and qualily. Incidents that mpact these areas are nol acceptable
ando worldwide. organizations are being required to improve their operations and culture lo address these
issues. While sorne industries have made significant progress, govemmental entities and the public often
demand more.

It is easy to say tnat it canoot be done. We are already so muen bener than we were in the pasto But sorne
organizations (including some of your eompetitorsl eontinue to improve. To remain competitive. your organi-
zation musl maximize !he efficiency with which il spends resources. Your organizanon must recognize the
ehanging c1imate and aceept the ehallenge of aehieving bener results with fewer resources.

[f you find yeurself in this position, root cause analysis (RCA) and ABS Consulting's SOURCE" (Seeking Out
!he Underlying Root Causes of Eventsltechnique fer performing RCAs (which is described in Inis handbook)
can benefit your organizaton. The handbook describes a simple, step-by-step method for perfonning RCAs.

RCA is a struetured method for determining whether alllhese new programs and iniliatives are real1y helping
your organization and how these programs (and their interactions and interrelalionships) can be improved by
leaming from experienee. RCA methods can be applied to a wide speetnlm of problems, inc1uding those with
safely, reHabilily, environmental. qualily, produetivily. and security consequences. And. not only can these
me!hods be applied lo acute. one~time incidents, they can aIso be used lO undersland Ihe underlying or
chronic problems wilhin Ihe organization.

We try hard to make implementation o( any new program go wel1. Bu! our firs! efforts often leave room for
improvemenl. RCA provides a struetured approach for identifying and largeling mose
improvements. and it
allows us lo see how our organization is fundioning.
. . Roor CAUSE ANAlrslS HAND800K

Why nOl conlinue lo do it Ihe old way? Why use a structured approach? Accidents, errors. problems. near
misses. and deficiencies al] provide an opportunity to learn about OUT organization's performance at many
levels. The following figure shows different organizationallevels and the corresponding levels of learning thal
can be accomplished based on an incident.

Ine....lng
In".... ln 9 Inc 1n9 Scope 01
Depth 01 levelol COl'rllCliv.
Ana sls learnlng A~lons Human
Error.
Equlpmllnl
hllulll,or
Extemal Faetor

soIutions. RCA processes help organizalions identify andjustify leveraged changes lo improve their organization's
performance. By investing resources in en RCA. the organization salves problems once. not repeatedly.

./.u 1[. 'P~ ~e.wd

Manager - lncidentlnvestigation and Root Cause Analysis $elVices
Operational Risk and Performance Consulting Oivision
ABS Consulting
June 2005
-------------------
A NEW Version of the Root Cause Analysis Handbook
Is Coming in 2006!
The current lex! is targeted al environmentaJ, health, and safely (EH&S) professionals, as weJl as reliability
program slaff. Quality and security issues are also addressed, bul they were nol a primary focus whl?n
Ine lext was originally written in 1999. Justlike your organizalion, we strive for conlinuous improvemenl.
Over the years we have seen an increased focus on Ihe negralion of traditional EH&S, reliability,
quality, and security programs within organizations. OUT inciden! investigation and rool cause analysis
training courses have evolved to address this integration. In 2006 ihe nex! version ol the Roor Cause
Anolysis Hondbook will be published by ROlhslein Associates. 11. loo, will address this nlegration and
will conlajn numerous other jmprovements:

lncreased Focus on Quollty and Securft)l

The currenl versians of the SOURCE'w technique and Rool Cause Map'w were developed with an
emphasis on EH&S and reliability. The revised approach will pravide additianal emphasis on quality
and safety lssues.

lmproved Step-by-Step Approach

The current version of the handbook contalns a number af graphics to help the user work through the
process. The new handbook will cantain more detailed graphics and flawcharts to provide the user
with acJlitional help and guidance when performing an RCA.

An Improl.led Root Cause Map

A number af changes are planned for lhe Rool Cause Map. These changes are based on interactions
with our customers and our expe:rience in pe:rlorming RCAs. They inelude:

Greater Flexlblllt)l
The new structure of the map will allow organizations to incorporate their own management system
structures into the map without extensive effort.

Addltlonol Detoll~
The map wil1 be expanded in the following areas:
Human factors
Equipment design
CocIes and standards issues
Quality assurance and oversight actlvities
Management of chzmge

ModljJed Termlnolo!l}l
There will be greater focus on information processing organizations and transportatian issuS.

Increosed Focus on Anol)/sls 01 Chronfc Problems

Additianallools for the analysis o chronic problems will be provided, along with practica! guidance on
how to develop and implement a dala analysis programo

More lmplementatlon Too's

Additional forms and checklists will be provided lo heJp you apply information in the handbook to
aClions in Ihe field.
. . Rom USf AAAlYSIS HANDBOOI(

Thank You for Choosing the Root Cause Ana/ysis Handbook as

Your Root Cause Analysis Resource.
If You Are Looking for More He/p...
ABS Consulting personnel have warked on all types af tOO! cause analyses and incidenl investigations. These
ABS Consulting personnel nave performed Roo! Cause Analyses (RCAs) and incidenl investigations far a
wide variery 01 organizations. These efforts renge from identifying human and componen! faHures which
contrihule 10 simple syslem failures, lo discovering Ihe origins of catastrophic incidenls by piecing together a
complex chain of events through rigorous application of OUT SOURCE'~ technique. We can also assisl you in
tackling Ihe chronic failures that degrade perfonnance. OUt tchniques have been applied to industrial aed
denlS. production bottlenecks, reliabiJjty problems. quality concerns. and financial issues.

ABS Consulting 24/7 Investlgation Assistance

If you need help invesligating an accidenl or problems wilh reliabilily, safcty. quality. environmental, or financial
Impacts. ABS Consulting can assisl you. We have worked witn organizalions in a variery of different industries
lo investigatE' large-scale industrial accidents, reliability problems, and chronic failures. Call our 24/7 hotline
nowal (865) 368-4357 lO speak wiln an investigator.

ABS Consulting Trainlng Serolees

Based on our experiences, we have trained tnousands of individuals using the proven techniques outlined in
this handbook. And because thesc courses emphasize a workshop approach to leaming, studenis galn valu-
able experience by praclicing whal they learn on realistic industry examples. We can even customize these
workshops lo make them specific lO your company or fadlity The (ourses can range from 1 to 5 days in
duration. Fol1owing are summaries of sorne of our slandard public courscS.
Incident InvesUgatlonlRoot Cause Analysls (Course 106). This course expands on Ihe topies in
this handbook and provides numerous workshops lo allow you to practice Ihe lechniques under me
guidance of an experience invesligalor.

Marfrlme Incldent InvestlgatlonlRoot Cause Analysis (Course 106M). This course covers a
modified version of the SURCE' lechnique thal was developed for ABS. ABS's MaRCAT addresses
the unique issues and terminology associated wilh marilime RCAs,

Sentlnel EvenJ Investigation Jor Healihcare Organizatlons (Course 406)_ This course also
covers a modified version of the SOURCE' technique. 11 is tailored to meel the challenges an inveslig3lor
will face in fhe healthcare environment.

Preventing Human Error (Course 124). [f you wanllo address Ihe primary cause of most incidenls
- human error - Ihis course will give you Ihe tools and lechniques you'U need to make that happen.

Preventing Human Error Jor Healthcare Orgonlzatlons (Course 424), This version of our
Slandard human error course ineludes examples and terminology related lo the h;althcare field.

Component FaUure (Course 208), This course covers the lechniques and melhods you'l] need to
examine equipment tailures a1 your facility. II covers mas! mechanical equipment failure modes,
------------------
Contaet Us for Information and Assistance
Contad us to see how we can help you address your RCA and incidenl investigation training. seJVices, i:)nd
software needs.
By phone: 1-865-966-5232
By f~' 1-865-966-5287
By emoll: jnyestigate@abscoosultjng com
O" the web at: WWW8bsc0osultjog comfjnyesUgate

Worldwlde Headquarters
ABS Consulting
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Houston, TX 77060-2329

We have offices lhroughoul lhe world. Visir our web sile lO find your nearest office.

Information Request Form

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 -------------- ..
TABLE OF CONTENTS

Organiultion of me Root Cause Analysis Handbook x

Aa'onynlS and Nomenclature xi

Umitations of Uability xii

1\ckn00000edgements , xiii

Chapler 1 Introduction to Root Cause Analysis }

Chapler 2 Collecting and PreselVing Data for Analysis 9

Chapter 3 Data Analysis Using Causal Factor Charting 11

,Chapler 4 Roo! Cause Identification 25

Chapter 5 Recommendation Generation and Implementation 33

Chapter 6 References 37

Appendix A Root Cause Map' Indexes Nade Descriptions A-}

Appendix 8 Root Cause Map B.l

l1li Roen CAUSE ANALlSIS HAND8OQ1(

ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOK

The focus of this handbook i5 on the application af lhe Root Cause Map' to ,he rool cause analysis process.
The Rool Cause Map is used in one of the laler SlepS o the rool cause analysis process lO identify the under-
lying management syslems 1hal caused the event to occur ar made the consequences o the event more severe.
The fJrsl five chapters of Ihis handbook aTe an Qverview of the root cause analysis process. These provide the
context far use of he Rool Cause Map. Chapler 6 provides references.

Chapter 1. "Introduclion lo Rool Cause Analysis," presents a basic overview ef the SOURCE ,. (Seeking Out
lhe Underlying Roo! Causes o Events) rool cause analysis process. Chapter 2. "Collecting and Preserving
Dala tar Ana[ysis, ~ outlines Ihe types o dala and data sources that are available. Chapters 3, 4. and 5
describe the lhree majar steps in the root cause analysis process. Chapter 3. ''Oala Analysis Using Causal
Faclor Charling:' provides a step-by-slep description of causal factor charting lechniques. Chapler 4. "Roo!
Cause ldentification," explains the organization and use of the Rool Cause Map. Chapter 5, "'Recommenda-
tion Generation and lmplementation," provides guidance on developing and implemen!ing corrective actions.
The references section. Chapter 6. provides additional infonnallon far those interesied in leaming more about
specific items contained in the handbook.

Appendix A. "Root Cause Map Node Descriptions," describes each segmenl of Ihe Root Cause Map and
presents detailed descriplions of Ihe individual nodes on Ihe map. Appendix B is Ihe Root Cause Map itself.
-------------------'--

ACRONYMS AND NOMENCLATURE

CF causal factor OSHA Occupational Safety and Heallh

Administration
DG diesel generator
P&ID piping and instrumentation diagram
EPA Environmental Prolection Agency
PPE personal protective equipment
EQE EQE lntemational, [oc., an ABS
Group Company PSSR pre-startup safety review

FMEA faHure modes and effects analysis SOURCE .... Seeking Out the Underlying Roo!
Causes of Events
HAZOP hazard and operability analysis
SPACs standards, polides. ar administrative
LTA [ess than adequate controls
. . Roor CAUSE ANAL'I'SIS HANDBOOK

LIMITATlON5 OF LIADILlTY

This handbook is ntended for use by professionals who nave been trained in the SOURCE'~ (Seeking Out he
Underlying Root Causes of Events) method of perfonning rool cause investigations. a method developed by
ABSG Consulting lnc. (ABS Consulting). Neither ABS Consulting nar any employee thereof makes any war-
ranty ar representanoo, either express al implied, with respect lO Ihi5 documentation, induding the document's
marketability, accuracy, ar fitness for a particular purpose. ABS Consulting assumes no legalliability, respon-
sibility, ar cos far any third party's use, ar the results of such use. of any information, apparatus, produet, ar
process disclosed in this handbook.

ABS Consulting may periodically change the information in Ihi5 handbook; changes will be in:orporated into
new editions. ABS Consulting reserves the right to change documentation without notice.

ABSG Consulting lnc.

10301 Technology Orive
Knoxville. TN 37932-3392
_ _ _ _ _ _ _ _ _ _ _ _ _---..I1:1III

ACKNOWLEDGEMENTS

ABS Consulting thanks the many personnel who contributed lo the development and 009Oi09 revision o this
handbook, particularly its primary author, Lee N. Vanden Heuvel. We also thank Leslle K. Adair, William G.
Bridges, Rebekah S. Blis, Donald K. Lorenzo, Randal L. Montgomery, Tom R. Williams, and David A. Walker
for reviewing this handbook. And we thank JiIl M. Johnson, Nicole M. LepoutreBaldocchi, Paul M. Olsen,
Robln M. Ragland, and Maleena L. Wright far their skill and crahsmanship in preparing ths handbook. We
are also grateful for the support and assistance of the rest o the staff at ABS Consulting.

INTRODUCTION lO ROOT CAUSE ANALYSIS
ObJecllves and Scope
The roo! cause analysis system presented in this hand-
book is designed for use in investigating aod calego-
rizing the roo! causes o events wilh safety, heahh,
environmental, Quality, reliability, aod produetion im-
pacts, although the examples used in Ihis handbook
are predominantly those having safety and health
impacts. The term ~evenl~ is used lO generically iden-
tify events thal have these type.s of consequences. The
SOURCE' (Seeking Out the Underlying Roo! Causes
of Events) methodology is based on cne developed
for the Department o Energy by the Westinghouse
Savannah River Corporation in 1991.
. Roo! cause analysis is simply a tool designed lo help
invesligators (1) describe WHAT happened duriog a
particular occurrence, (2) determine HOW it hap-
pened. and {3) understand WHY it happened. Only
when investigators are able to determine WHY an
event or failure occurred wil1 they be able to specify
workable correclive measures.
Mosl event analysis systems allow investigators to an-
swer questions about what happened during an event
and about how the event occurred. but often they are
nol encouraged to determine why the Venl occurred.
Imagine an occurrence during which an opera1or is
instrucled lO clase Valve A: inslead, lhe operalor clases
Valve B. The typical investigation would probably Te-
sult in Ihe conclusion 1ha1 ~operalor error" was Ihe
cause of the occurrence. This is an accurate descrip-
tion of what happened and how il happened. An op-
CHAPTER 1
erator comrnitted an error by rnanipulaling Ihe \AlTong
valve. If!he analysls slop al this leve] of analysis, haw.
ever. !hey have nol probed deeply enough to under
stand the reasons lor the rnistake. GeneraJly, mistakes
do nol "jusI happen." They can be haced lo sorne
wel1-defined causes. In !he case of !he valving error.
we might ask: Was Ihe procedure confusing? Were rhe
valves c1early labeled? Was Ihe operalor who made
the mistake familiar with his particular lask? These
and olher questions should be asked to determine why
the eITor took place.
When the analysis slops at the point of answering
WHAT and HOW, the recommendations for prevent-
ing recurrence of the evenl may be deficient. In the
case of the operalor who tumed Ihe wrong valve, we
are likely to see recommendations like "Retrain the
operator on the procedure," "Remind aH operators lo
be alert when manipulating valves," or "Emphasize
to a1l personnellhal careful attention lo Ihe job should
be maintained al all times." Such recommendations
do little to prevenl future occurrences. lnvestigations
that probe more deeply inlo WHY the operator error
occurred are able lo provide more specific, concrete.
and effective recommendalions. In the case of the
valving error, examples might inelude. "Revise !he pro-
cedure so thal references lo valves match !he valve
labels found in the field" or "Require operalor train-
ees 10 have a training procedure in hand when ma-
nipulating valves."
The SOURCE root asuse analysis system provides a
structured approach lor Ihe investigalors tTying to dis-
_ _ Rom CAUSf ANALYSIS HAN0800K
covr the WHYs sUTTounding a particular occurrence.
ldenlifying these roo! causes is the key lo preventing
similar oc:currences in ihe future. An added benefit of
an effeetive root cause analysis is thal, over time, the
roo! causes identified across lhe population af occur
rences can be used lO li:lrget maJor opportunities tar
improvemenl. For example, if a significan! number of
analyses poin! to procedure inadequades as roo!
causes. then Tesources can be focused on procedure
improvement programs. Trending of roo! causes al
lows tracking of occurre:nce causes. development of
systematic improvements. and assessmenl of the m-
pacl of corrective programs.
This handbook does nol address programmalic issues,
such as how lO classify events, the definitions of aed-
dents and near misses. how and whom lo notify fol
lowing an event. how lo determine team composition.
foUow-through on results and recommendations, mand
ing. ele. Figure 1-1 iI1ustTates Ihe overall event analy-
sis process: Ihis handbook covers the topies indicated
in lhe figure.
Delinilion 01 Rool Cause
AJthough there is subslantial debale concerning Ihe
definition of a root cause, Ihe SOURCE melhodology
uses Ihe following definition: Rool causes are the most
bas;c causes rhot con reasonobly be identified, which
monogemenr has control to fix ond for which elfectiue
recommendotions for preuenting recurrence con be
generolcd This definition contains Ihe following four
key elements:
Root causes are basic causes.
The investigalor's goal should be lo idenlify basic
causes. The more specific the invesligatOT can be aboul
lhe reasons why an evenl occurred. the easier il will
be lo mive al recommendations Ihat will prevent re-
currence of the evens leading up lO the occurrence.
Root causes are those causes that can
reasonably be identified.
Occurrence inves1igations muS! be compleled within
a reasonable lime frame. 11 is nol practical lo keep
valuable manpower indefinitely occupied searching
for the root causes of occurrences. Root cause analy.
sis helps analysts gel !he masl out of Ihe time they
have al10ned for the investigation.
Root causes are those causes over which
managemenl has control.
AnaJysts shoutd avoid using general cause c!assifica-
tions such as Moper<~tor error. ~ Such causes are not
specific enough to allow hose in charge to rectify the
situation. Managemenl needs lo know exactly why a
failure occurred before aetion can be laken lo prevenl
recurrence.
Root causes are those causes for which effective
recommendalions can be generated.
Recommendations should directly address Ihe rool
causes identified during Ihe investigalion. If the ana-
lysts arrive at vague recommendations such as "Re
mind operalor lo be alert al al1 times. ~ Ihen lhey
probably nave nol round a basic enough cause and
need lo expend more effort in the analysis process.
 INTRODUCTION TO ROOT CAuSE ANALYSIS . .

!.lanag.m.nl Support an AnponSlbihhn

EslaDhsll Aaot Cause Cullula

Pr.pllnnlng
CliSlilticallon syslem
Pohcy/proceulu tor noliricatlon
Investlgatlon t82m establlshmenl
T82m supplies an llaining

Th.
Incldent!

AltllJNatilicalion lO Classlry Ev.nt an Activall Tllm

8e91n Investlglllon
Oev.lop speclllc plan
Seeure eVlence

Cflli~uean Molry
Eyenl InvUIIgatlon
Implemenl Aecommenallons Syslem
andlor Dacumant Resolutlons

Follow-uplAuu

Compl.l.

Figure 1-1 Overall Event Investigation Process

_ _ Rom USE ANAlrslS HANDBOOK
Root Cause Analysis: Four Major Steps
The SOURCE root cause analysis process is a four-
Slep process involving: (1) data collection aod preser
vation. [2) causal factor {CFl chal1ing, (3) root cause
identificanoo, and (4) recommendation generatlon and
implementation. See Figure 1-2 far a summary of these
sleps.
Step 1: Data Collection and Preservation
The firsl slep in the analysis is lo galher data. Without
complete information and an understanding of Ihe
evenl. the causal factors and roo! causes a.ssociated
with the evenl canno! be identified. The majority of
time spent analyzing an evenl is spe:nt in gathering
dala. Data calleclian and preservation are discussed
in Chapler 2 of this handbook.
Slep 2: Causal Factor ChaTliog
CF charting provides a \'uay far invesrigalors lo orga
nize and analyze the information gathered during the
investigation and to identify gaps and deficiencies in
knowledge as the investigalion progresses. The CF
chart is simply a sequence diagram thal describes the
events leading up lO and folJowing an occurrence, as
well as the conditions surrounding Ihese events. The
final Slep in CF charting involves identifying Ihe ma
jor contributors lo the occurrence (i.e.. causal factors).
CF charting is discussed in detail in Chapler 3 of Ihis
handbook.
Step 3: Rool Cause Identification
The nexl slep. root caUSE! identification, invo\ves the
use of a decision diagram caUed Ihe Rooi Cause Map'~
lO idenlify lhe underlying reason(s) for each causal
factor identified during CF charting. The idenlifica-
tion of root causes helps Ihe investigator of a specific
event determine lhe reasens why Ihe event occurred
so thal the problems surrounding the occurrence can
be fixed. In addition. trending of the root causes of
occurrences idenlified over a period of lime can pro
vide valuable insight conceming specific areas for im-
provement. This is an added benefit of the SOURCE
root cause analysis process. Nol only can il be used
lo prevenl Ihe recurrence of specific evenls. bUI les-
sens leamed from individual occurrences can be com-
bined lo idenlify major areas of weakness. This allows
actians lo be taken before a seemingly unrelafed ac
cident or failure occurs. The rool cause identification
process is discussed in Chapter 4 of this handbook.
Step 4; Recommendation Generation and
Implemenlation
The nexl step is Ihe generalion of recommendations.
Following identification of Ihe roo! cause(s) far a par-
ticular causal factor. achievable recommendations for
prevenling ils recurrence must be generajed. Chapler
5 of this handbook provides sorne guidelines for the
developmenl and implementation of adequate correc-
tive aetions.
Root Cause Analysis: The Process
Figure 13 illustrales the majar steps in Ihe SOURCE
rool cause analysis process. Preparation of Ihe CF chart
should begin as soon as investigators 51art to collect
information about the occurrence. They begin wilh a
~skeleton- chart Ihat is modified as more relevant facts
are uncovered. Data col1ection continues until the in
vestigators are satisf1ed with toe thoroughness of the
coar! (and hence are salisfied with the thoroughness
of the investigation). When the entire occurrence has
been charled out. tne investigalors are in a goOO posi-
tion to idenlify Ihe major conttibutors lo the inciden!.
These are labeled as causal fadors. Causal factors are
those contributors (human errors ond componem loil-
ures) lhar, jI eliminated. would haue either preuented
Ihe occurrence or reduced its seuerily
After all of the causal factors have been identified, the
investigalors begin raot cause idenlification. Each
causal factor is analyzed. one at a time, using the
Rool Cause Map. The map struclUres the reasoning
process of the investigalors by helping them answer
questions aboul why particular causal factors exisl
or occurred. After each causal factor is analyzed. the
investigalors altempl to arrive at recommendations
tha! will prevent ils recurrence, This process contin-
 INTRODUCTION lO Roo! CAUSE ANALYSIS IIIEIIII

Step 1:

Data Callect/on

_"]
( lo... ~ .,
,,
5tep 2:

Causal Factor
,':'" 1_" o,.e".
E" ,

CharUng -/-
I ,00-,.IlI01I, ~o; .....; ..n ~'n".
/
<"U'",,'' I

Step 3:

Root Cause
Identification

Conec!lve Acllons

5tep 4:
1:71
~
,
.... "".-
C.,.... "'....."""'_".,....."....

~ 0"0'"'''' ,..... ~ ...' ....01."' .. " "

Recommendallon I!'J """0 '~<' """
Generslon 1:71 1 c.~., r,. ."".,"'" '''lO' -, .
[!J "0'"'''''' <:"_" ""o-o .'o~.~.

Figure '2 The Four Steps of Root Cause Analysis

ues until TOO! causes have been identjfied far each
causal factor.
In many baditianal analyses, Ihe mos! visible causal
factor is given al! of the attention. Often. !he investiga-
tors are tempted 10 "jump to conclusions" about how lo
sok.oe !he problem. RareIy are events caused by one causal
factor. They are usually the result o a combination af
conlnbutors. When only one predominanl causal factor
is addressed. the lis! of recommendations wiU likely no!
be complete. Consequendy. the occurrence may repeat
itself. To help prevent the analyst from omitting
important recommendations, ihe SOURCE rool
cause analysis process requires that aII causal factors
be determined from analysis of the relevanl events dala
and tha! each causal factor be addressed separately.
Root causes are idenlified tor each causal factor. and
recommendalions are developed lo address each rool
cause. When recommendations are generated in this
manner, one a! a time. the probability of missing im
portan! details decreases.
~ Rom us~ ASAll'SIS HAN0800K

STEP 2 Causal Factors Charting

Al/he Slaft oi he mves/Jgs/lon. a

skeleton" causal facfor charl
;5 genera red usmg he mil/al dala
ya/heredo

As (he investigallon progresses,

he causal factor cflarllS
mod{ed lo incorporate he
fmdmgs. Dala col/eelion con/mues
un/JI mvestlgalors are satlsfled I I
Wllh Ihe fhofougnness of Ihe .----,
chart. Usmg he compleled
I
causal faclor charr, 'he maJor ; ---',
conrnbutors ro Ihe event are :. ---:
Identl/led. These causal faclors
are indicated usmg a camman
symbol(1 l.
STEP 3 Root Cause Identlflcatlon

Each causal factor 1$ analyzed

usmg he Rool Cause Map

. . 4" f'VSIS (0"''''1.1,'5 ',nr.1 J'I CJ~<ar

STEP 4 Recommendatlon Generat/on IJcr,',S ~Jve treon Jna,yud

Recommendallons lor prevenling recurrence 01 Ihe causal factor(s)

are generaled; recommenda'ions address lhe root cause(s).

The inCiden! report o( faiture analysis repor, 15 prepared

and recommendations are implemented.

Figure 13 The Analysis PrOcess


Root Cause Analysis: Presentation 01
Re,.,lts
The SOURCE methoclology uses root cause summary
lables. 5uch as the ene presented in Figure 1-4, lo oro
ganize the information compiled during CF charting,
TOO! cause idenlification. aod recommendation gen
eration. A summary table is prepared for each causal
factor identified during CF charting. The table is di-
vided iolo three columns wilh each columo represent-
ing a majar aspect al the rool cause analysis process
(Le.. identificalion of l causal factor, rool cause iden-
tification, aod recommendation generation), In the firsl
columo. a general descriplion al Ihe causal factor is
presenled. This column provides suffident detail fer
he reacler of an occurrence Teperl lo be able to un
demando in a general sense, Ihe scenario surround-
ing Ihe causal factor. The secend columo shows the
path ar paths through !he Root Cause Map Ihat were
used lo categorize Ihe causal factor. The !hird column
presents recommendations to address each of the root
causes idenlified for Ihe causal fador. Use of Ihis Ihree-
column fonnal aids the investigaior in addressing each
causal factor individually and is effective in ensuring
that all important items are sufficienlly covered.
The end resull of a rool cause analysis investigation is
generally an mvestigalion reporto Reporting formats
vary according lo the particular reporting system re
quiring the investigation. The formal of the report is
generally well defined by the administrative docum,ents
governing Ihe particular reporling system; howver, a
Ihorough root cause analysis wil1 greatly simplify the
preparation of any type of investigative repar!. The
completed CF chart provides an excel1ent basls for
the occurrence descriplion required by most reporting
systems, Root cause identification should leave the in
. vestigalors feeling confident Ihal they have discovered
the reasons why the event occurTed. In addition. a
quick check for obvious blank spaces in lhe rool cause
summary tables should help ensure thal Ihe investiga-
lors have generaled recommendalions for each root
cause.
'NTltOOUCTION lO Roor CAUSE ANALYSIS . .
If the investigators nave completed atable for each of
the causal factors identiflee!. then Ihe results of Ihe rool
cause analysis are completely documemed. A1though
lhe inlerna! requirements of a company for an evenl
report formal may not be nex.ible enough lo a1low Ihe
complete rool cause analysis lo be placee! in the body
of the occurrence report, il is usually appropriale lo
altach the CF charl and the lables as appendices lo
the final document.
The root cause analysl is often not responsible for the
implemenlation of recommendations generated by the
analysis. However, jf Ihe recommendations are noi
implemented, the effort expended in performjng the
analysis is wasted. In addilion. Ihe events that trig-
gered Ihe analysis should be expecled lo recuro Be
cause the recommendations are nol implemented. the
sirualion has nol been changed and il is inevitable
that the event will accur again.
Summary
The goal of rool cause analysis is nol only to under
sland lhe what and how of an event. but also why it
happened. The analysis of an event begins wilh Ihe
gathering of data. As lhe dala is gathered. it is orga-
nized and analyzed using causal factor charting. The
goal is lO idenlify Ihe causal factors for the evenl.
Causal factors are those contributors (human errors
and componen! failures) mal, if eliminaled. would have
eilher prevenled the occurrence or reduced ils sever-
!y. Once Ihe event js underslood by using causal fac-
tor charting and other analysis lechniQues. root causes
are identified for each causal fador. Rool causes are
the most basic causes Ihae can reasonably be identi-
fied. which management has control lo fix and for
which effectve recommendalions far prevenling re-
currence can be generated. Rnally, recommendations
are developed and implemented to preven! Ihe causal
faclors from occurTing again.
lIIIiIII ROOT CAuse ANAU'SIS HANDBOOK

-
stelJ 1 stelJ 2
~
e....... .. """'~
Even!
'"""""
!IiI! v
\
~~ ~

g=
I ~~ 1""""" ~L~ ~,.;.,
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E-... -...- e-enl Evem
- - '--J ~

-f-
,
~
'"""" /lJgII"*'!l DolI onaca'.es

,--;;p- . /rrtl, o! h.nt In..-.lillotion Report

Palhs ThroulIh
Causal Factor'1 Root Caun Mlp R~commendltlonl
In _1itsI _
one. ~llhe ctUHI
ln c:olurM

IlICIO' .. ~ appM!S ... !he

caus.al_ dw'.
-
""""'rycfdl<\ft)'

p _ colegO')o
In 1M coIuI!'n, liIt (01
'liIe<er<:eJ 8IIY
'~l'"
Roce Coa"'" caIa9O'V llKlSlon IlCIlIC ....."
NeI<I'OOI _ _ _"""llo
BACkGROUND,
In IIIIS "III't" prtMlIe'
llnIlI_1l'OI"I , .

._-
""'-
ln l1'li "*" !lsl1I'.- -
a<lIl qud\to<lI

_.- ....
_"'I:n........, rae... pWd~m.mag"

- . n:iuaong UNlerI)'Ing
"""""" Vofry!he CltIINII
.....,-
IIdot~Otw",
~lIle

5PKl1 WI.AII
___ 1M
me 1MI .-o lo
el3~:e lltllN COl.......
taetot. d Il1O ea;,s.aI bOo!
-
Roo! cause CllIeOO'Y
Ne., fQQl causa
Usl tfICOIIlI'I\eI'lictII

....
""1N_fQQl~
ltSSCOlI!1Id wilh 1IIIS

1II\eII'ItI'II .. _
""'-
u.: IIW llUW; lar t/IJ'
00* fOOl UlM(i) r

Step 3
,V Step 4 '\~
-- Corrective Aclions
c;=
~ ~
A , Cotrecl
e 0 tn.~ ll'IM ~ lhe

88 l~:;C: -. ~-::=~~
R(: 0 OI'len'rwlIlllllllr UTiIr loIlualuls IlCSl
U'Iey 00. ~ llIem
~

11~0~1jg 0 :; C<>tred. lhe '~11tlI1ha1 c:aUlMll h pt<ICllofnI

11 01....... " . Clulicln fA .cldilional P'~

Figure 14 Root Cause Summary Table


COLLECTING ANO PRESERYING DATA fOR ANALYSIS
Factual evidence derive<! tram data-gathering activi-
les serves as Ihe basis for al] valid condusions and
recommendations from a rool cause analysis. With-
out effective dala gathering, the event (probleml can-
nOI be truly delinee! and solved. Dala gathering i$ an
on9Ol09 process throughout the analysis. It is Ihe firsl
step of Ihe process and continues while causal factors
aod TOO! causes are identified.
There are a number of differen! types and SOUTces of
dala. The fOUT basic types of data are:
People - witnesses, participants, ele.
Physical - parts, chemica] samples. etc.
Position -Iocation of people and physicaJ evidence
Paper - both hard copies and software versions
Data gathering mus begin as saon as passible after
Ihe event occurs to preven! 1055 ar alteration of the
dala. Dala from people are the mas! fragile; Ihal is,
most easily altered or deslroyed. Galhering data from
people needs lO be the first prioriiy. Other forms of
dala are more slable; however, physical dala need lo
be idenlified quickly to prevent Iheir inadvertenl de-
struction.
To galher data from people. the analyst must be a
skil1ed interviewer. Figure 2-1 describes the overall in-
terview process. Planning for!he inlerview is essential
if lhe interviewer wants to get the maximum amount
of data from !he inlerview. During !he interview, the
inlerviewer must ask open-ended questions - ques-
lions hat require !he interviewee lO respond with a
long, descriptive answer. After these questions are
CHAPTER 2
asked and answered, !he interviewer can follow up
with more detaiJed queslions. Al !he conclusion of the
interview, lhe analyst will use the dala gathered to
updale!he causal factor chan andJor Ihe fault tree (see
Chapter 3).
[f investigators cannol arrive at the event scene quickly,
the witnesses should complete initial witness state-
ments. These will help during lhe interview process
by providing !he inlerviewer wilh an Oulline of the
informalion the witnesses can provide.
Follow-up interviews may be needed to answer addi-
lional questions lhal arise during the course of the
anaJysis. These interviews are conducted in the same
general manner as Ihe initial interviews. but a more
structured. straight-to-the-point interview style is de-
sirable.
The second type of dala are physical dala. Physical
data consisl of parts, residues, and chemicaJ samples.
To analyze physical data, the dala must first be identi-
fied and preserved. This is to prevent inadvertent de
struction of lhe data. Tesl plans should also be used
for analysis of physical dala. Test plans are developed
to ensure complete colleclion of required data and
complete analysis of Ihe evidence. and lO prevenl in
adverlenl deslruetion of evidence by the investigatoTS.
. . Rom USE A.... AlI'SrS HAND&OOK

Pl,n
I~~"t '1- ,.." ....
1:.,1,') ,"11'",,,,,
Sf'f'~ 10CH:-
r----I' s.:"'" e'" .-.....
I~tl" u 1<"nC"'
Co'. '00:0 t.tll'O"1
~ICor"O.' """'.'0'0
Dct""'.":"'O"
Pol.rorCI"niOr","'."

e5tlblllh Rapporl
l"t'~o.cllo'l d ""CIUI'1
IhotaIO"'oO'.

Unlnterrupted Narrativa

Intcl.ctlv.Dlaloglll
O.UIIOS
, ~11I"1"" III."",~

ConclUllon
1" to' co ",onll"~
'loo .. m'"01110"1
5...... ",.10 .. 0:. . . . 10
tOnh'",
Doc.ml"' cOU'''I.enl
':onU, 101'0"'"0 ~Im.

SitO"' lIOI, .ol ,..

'tu." U~.'I
<nl''''eo- ,1 "HOlo '"t!> to .reg'ul
".'" <aunl liCIO'
enl'!

Figure 2' Interview Process

The third type of data are position data. ?ositioo data
consist of:
Physical relationships among iteros and people at
the scene and environmenlal facters
Functional relationships among control devices and
safety devices
Time relalionships Ihal will define the squence of
events and help identify cause-effecl relanonships
Physical position data can be obtained by using pho-
tography to record physicaJ position information. Func-
lional relationships among syslems an time
relationships can be understood by analyzing other
sources of data.
The 12151 lype: of data are paper dala. Paper dala con-
sisl of data on pape:r and data slored electronically
that can printed out on papero Examples of paper dala
include dacumentation records. logs and data-record-
ing results, pracedures. memos. correspondenee. pro
gram manuals. and policy statements. Paper data can
aften lead lo root eauses beeause many management
syslems are documemed on papero
The causal factor chan and fault tree teehniques eov.
ered in Ihe next chapterwiU help guide Ihe data analysis
process.
Summary
Factual evidence derived from data-gathering activi-
ties serves as the basis for aH vali conclusions and
recommendalions generated by a root cause analy- I
siso Dala gathering is an ongoing precess throughout -ti
the analysis. The four basic Iypes of data are: people, 0,)
physical, position. and paper. The most fragile type ofc-:l
these is people data. Dala musl be gathered quickly
lo preven! lheir inadverlent destruclion.
 CHAPTER 3
DATA ANALYSIS USING CAUSAL FACTOR CHARTING
When an investigator or investigarlon leam begm5 an
analysis, the analyst uses a causal factor chart ar fauh
tree to organize lInd analyze Ihe data. A CF chart is
simply a sequence diagram mal allows investigators
to.graphically depia the mishap from beginning lO
end. The CF charting lE'chnique was originatly devel-
oped by Lud'A'jg Benner and his colleagues al the U.S.
ational Transportatian Safety Board for use as an
analytical 1001 in acciclent investLgations. The too 15
designed lo help investigators chronologically describe
the events leading up to an unu:anted occurrence and
the cenditioos sulTounding these events.
Fault trees are a struetured process for postulating ways
the syslem could fallo The rree is developed only in
'enough detail to understand how the syslem failed
Benner (1975) 5uggesls that an acciclen! involves a
sequenc!? of events (ie.. happenings) lhat accur duro
ing me course of good.-intenrioned work activIIY bUI
that culminale in unintenlional personnel inJury or
damage tO a syslem. Experience has shown tha! in-
cidents develop from clearly defined sequences of
events mal invo/ve periormance m"ors. changes, over-
sighlS. and omissions. The event invesligalor neros
lo identify and docurnent nol only Ihese negalive
ev~nts, hui also me relevant concllions and nonhaz-
bl'dous events relaled lo the incidenl sequence. CF
charts and fault trees are e>..ceJlent vehicles for ac
complishing lhis purpose.
The Cf Chart: Delinition 01 Elements
The principies of CF charting are quite basic. Figure
31 presents a sample CF charl. and Table 3-1 pro-
vides definitions of the CF chart elements. NOlice mi!ll
the sample CF charl is conSlrUcled of a number of
dlfferent building blocks.
The objeetive of creating building blocks is lO trans-
form observations and data acquired from people and
ungs 0I0 a common formal needed to construct Ihe
CF charl. A buildmg block is a fundamenral. common.
and irreducible unil thal describes events conditions
of an event. These building blocks are used to charl
!he sequence of events and condtions mat le<! to me
incident under inveslig,ation. This procedure will work
wi!h any observation or dala about any occurrence.
Events and Conditions
The mosl basic etements of a CF chart are events and
conditions. Events are simply !he aetjons or hcppen
iogs lhat accur dunng sorne sequence of activlty.
Events make up Ihe backbone of the CF chart. Event
slatemenls describe specific occurrences (eg. ~4-12
shift operator filled Tank 123" or "Conlrol room op
eralor acknO\Vledged level alarm for Tank 5Tl.
 ltem 01
o, r Note
Causal
* _ - - - Faclors

-3

Cllfe t,an
.,
r--v~--l

I I
I P,nu-lIt , I lan E~enl
Pwnry o, LOH
Eve~r CO"~ 'an

r------l
I I
S.eo~ay
I P'tluma!'~' I
Even!
----..; SHonOa,y OUHloan ;>
f E,en! I
I I

Figure 31 Sample Causal Factor Chart

Conditions are not specific aClivilies, bul circum-
slances pertinenl lO Ihe srtualion. Condrlions usually
provide descriplive informarion (e.g,. "Pressure was
1.000 psig') as opposed lO slating aetion (e,g, "Op.
eralar placed Valve X inlo apen posilion'). Condl-
lions typical1y describe a slale of Ihe syslem. a value
of a sy~lem, or a:1 environmenlal parameler, Condi
lions can also be used lO slale background informa-
lion (such as Ihe level of traimng of an operator) 01 lO
summarize Ihe stale of Ihe syslem al sorne poml in
Ihe CF chan (such as "The line is now completely
open allhe decanler~l,
loss Events
The event(s) that describes Ihe negative consequences
of the event is refened to as Ihe loss evento Another
lA'ay lO Ihink of lhe 10ss evenl is thal il probably de
scribes the reason an invesligation is required (e.g..
pen;onnel injuries. fires, explosions. release of malen-
als. unscheduled shutdowns 01 equiprnenl. scrapped
produet). Loss events usual1y appear on Ihe right-hand
side of lhe causal faclor char!.
Questions
Questions wi1l be placed on Ihe eharllo identify gaps
in lhe understanding of Ihe analysis lO guide h.lrther '
data-galhering adivines. For eaeh queslion, a polen-
tial source of dala lhal can resolve the issue is also
idenlified. This allows the invesligalor lO prepare fer
interviews of people and lO prepare lest plans for the
analysis of physical dala
,
Faets Versus 5uppositions 1,
,
During Ihe analysis. there may be sorne gaps in Ih~r:1
dala that are galhered thal simply eannol be filled in,
The dala that can fiU in these gaps may no longer be ::.
avarlable. or the cosl of oblainmg the dala may be too ~
 USAl FAaoRS CHARTlNG . .

Table 3-' Definitions of Cf Chart Elemenl5

Elemenls Deflnltions

Lon EI/enl A slalemenl 01 lile negallve cOnStllUeI\Ct 01 'neal hIt-,llle evenllllal neCeSSlales lile
evenllnvesllgallon

Prlm.ry Evtnls ACllOns 01 lIappel'llngs tead.ng up to lh. 105s tven!. lllese can be negallVe evenls or
expeeled everllS

S.tond.ry Evenls ACllOns or happenlngs lnal explain wlly lila pnmary tvenls OCCUlred

Prtlvmpllve ev,nl. Acllons or happenings nol basad upon valid' laclual tvldtnca, IIIal are aSSllmed
beca use llley apprar (oglcalln lile stqutnct 01 evtnls

GncumSlances perllnenllo Ihe Sluallon; usually provlde descnpl!ve Inlormallon, suell

Gondlllonl as paamelne eondlllons (can also be used lO denole summaty slalemenls Ot
conclusions)

Lou Condlllon A slalement 01 lhe hezarll condlllon lhal could llave (bul (lId 1'1(1) resultln lhe negellve
consequence. Ine condlhon lllalneceSSllales lile evenllnvesligallon

Prllumpllv. Clrcumslances, nol based upon valld' lactual evidence, lllat ale assumed becallse Ihey
Condlllons appealloglcalIn lile sequence 01 lne el/enls (can also be usedlo denole summary
,talemenlS or concfuslon,)

e.uul Flclor5 Human ettots and eQUlpme(l\ lallules IlIaI.11 e)lmlnated. would have e!lher prevenleo
Ihe occurrence or reduced 115 Slverlly

PrtlvmpUv, CausallaCIOIS, not based upon valld' factual evldence, 111.11 ale logcal!y assumed lO be
e.unl Faclor. maJor conlllbulors lO Ihe evenl

5ignllll;anl dellclencies Identrliea dUllng lile eoutse 01 lile Invesllgallon lhal were Mil
Il.m. 01 Note maJor contrlbulors lO tlle evenl, bul snoula oe aadtaSSea before they have the
opportUl'll1y lO cause problems

Tnf deMnlOn al vI/J!1IS SUO)fC1JVI. USUl.lly ~ lum mlmblrs ~;' O~ 1M ulullly o/ I dl.l~ l1em .... 1 e"l '141 14lel
SlalementS 110m WllneSSf5 or 11ems al d~l' lrom tomOUler COnT'o! syslfms ~rf usullly Iceeoleo as Vil/Id ""5

high to justify its gathering. These gaps may be fil1ed
in on the chart using supposilions. Suppositions are
good guesses about what happened based on aH the
other facts Ihat have been colleded. It is importanl to
diffeTemiate between !he facts and the suppositions
!hal are shown on the chart. By doing so, it is clear to
the reader what items on the coart are facts and what
information on the chart are suppositions.
Sorne evenls and conditions. a1though they may ap-
pear lo be logical in lhe sequence of lhe diagram. can-
not be substanliated with valid factual evidence. These
are referred lo as presumptive events and presump-
tive condilions (or can simply be referred lo as suppo-
sitions). On the CF chart, evenls and conditions of
this type are dearly distinguished from elements based
on hard facts (such as by using a dashed outlioe in-
slead of a solid outline),
One of the first decisions lhe investigator wiIJ have lO
make is whetheT the evem is based on fad aT sUPPO-
sitian. Uncertainty in the data collected from wilnesses
and lhings IS (ommon This uneemunty arises for many
rea5Ons. includmg the mind sel of v.itnesses. the mo-
tives of iA:imes.scs. detenoralion of me data 5Ouree. or
gaps in the dala. The invesugator can choase tO CTe-
ale a building block for data with uncenainty ti e . a
sUPposltion), but a dear diSlinetion should be rnade
berv.:een a faet aOO a supposition Investigators corn-
monly feel uncomfortable calling any item of data a
fact. since al] 5uch judgmenls are subjec:!ive.
When developing bUilding blocks. a simple rule of
lhumb is to treal any of the fol1owing as facts:
Om!o observanon by a witness lindudmg memory
of time and field readmgsl
Data recorded by process instrurnents
Srrong conclusions reached by those \'\"ho anal~'Ze
pnysiclll evidence such as par equlpment or re-
sidual ehemlcals
Paper eVldence (to he extent that the progT<!lm.
procedure. or record relates to me process in \'\'-hich
(he incident occursl
Examples of suppostllOns include~
Second-hand testimon~' or hearsay
Conclusions by witnesses or others (except as stated
abovel
Sorne slaiements by witnesses may be classified as
either a ract or a supposllion. depending on Ihe per-
spective or lile IOvestigator{s). Fer example. in the
stalement wh ",as very bright that day.- the conclu-
sion drawn by the l,4.itness of lhe day being very bright
may be accepted as a fact ir an interested parties are
expected 10 understand the qualitauve meamng oi
"very bnght." In most cases such as this. me distine
tion between fael and supposlllon is of minor impor-
tance and probably not worth debate by investlganon
leam members. HOIAiever. if IhlS issue affeets the ree-
ommended eorrective aetions, or If the LnVesligatlon
results will be used in a court ~se or in dealing u.'ith
regulators on potemial cilatiom or Judgmenrs. Ihen
clearly differenlialmg belWeen fa(IS and supposition
is very importan!.
Caus.11 Faclors and Hems of Note
The goal of dala anaJ~sis is to ider.tif!,, the key human
errors and equipmenl failures ihal led to or a1lowed
the 1055 cvent lo oceur. or mcreased Ihe size of the loss
eveni. These are caIled causal faclors. In the nexl Slep
of the proces~_ the root causes of each causal factor
will be identified. Ohen the investigation wil1 uncover
deficiencies that did nol eontribute to the ineident. but
which muS{ be addressed before they have lhe oppor-
runity tO cause problems. Often tir:les these defieien-
cies will be relalively easy to fix: however. in other
instances. they may represent large programmalie
deficiencies_ These ilems should nol be ldenufied as
causal factors because they dld not contnbute directly
lo (he 1055 event: hOI,4.'ever. It is importanl lO highlight
them on me CF chan 2;. ilems of note aOO to generate
rt!commendauons addrt!sslng Ihem.
Causal Factors
Aher the CF chart has been completed. the investiga.
tor5 aTe in a good posilion to identify faoors thal in
Oueneed the (ourse of events. These elements are
labeled causal faaors. Causal faetors. which may be
LO the form of negative events or hazardous condi
tions. are those Items that are considered major eon
tributors lo the occurrence Eliminaiion of these casual
factors would have either prevented the occurrence
or reduced its severiry
rrelevant Data
An investigator collecls considerable data during a
thorough invesugatlon lnformation {datal Q\<erload
~n doud me reallSSUe5 and lmpede the progress of
an investigation. With experience. an investlgalor v.~ll
learn to recognize !he difference between lmponanl
dala and extraneous. irrelevant. or redundam data. A
goal of Ihe invesligator should be 10 create one build-
ing block for each relevant data Item. Examples of
irrelevant data might be the color of a su.'ilch in a
chemical proces5. The color of the su.itch rnay not be
relevem lO understanding why the operator seleoed
Ihe wrong switch. However. if the switehes are color
 USAl fAaoMS CHARTtNC . .

coded, the color becomes importan! in understand-

Evan!
ing lhe human error assodated with operating the Dlt.
Loe.tlan
Sourc.
switch. Common sense and experience should be used
by investigators lo ensure !hat their limited investiga-
5wppjy 'l~.
TG Actorl
tion resources and efforts are focused on determining .. Tony GllIents'lecl5 P.remeler
- - rubberw8sners.
cause-effect relationships directly related to {he actual !Iom H2C
_UIlO,I2/1 .... J Verb
incident or similar inciden!s. Evenls charling and de-
ductive reasoning analysis lechniques (using Ihe build- Descriptor
Time 01
ing blocks) will help guide Ihe investigator in the search
Event
for relevant data.

The procedure for formulating building blocks from

any kind of data requires that the "aetor!parameter + Figure ]3 Comprehensive Building Block
verb" format be rlgomusly followed. During an in
vestigation, investigators O'ansform all releuon! infor- Rectangles are used lo illustrate elJents and conditions
and diamonds are used for questions. Some investi-
mation they gather from people or things into this
galors use one color for evenls and condilions and a
formato and hen documen! it as building blocks. (Note
different color for questions: in this case, using dia
that 01/ can be taken to extremes. Much of lhe data
monds is nol necessary. For aelS we use a solid !ine
collected may be lrrelevant to Ihe scope of!he investi~
and for suppositions we use a broken lineo When us-
gation or redundant, as discussed earller.) To record
iog Post-lt Notes. you do nol need to pUl a solid recto
invesligative information, use selfstick notes (such as
angle around events thal are facts. If only par! of me
Post~lt" Notes) of 3" x 3" sile. Have at least two differ-
en! colors on hand. data is supposition (such as "time"), then simply place
a dashed line under thal portion of the dala on the
building block. [f all of the information on Ihe building
A very simple building block is i\IustTated m Agure 3-
block is a supposition. underline al! pieces of data.
2. Figure 3-3 shows a comprehensive building block.

Procedure
Actorl D.t.
Plramlter SourcI
Follow Ihese steps lO prepare any building block:
Verb
TG
Tony Glllene selecls
1. Thfnk actlons (and then condUlons). A build-
rubber washer5 ing block consists basically of one aclor!parameter
Irom H2C
+ one verb, accompanied by limiting descriptors.
ElJents!od;ons typical1y cause accidents, and con-
Descrlptors ditions typically contribule lO accidenls. Therefore.
during invesligalions, keep tislening and looking
for aclors whose actions inilialed a change of siate
during an accidenl sequence.
Figure ]2 Abbreviated Building Block

2. Always wrlte the name 01 the actorlparam

eter before you wrHe onything else. You will
be tracking actors/parameter.>. Actors can be people
or things. For example. an actor can be Tony GilIette
(a person), Valve V-23 (a Ihing), or temperalure (a
paramelerl. Give each persan or thing a name,
_ _ Roen USf ANA,lYSIS HAND800K
then use only Ihar name heTea/ler. Enter only one
spClfic name on each buildmg block. Pronouns
and plural nouns are polson words for he ana-
lysI. The "actor" you name must be he "doer" of
the aCIon. ralher lhan somerhing or someone (ha!
was acted upon or had something done lO l. eri-
teria forcondition building bloc.ks arE' nol reall)' nec-
essary slOce we tend lo "atural1y delauh lo passive
tense: however, il p..:'ys lO be concise.
3. Nut. wrlte down what the odor did or the
state 01 the parameJer, uslng post tense verbs
wlth descrlptors. An aclOr's name mus! be fol-
lov,;ed by the action verb describing lhe adian tha!
initiated a change af state in someone or sorne-
thing during the incident PeopJe aclions nelude:
- Sensory actions (like saw. heard. smelled.
touched, or lasted - data acquired by the five
sensesl
- Physical actioos (like rurned, reset. hit. pushed.
pulled)
- Mental actions Wke decided. calcu1ated. chose.
cooduded, thought)
For thiogs aod parameters. aetioos should be de-
scriptive of what they did (rose. SlTUCK. separated.
scored. deposited. etc.) aod not generic c1assifica-
1I00S such as failed. erred. elc
The verb should be qualified by additional phrases
to achieve speclficity (see Step 6 below). NEVER
use !\Va verbs in ane building block l
4. Llst the source of the data. Every pieee of evi-
dence originated somewhere. Sorne data come
from an analysis of the affeeted parts. debris. ete.
Other evidenee may come from eamputer files.
dataloggers. legbooks. a person's testimony, etc.
The investigator should list (he souree of the evi
denee on eaeh building block. Deve10ping a eocle
fer eaeh source may be helpful if the source de-
seriptions are loog or there are numerous data
sourees. For evidence from witnesses. simply pro-
vide Ihe initials of the person who supplied Ihe in
formatlon. cven if the evidence penains lO anOlher
persono The lisling of lhe data 50uree will help eor-
reh'Jle eaeh building block to the supporting (de-
tailedl data files.
5. Enter times for the event/condltlon. You wiJ1
use ihe time an event or conditioo began aod
ended for p1aeemenl on the CF ehart and for !ruth
testng. Therefore, the beginning and ending times
should be acquired or estimated for eaeh event or
eondition. The time eaeh event begon should be
entered on the building block. If time is essential
but IS not preeisely known. underline the time with
a dashed !ine to show thal the time is estimated,
and investigale the time rurlher. In many cases,
simply the duralion of an evenl or eondition is im-
portant.
6. Enter the locollon where the elJent/condl
tlon begonJoccurred. Next. if physical mollon
or movement is involved. show where Ihe actor
was when his'her1its aclion began. This may re-
quire eoordinates and referenee(s) lO points on
skelches or maps.
7. Enter descrfptors limltlng the ocllon. After
enlering Ihe previous data, you are now ready to
enler any deseriptors needed to Jimit he aetion
(quantilative measures, name of the person or Ihing
Ihat started lo ehange stale when acted upon. ele.).
Forexample. in theevent -Oriverpressed on brake
pedal with aH her strength,"' the VJords following
the verb 'pressed' are limitiog deseriptors used to
make the event more specific. In the event "Air-
erah descended 500 feel,- 500 feet is the limiling
descriptor. These descriplOrs should be as specifie
as the data alloVJ.
Recheek each bUl/ding block before you use ir. Befare
you use a buikling block in !he subsequent events a~is
steps (such as CF eharting), recheck it to be sure you
have reeorded al1 of !he available data correctly. cross-
checking il against the original data if neeessary. When
the reeheek is complele. you are ready to proceed to CF
charting and other analysls methods.

Sometimes you will not be able la enler all of the data
for every event. Make sure you oblain !he informa
lion in Figure 3-2 and cry lo obtain all the informalion
shown in Figure 3-3.
Oplional Procedural Steps
One feature of CF charting is its l1exibility. Investiga-
lors ohen find it useful lo add speclal data aboul an
event lO a building block. Use whatever cedes you
wish. but make a note about each cede used so you
wiU use the dala consistently when writing a repor!.
For example, a witness may provide a phOlograph or
sketch in addltion to a stalemenl. If so, you may wish
lo lldd a "p" or ~Sk"lo the source entry. Spatia! refer-
ences 5uch as maps or sketches may be needed lO
rrack an actor's actions during an acddent; you may
wish fa develop a Rlocation" grid code tied to a map
and "x.y" map coordinates or symbols. Using ~C."
-S," or -R" 10 indicate that the event was addressed
by acode. tandard, or regulation might be useful.
Once recorded on the building block, coded entries
will remind you l:!f the issue when you use the build-
ing block in discussions. presenlalions. ana!ysis. re-
port writing, ele.
Application of the Building Block Procedures for
the Two Primary Data Sources
,
One procedure can be use<! lO document dala de
rived directly from people during intelViews. Another
procedure can be used lO document dala from things
or from people in noninterview situalions.
A. Documenting WUness Testlmony
Two types of dalll are available from a witness nter
view. simulation. or similar direet observation of wit-
ness actions:
The actions of !he Wltness
The actions of other people or lhmgs the witness
observed
CAuSAl FACTORS CH.unNG I11II1I
Eilher rype may be:
Explicitly reported by a wltness or
Inferred from a witness' testimony
Data about witnesses' actions ate usually acquired:
In writing from wrinen witness stalements,
Verbally and visua!ly during witness inlerviews, or
From docwnentation of witness action5, recorded
on:
- audio andlor videotape,
- inslJUmenl charts,
- operating I09s,
- license examinations.
- elc.
Be a1ert for olher data sources lha! might have ob
served and "reootded~ the witness' actions.
l. Wrltten wltness statements.1f lhe wimess wrote
an initia! or foUCI\N'-up stalement. or ir you use a
wrirten slalement mal you or another inlelViewer
recorded. creale (he building blocks as follows:
a. UnderllOe everything lhe witness says she'he
did (aclion words).
b. Number the aelian UJOrds mat imply that the
wllness did something. Be especially alert for
camments suggesting that the wilness moved.
chose. conduded something, elc.
c. Rnd and arde mose spedfic aCtlons by !he wil-
nSS Iha! ini!iated a change af state:
- in the wilness or
- in someone or some!hing else
d. Wrile lhe aclor's name and each circled aclion
on a self-stick nOle in the actor aclJon formal.
Each self-stick nole becomes an actor action
phrase Ihal constitules an evenl building block
(also note !he source of Ihe building block at
this time).
~ ROOT USE ANAll"SIS HAf'"D8001C
2. Witness Interolews li you use personal ar lele-
phone I.A:itness intervle'.'.'S. do the foJlowing
a. lisIen tar and make note ofthe aetions (he wit
nSS took by WTlling down the aClion verbs and
any addltional descripfors you hear. As you lis-
Ien. rry 10 form a "mental mOlJie"' 01 he ac-
lians belOg desaibed by a v"itness
b. Ouring he interview. listen far descriptions af
nferences of actions by olher pE'ople ar things.
When y<?u hear one. wrile down Ihe actor's
name aod !he aetion verb mal accompames
!he name.
e. As saon as feasible. TTansfer your notes ahout
events and conchtions onlo selfstick notes la
form a building block. Do thls before your
memory fades
d. Although a delailed discussion af interviewing
skalls is outside Ihe scope af this handbook. you
may find it helpluJ 10 ",Tite your notes dov.'T1 m
a narrative or oulline format and offer them lO
Ihe witness to correct and inilia!. signifying the
witness' concurrence \li"lIh whal you recorded
This is a useful way lO ensure 11'1211 l/C'.Jr nfor-
mation is corree!.
Al Ine conclusion of !hIS effort. you snould have a
significan! quanliry of building blocks (probab~' ....lth
many redundan! items) to use for analyslS.
B. Documentlng Eve.nt.5 from Observotfons o/
Thlngs
A1though this documentation melhod is similar lo
thal described above. acquiring .. things~ informa-
tion upon which the building blocks lIre crealed is
differen!. Things cannol tell you whal lhey did or
saw. The invesligator has lo "read" Ihe informa
lion from Ihe thing that provides il. This involves
many special skills and a (echOleal background
on he Ihings. Unless you are an experto you may
wish to ohlain expert help in developing this in-
fonnanon.
Once the Ihing5 dala are available. the general
procedure for crealing building blocks from things
data is (he same as described previously. How
ever. (1' lhe actor will have a Mlhing~ name rather
[han a -person- name and {2llhe aclions will be
different (5uch as shlfted. breached, punctured.
actualed. separaled. eroded. slopped. rolated.
combmed \,l,'ith. f1oo:ed. bridgedl. depending on
Ihe Ihings involved.
laying Out the Chart
links Between Components
The basic elements of the CF charl are Iinked together
by Ihe TE'laltve positions of Ihe building blocks. The
arrangemenl serves lO complete the chart by iUusttal-
ing Ihe relationshlps among elements For summary
defiOltions 01 the building blocks 01 the CF chan. see
Table 3-1.
The Cf Chart: Formal
TraditionaIly. the ronnalofCF charts has variedu.idely:
n()U.(>Ver. Ihe SOURCE methodology uses sorne gen-
eral gUldelines for developing CF chaTlS_ The under-
Iying philosophy is Ihat slandardizalion will help
ensure cons;slency and comparability (audilingj in
Venl repomng u.llhin your organizanon.ln addition.
common guidehnes will facllitale communication
among personnel who routinely prepare incidcnt re
pons and !hose who revieu.' Ihese reports.
Development of the CF Charl
The guidehnes for Ihe CF chan formal are listed in
Table 32. They are not complex. The mlenl is only to
provide some basic strueture. nOI fO inhibit investiga-
IOrs wilh many complex and cumhersome rules
The firsl step in laying out lhe chart is lO capture the.
general sequence of events and condilions that are '
knou,"" from Ihe initial information provided tram per~:Tl
sonnel. parlS. and plIper You will wanl lO arrange me ~
building blocks on a CF chart as Ihey aTE' prepared.
 CAUSAL FACTORS CHAAT1NG ...

Table 32 Guidelines for CF chart Format

Pnma;.r SICO~dlry
Primary and second.ry evenls and conelllions snould be enclosed in lecl.ngles EVln Ev.nV
Cond'lllln COndlllon

EvenlS o/ conellllons 1'101 basad upon v.lid l.clu,' eVldence sMuld ba clearly Idenulled
I)y encloslng lllem In duhed rlclangles. or by unel,rhn,ng lne spacllic dal' lila! are
-
IPrlSurnphVt I
,
- -,
I PrtsurnpIl'Il1
I _Evtnl
_ _ _ .JI _ _ _ _ .JI
I'- Cono,rlOn
supposillons
~

Tne prlmary sequente 01 evenls should be aeplCled In a sualghl horizorl1al hne ..... ilh
Ivenls joined by tonnetling atto..... s drawn In lIoltl prlnl. The loss evenllS \Jsu,lIy allhe
entl 01 the primary event Ime I
Pllrnilly
Evenl
H Pntrlilly
EV'nl

Setondilry
Ev.nt

Setonda/y evenls and tondllions should tle deplcled on ho/izonlal hnes al dlUeren'
S,tond,/y
levels above ano belo..... lhe prim./y sequance 01 nenls SacondalY evenls should be Evtnt
jOlnecllo eath olner ancllO p"malY evenlS tly solld conn,cMg arrows

Pr,rnilry
Evtnl

. Condlt,on

COncllllons should be connected lO ..ch olher or avenls Evtnt

Condlhon

, , ,
Evenls should be a/fanged chronologlcally Irom lelt lO IIgnl amllop lO bollom; however.
a selluente 01 secondary evenrsleondlllons may be on iI dllttlent l,me IIne !hiln lhe
pllmary evenllcondl!lon lhey connee! lO I H I
n.m o,
Causal 'aclors should be Idenr,lIed by lighlnlng bolls Ilems 01 nole should be
emphuized by asle"sks
Caunl
Fltlor NOI.

Creale a chan background by taping logelher f1ip chart
paper or using a large strip of wrapping papero This
will allow you to retajn the completed chart in a file
for later reference. (A1ternately. you could take a pho-
tograph of me completed chart tor use in the repon
;and for archiva! purposes. or you could convert the
chart lo a hand or computer-drawn flowchart.)
Slart the chart by putting a tentatiue lime Une or time
markers along the lop or bottom of the chart. Use
major events in Ihe sequence such as an explosion. a
release, an alarm adivating, a shih change. !he startup
of Ihe syslem. elc., as key time markers on the time
line. Sorne of Ihese events may be used to link the
evidence col1ected from various sources logelher. For
example. allhough Ihe witnesses may have been 10-
caled throughout the faciJity. their event time lines can
be linked by the actuation of Ihe evacualion hom since
they were a1l able lo hear il when i1 aetualed. Vou are
now ready lO place each event building block onlo
Ihe chart as you finish it. As the charl develops. you
may find il necessary lo expand the time line scale.
Feel free 10 do so at any lime. Using selfslick building
blocks makes il easy lo move the events around dur-
ing the developmenl of !he chart.
The first buUding block you place on he chart should
be the primary 1055 event or condition. lf Ihe scope of
~'our investlgation ineludes posl-evem analysis {such
as analysis of the emergency evacuanon and response
efforts}. Ihis building block should be placed a mird of
the way from the rght hand side of Ihe chan (lime
progresses from left to righl on the chart). Then. iden-
tify the event or condition thal probably immedialely
precedes !he 1055 event100ndirion Keep working back-
ward in time until me dala are exhausted or you reach
an unknown. When you amve at an unknown. you
will need iD develop quesiions (funher analysis needs)
aod place lhese on the chan at mat lacation on the
CF chart. These queslioos may be resolved directly
by gachering more data.
If the data do nol allow a direc! answer to che
question(sl aod the gap prevenS you from uodersland-
jng whal happened and why it happened. try using
fou/I lree onolysis to bridge !he gaps in your lagica!
evenl flows. Fault tree analysis is a deduetiue reason-
ing technique that helps you identify what data you
should be seeking to verify your educated guesses.
If you do not have sufficiem understanding of the
physic.aVchemic.a1 process lO allow consrruction of a
fault tree. then your leam may want lo use an induc-
live technique. such as hazard and operabilicy
(HAZOP) analysis or failure modes and effects analy-
sis (FMEA) lo strucrure "brainstorming" of whal could
go wrong. which in turn will allow developmem of a
more comprehensive fault tree. The faull tree can be
construcced separately from the CF chan and should
be used lO gUlde furlher dala colleclion lO either elimi
nale ar support a possible event palh. If more Ihan
one possible palo remains for the event thal yOu are
stuck at, even after more daca collectian, Ihen it is wise
lo relaio eaco palh as a possible palh lo bridge lhe
gap in the dala.
Nexl. examine che evenlS on the chart to verify rela
lionships amoog Ihe events. Look al Ihe data pravided
by all dala sources lO determine evenl-condition rela-
lionships. Tesl each event against the preceding event
and Ihe fol1owing event lo ensure mal it is in i15 proper
lime and spalial sequence. This will help provide furo
Iher order lo the chart. Nole Ihal events mal could
have taken place months before the event may be a
direcl cause of ao Vent that lakes place far into me
event SQuence.
As these relationships are identified. the primary se-
Quence of events will start lo become Viden!. lnitially.
il may be difficult to determine whether ao evenl is
primary or secondary. Each building block should be
added lO Ihe "skeleton" chart as it i5 uncovered. As
additional facls aTe uncovered. a more complete pie-
tuTe of lhe accurrence will emerge, and il will become
easier to determine whelher or nol an Venl is directly
relaled to the 1055 evento Modiflcations can be made
lo the chart as appropriaie.
Presumplive events and condilions should be c1early
identified as such by enclosing Ihem with dashed lines.
Every effort should be made lO subslanliale presump-
tive events and conditions with factual evidence. Al-
lowance of presumptive components on Ihe chart
should nol provide an excuse far a less Ihan Ihorough
invesligation.
See Rgure 3-4 far ao example of a CF charl lhat oon
lajns events. condilions. supposilions. and questions
(or possibilities Ihat have not yet been eliminaledl.
Qualily Control Check.
Check your building blocks for certaln poison words.
This step could be done wlth each building block flS it
is developed.
Poison words like "ond" and "or" indicate that you'
are covering more Ihan ane event or condition in
a buildmg block.
"Was" and "were~ refleet the passjve voice. which
indlcales mal you may nol have named the righl
actor. Passive voiee is acceptable. however. for stat-
in9 conditians.
Words endmg in .. .. .Iy" are usually poison. because
they are merely disguised. implicit investigator value
judgments wilh no crileria or evidence lo juslify
thelr condusian.
 CAuSAl FACTORS CHAllT1NG EIII
Ho..... much \1mB al a "t\ighO selllng
""OU'd lllake lor lile lI,usa 10

,--- ----1L
r Grease aulO- I
18eh ns auto-lgnlllOn
temperatura?

I Ignllad due 10 ~
,,'" uCIsslve 1"
" " I Dvarheatlng j "
.---__-</ L J '4/-.......
MalY pull 3 MalY nts
1--------,
Frylng pan was I I
el/ps 01 elecuic lell unBltended --..r Eleel'lc eye L _ llylng Pi" Smoke alarm

", ~;;;~~;d~; / ""..

gltase in !tove eye

lo~~~~~j7q,l::n
lO annunclales
Irylng pan hih $I1tlnll

'~ by an UhHUI v.. .

t spark/tlame 1
Do&S lhe burn81 silo..... slgns I souree J
o! an electrlcer '110ft? L _ _ _ _ __ J

~
, , - - - - 15 ttlel!! eVldence DI combuSllf)le
material near lhe S10ve eye (SUth
as a POI hold8l, a paper IOw,!,
elc.)?

Figure )4 Incomplete Cf chart fOr a Crease Fire on an Electric Stove

Other poison words are words that describe a
sleady stale, ralher than an event or condition.
As you gain experience, you will begin to spol your
own signals lhat a building block is really not an event
at a11, but rather is a eonclusion, supposition, or other
unaceeptable entry. Summary statements {which are
also conC!usions. but are clearly based on datal are
acceptable (and useful) on a CF ehart.
Nter a chart is completed, have someone who does
not know what happened review your chart for the
logical flow and sequential ordering of ilie evenl. This
process often generales either a need for more dala
or better event f1ows.
Causal Factor Identification
After Ihe CF chart is complete, the investigators are in
an excellenl position to idenlify factors that were ma-
jar contribulors to the incident. Delermination of these
causal factors requires judgment on the part of the
invesligalors. Causal factors are those human errors
and equipment failures that. if eliminated. would have
prevented the event or redueed its consequenees. fur-
thermore. presumptive events and conditions may be
identified as presumplive causal faclors.
It is important to remember that mast incidents do
not have a single cause. Usually a number of factors
contribute to an incident. The evaluation should not
_ _ Roen USE ANAlVSIS H"'~DIlOOJr(
stop after {he firsl causal factor i5 discovered. The in-
vestigators should continue unlil al1 major contribu-
tors to the incident have beeo identified. Each of he
causal faclors should be marked on the chart usiog a
Iightning bol! symbol.
Practical Application 01 CF Charting
The insrruetions for preparing a CF chan presented
in this handbook should serve as basic guidelines.
Strict adherence lO these guidelines is not necessary.
The comhined experienc\? of many OCCUlTence oves-
igalors has led 10 (he idenufication 01 several ~rules
o thumb" to follow when developing a Cf chan.
These suggestions. applied judiciously, should help
achieve high-quality inVe5ligalions.
Start early.
The investigators should slart he CF chan as soon as
Ihey begin lO calleet faro ahoul Ihe incidenl They
should construct a "working charl, slarting Wilh Ihe
H thase involW!d in the investigation. Ven \.\Ihen usng
loss Ven! and working backward in lime. This will be
only a skeleton of the final producl. bOl l will serve lO
ensure that valuable information and questions are
nol forgorten or losl during the investigation. Care
should be taken. however. lo avoid 10cking the inves
tigaling team inlo a preconceived scenario.
Follow formal guidelines.
The investigalors should use Ihe guidelines for
formaling described in this documenl. This witl help
them gel starled and slay on track as Ihey reconstruct
the events and canditions surrounding the inciden!.
Proper perspeetive should be mainlained in applying
the guidelines. They are inlended lO assisl you in simple
application af Ihe invesligative 1001. They are nol hard
;.nd fasl rules tha! must be applied Wilhoul exceplion.
They oave grown OUI of experience and fil well for
mosl slUalions. If the investigalors believe tnat they
have a rruly unique silUalion and need lO deviale from
loe guidelines, Ihen they should feel free lO do so.
Procccd logically with available data.
Nalurally. events and conditions are nal gong to
emerge in the sequence in which Ihey occurred dur-
ing the inciden!. Initial1y. lhe CF coarl will have many
unresolved gaps and queslions. The job of Ihe inves-
tigaling leam is 10 probe deeply enough lo gel Ihe
faets needed lO fill these gaps. Use "gap bridging~ tech-
niques. such as fault trees, to deduce what might oave
happened. !hen search for dala lo support or elimi
nate possiblc Veni paths.
Use an easily updated formal.
As more information lS leamed aboul the incidenl.
loe v,!orking CF char! will need to be updated. lt is of
extreme importance to choose a fOTlTlal !ha! can be eas-
ily modified: otherwise. the chart will become lOO cum-
bersome lO be of any value. In the pasto investigators
have attempled lo redraw the chart rcpeatedly. Ths
approach is both time consuming and frustraDng for
compuler software speciflcally crealed for this purpose
(me monitor is too small to alI01A1viewing lOe entire chart).
The technique thal has proven most eHective involvcs
the use of selfstick noles (e.g.. Post-it Notes) aOO a large
sheel of papel' (e.g.. f1ip chart paper or IA.'repping pa-
perlo A single evenl or condition 5 wriftcn on each self
stick note and afflxed 10 the paper. This lechnique has
the advantages of being simple. nol requinng any spe-
cialiools or software. and being 10000lech. This allows
me investigalors to focus on !he investigation inslead of
the melhod of updating the chart. As a more complete!
pjeture of !he occurrence emerges. the self-stick notes
can be added. deleled. 01' rearranged. Using the large
sheet of paper as a base alJc,.....s!he investigalors lo take
lOe chart wilO them ifthey need lo move among confer
ence rooms. offices. Of locations invoJved in lOe even!.
Once the working chart has been compleled. a final ver-
slon can be draum for nc/uson in me occurrence re-
port. Experienced occurrence investigators have
discovered thal !he man's mast useful features are thal
it illumin;.tes "gaps" in knOVJledge, points lO areas for
further inqUlry. and makes report writing relatively
straightforward_

Use olher invesligalive le<hniques when
appropriale.
CF charting provides a way for investigators to orga
nize !he dala collected during the incidenl investiga
tion. Numerous techmQues exist fer coUeeting the dala
Ihat 90 inlo the chart. Sorne o these are presente<! in
documents listed in lhe Referenees section of lhis hand-
book. The more skill the investigators have in colleet-
ing evenl dala. Ihe belter the CF eharl. The
investigaiors should make every effort lO build their
knowledge of investigative lechniques.
Seled the appropriale scope for the Cf chart.
One of the first things lO consider when creating me
CF chart is me scope of the investigation. h is neces-
sary to decide. on a case-by-case basis, upon the ap-
propriate depth and sequence length of the CF chan_
Unless the scope is defined early. much time willlikely
be wasted coltecting information Ihat will later be dis-
carded because il falls outside the boundaries of the
final investiganon. For example. many investigallons
are Iimited to pre-evenl events and exdude posl-event
ilems (such as emergency response).
Provide an executive summary of the Cf chart.
'C,gndense the working CF chan inlo an executive sum-
mary chan for pubheation in the event report. The
working chart will contain mueh detail. so il isof greal-
est value in guiding the Lnvestigation. However. for
!he evenl reporto Ihe pnmary purpose of Ihe CF chan
Is to provide a concise, easy-Io-follow representalion
of Ihe evenl scquence for the repon readers.
Advantages 01 Cf Charting
The benefits of CF charling for event invesligation are
numerous. Severa! of the masl obvious advanlages
are Usled below
USAl f.t.crORS CHAJlTI"'IC . .
Provides organization of dala.
The chan provides a way 10 organize the dala galh-
ered during lhe event investigation. Oflen, important
datll are losl or fargonen as the investigation
progresses. If the investigation is being condueted by
a team. differenl investigalors may colleel differen!
pieces of information. The CF chart helps ensure thal
everyone involved has lhe benefil of the group's total
knowledge.
Cuides the investigation.
The technique 15 excelJenl ter group investigations. The
CF chart provides a common reference for everyone
involved. While inexperienced invesligalors can use
Ihe melhod lo stnLcture their investigalions. experi
enced investigalors can use Ihe chan as a way lO avoid
drawing conclusions before they have aD of Ihe rel-
evant faets. CF charting forces investiglllors to think
aboUI causal raetors, cne al l time, inslead of consid-
erng the occurrence in global terms.
AJlows validation of the incidenl sequence.
A CF charl provldes a good reference during lnler-
views for Ihose direetly involved in an even!. The in
vesligalors can ask interviewees if Ihe chart $ correcto
Inlerviewees have a graphic representation of whal
the invesligators Ihink happened during Ihe event.
They can easily poinl out discrepancies. Nole thal we
recommend nol showing the chan lO inlerviewees
untillhe follow---up interview phase.
Allows idenlification of causal factors.
Many limes even! investigalors are templed to Ihink
of an event in global terms They ask themselves whal
Ihey can do to ~fjx the problem. ~ Using Ihe global
approach. we often address only parts of the prob-
lem. A CF charl a110'.l.1S us lo see Ihe entire evento bro-
~ RooT CAUSE AN"LV'SIS HAN08001(

ken clown IntO its eomponents Each pan can be as-

sessed separalely. and solutiOn5 can be Tr2!:ommended
for individual causal fadors. This lessens Ihe probability
Iha! sorne imponanl contribulor lo Ihe evenl will be
overlooked.

Simplifies organization of event reporl.

Generally. <lo graphic representalian of an evenl is more

easily interpreled lhan a narrative representalian.
Readers of an event report can gJance al a CF chan
and qUlckly familiarize themselves Wilh lhe event. Gaps
in JoglC rha! might nol be so visible in a narralive re-
por! are far more apparent when presented in chart
formo CF charting has proven lO be a clear and con-
cise aid far teporl readers whose goal il is lO under-
stand Ihe causes of Ihe event.

Summary
CF chatlng (together wilh continued data gatheting}
15 Ihe second major slep in Ihe rool cause aoalysis
process. The technique is simply a 1001 designed lO
help event investigalors describe the evems leading
up lO and fol1owing an even!. as well as the condi-
tions surrounding these events. The technique pro-
vides a structured approach to col1ecting and
analyzing the fac!s pel1aining lO an evenl. [1 is up lO
the investigalors lO decide how detailed the invest-
gallon. aod thus the CF chart. should be.

The chartmg technique. in and of i!Self, does no! en

sure an adequate event invesligation. The investiga-
tion leam mUSI be knowledgeable about me processes.
fadli'ies. and personnel involved in he evento They
must know the righ queslio05lo ask. who lO ask. and
how to ask. Finally. they must be willing to probe to
he levels necessary to determine WHAT happened
during Ihe occurrence, lo describe HQW it happened.
and lo understand WHY. (The fol1owing chapler on
roOl cause identification explains how ro consislently
and thoroughly understand WHY.)

ROOT CAUSE IOENTIFICATION
.Once Ihe investigator has created a Cf ,harl describ-
ing Ihe even! and filling in al! the gaps possible, che
nexl step in he SOURCE roo! cause analysis process
is lo determine Ihe rooi cause(s) for each causal factor
(or tem af note) identified in he chan. Roo! causes
aTe he mos! bas;c causes Ihal car reasonobly be Iden
tified, which management has control lO {IX and for
which effectiue recommendotions for preuenting re-
cummce con be generared. Rool cause identificarion
is simply a process lO help Ihe invesligalor determine
he underlying problems (Le., root causes) associaled
with each causal faclor. As deflned earlier in ulis hand
book. caUS4J1 factors arE! human errors and equipmenl
jailures, which il elfminaled. would haue eilher pre-
uented rhe eueni or reduced i15 seuerily. A causal fac-
,tor, as identifled in !he CF charl. is a description of
WHAT happened lO cause Ihe incidenl or HOW il
happened. Before recommending workable preven-
tive measures, Ihe investigalor must know WHY Ihe
causal factor occurred. Rool cause idenlificalion helps
the investigalor examine, in a systematic way, pos-
sible reasons for the causal factor.
The Root Cause Identification Process
For simplicity. a map formal was chosen for use in
rool cause idenlification. Investigators use Ihe Rool
Cause Map (RCM) lo structl.ne their reasoning pro
cess. Consislency is ensured across all investigations
by using the same process for categorizing causal fac
torso A copy of the map is presenled as Appendix B to
(his handbook. Staning at Ihe top of Ihe map. Ihe in
vestigalor identifies Ihe rool causes {and higher cal
CHAPTER 4
egories of causes) for each causal faclor idenlified in
Ihe Cf charl by working down fhrough Ihe map as far
as known information will allow. For each causal fac-
tor, an invesligator determines which lop level nocle is
applicable. Based on Ihis decision, Ihe investigalor
moves down 10 !he nexllevel and selecls another ap-
plicable nocle. keeping in mind thal only lower level
nocles branching from the nocle chosen on Ihe previ-
ous level can be considered for identifying Ihe rool
causes of a causal factor. Palhs through Ihe RCM f10w
only in a downward direction. By following the seg-
ments of Ihe map. nocles mal do not apply lO a given
causal factor are nol considered. saving considerable
lime and effort during !he idenlification process.
Figure 4-1 shows Ihe map formal and demonstrales
how lO follow a path from Ihe 10p of Ihe map lO Ihe
lower levels. The arrows show examples of possible
palhs. When using the RCM, Ihe investigator always
Sfarts al Ihe 10p of Ihe map with a given causal factor
and proceeds down Ihrough Ihe map as far as pos-
sible, given Ihe information available. Movement
Ihrough Ihe map is always from Ihe top down. If infor-
malion is not available lO answer questions al the low
esl level of Ihe map, Ihe investigalor can stop al a
higher level. For example. in Rgure 4-1. the palh al
Ihe far lefl SIOpS shorl of Ihe lowesl level.
EiIIII ROOT CAUSE ANAlYStS H"r-.,OBOOK

Start Here

11 l
,
x

c..

, ,
x x x
Figure 41 Use o the Map Formal

The Roo! Cause Map
The Roo! Cause Map. me major 1001 used in rool cause
idenlification. i5 a decision diagram divided into many
difteren! nocles Al flrsl glance. the RCM appears lO be
unbalanced. The len side conreins far fewer nodes than
lhe right side Basical1y, Ihe map 15 divided into lwo
major parts. Nodes on Ihe len side o the map are
used lO idenlily and categorize causal faetors associ-
aled with equipment failure. Nodes on the right side
of lhe map are used lO identify and categorize causal
faclors related lO personnel error. This dvision is ilIus-
trated in Figure 4-2.
Nolice hal the tv. o sldes o the map are nol mutuaJly
exdusive. Al1 failures. with lhe exceplion 01 olher dl
{cutties. can evenrually be tr~ced b~ck lo some type
of human error. Even in the case of a lighlning strike
or f100ding. il might be argued that the system design-
ers did not provide adequafe profeClive measures. In
any event. equipment problems can ohen be traced
back to mistakes made by pcrsonnel. For example. a
pump malfunetion may be the result of a maintenance
mechanic's failure lo corredly follow the required pr~
cedure To deal wilh scenarios such as these. the fWo
sirles of the map inlersect al a number of Ihe second
level (B level) nades. This allows calegorizalion fram
,he equipmenl sirle af fhe map to eXlend over to Ihe
personnel side and vice-versa.
Segments of the Root Cause Map
As shown in Rgure 4-3 (and Ihe full-size map included
wilh this handbookl. Ihe RoO! Cause Map has been
divided inlo 11 segments. The segrnenls have been
color ceded so thal they are easily dislinguishable.
Each segmenl is made up of relaled nades. For ex~
amp!e. alt nades associated with communications in-
 -
Figure 4-2 Equipmenl and Personnel Sides of the Root Cause Map
aclequacies are located together in a single segmento
A1l nades related lO training difficullies are grouped
togelher in another segmenl.
Delailed Descriptions of Each Node
'Detailed descriptions of each nade are presented in
Appendix A of this handbook Typical issues addressed
by ea,h nade are presenled. usually in the form al
queslions. These Queslions are ntended 10 help the
investigalor determine whether ar nol a nocle is ap-
propriate for dentifying and ca!egorizing a parllcular
causal factor. In addilion io lhe typical issues, cne ar
more examples of the types af events coded uncler
Ihis nade are presented. Rnally, a se! 01 typical rec-
;ommendations is provided lo assist investigalors in
generaling effeclive recommendalions.
levels of the Root Cause Map
[n addtlion lo dividing Ihe RCM inlo segments, Ihe
map has also been divided into {ve major levels (see
Table 41). Each level on the map corresponds lO a
Roen USE IOfNTlflCATlON . .
particular c1ass of nades. When delermining lhe roOl
cause of a causal faclor. Level A nades require the
investigator to make only bread diS1indions. Level E
nocles require mal very specific questions be answered.
The nades on each level are ceded by shape fa help
the investigator differentiate between levels. Table 4-1
provides a description of Ihe different levels of Ihe map.
Prlml'Y This level is the most general level
Dl1tfltulty of he map. For each causal factor.
SOU.tl
me investigalor t5 firsl asked to make
broad distinclions concerning Ihe type of difficulty in-
volved. The investigalor may initial1y delermine Ihal
a partIcular causal factor involved an Equfpmenl Dif-
fleul/y or a Personnel DifficullY. Based on answers to
these general questions. the investtgator branches
clown to more specific levels of the map.
This level describes the type of prob-
P.oblfm
Cllll10ry lem that is being addressed. Ex-
amples of this level of nodes mclude
Equipmem Desgn Problem and Company Employee.
m. ROOT CAUSf A'lAL''SIS HAND800K

L!Lf--------::--;;----;;:-----j-@m
Ii\
I!'J
1,
I~

II

.
i i1
J l
1 I1

!l I!

1 !!
1 A I '1t. I
1
!
1 J

!JO oD001
Figure 4-3 Root Cause Map
 ROOT USE IOENTIFICATlON . .

Table 4-1 levels of lhe Root Cause Map

Levell Description Examples

Shape

O
Plimary EquipmelllOllliculty
Diffficully Personoel Dllhcully
Source Olher DiflicullY

O
Protllem Equlpmenl Deslgn
Calegory InslallalionlFatlflcallDn
Natural Phenomena

CJ ROOI Cause
Calegory
Design Inpul/Outpul
Equipmenl Reliatlilily Program Implemenlalion
Human Factors Engineerlllg

O
Near ROOI Preventive Maintenance less Than Adequale
Cause No Ttaining
Procedures MlsleadlllglConfuslng

O
ROOI More Than One Acllon per Slep
Cause Inappropriale Type 01 Mainlenance Asslgned
Traming Records Incorrecl

When the investigator reaches this
Rool e.u..
C'I'lI or y level for a causal faclor. lhe rool
cause calegaries mus be deler-
mined. This level contains 11 calegarles: examples
nelude Design /nputlOutput. rraining. Procedures,
AdminIstratiue/Managemenl Systems. and Human
Faetors Engineering. Using this level, lhe invesligalor
begins to become more specific abaul the nature of
the causal factor: lhis is an essential categorization slep
in any root cause analysis.
The investigalor now moves to the
near root cause level of the ReM.
which indudes subdivisions of the
majar root cause categories. Notice that mas! of lhe
nodes under the Il!'rsonalll!'rformance root cause cal-
egory are shaded. The shaded nades are intended to
provide guidance conceming the types of i~ues !hal
should be considered personal perfonnance problems.
Because of lhe sensitivity of personal perfonnance IS-
sues. lhe evenl report should stop at and reference
only Personal Performance. The reason for the per-
sonal perfonnance problem should be tTealed conn
dentialJy lhrough other channels (e.g .. medical
department, disciplinary system).
Finally. the bottam level lisIS a detailed
set of roo! causes for each rool cause
category. This level, the lowest level
of the map. requires tha! the investigator answer very
detailed queslions about he causal factor. Al1hough
we cannal predicl alJ the questions that might pertain
to a rool cause nade. Appendix A canlains several
examples lo help the investigalors consislently choose
lhe best fil. Examples of nodes localed al the lowest
level af the map include Wrong Revision or Explred
Procedure Used. PackaginglShipping Less Than Ad-
equate (LTA). or Labeling LTA. The goal of root cause
identificalion is lo allow Ihe investigator lo be as spe-
cific as possible about the underlying reasons for a
given causal factor.lf possible, the investigatar should
attempt to reach the bottom level nodes.
IIIEI:III Ro(n USE ANALV5lS HAND8001C
An investiga10r cauld go beyond (0010"-,) he roo! cause
leve!. bUI in mosl cases this will identify issues fha!
canna! be addressed effectively by recommendatlons
from investigafioo Icams. lt 15 probably besl lO stop al
lhe roOI causes on he map. unless the data from many
invesligations indlcate recurrence of a particular TOO!
cause.
Multiple Identification
Usually (here are mulfple rool causes for a causal fac-
tor. This is refened lo as mulliple identil'icalion. Mul-
tiple identification is used whenever more than cne
rool cause IS responsible for he occurrence of a causal
factor. Multiple coding is appropriale in many c;rcum-
stances; however, il more than three rool causes are
indicated. lhe causal factor is probably stated loo
broadly and should be divided me two or three more
specific causal factors. For example, a mechanlC fails
lo properly perform corrective maintenance on a
pump. Part of Ihe reason for the improper repar is an
out-of-dote procedure. A different motor h2ld becn
installed in the syslem and the procedure was not
updated lo relleet Ihis change. This evenl can be caded
under (1) Equipment Re/iabi/ity Pr-ogram Implemen-
tation LTA Corrective Maintenonce L.TA, and Repair
LTA (the repair was nol performed correctlyl. (2) Pro-
(dures. Wrongf/ncomplere. and Faets WronglRequire-
menlS Nol Current (lhe procedure was nOI updaled).
and (3) Administratille/Managemenl Sysrems. Docu-
mem and Canfiguration Control. and Documentarion
Not Kepl Up te Dote (the system for updaling docu-
ments failedl.
A Simple Example: The Pump Failure
The best way lO explain the mechanics of rool cause
identiucalion is Ihrough a simple example. Consider
Ihe following event.
During rhe operarion of a chemicol process, Ihe op-
erator on duly observed Ihe /low rafe for olle of rhe
streams decrease rapidly ond foil lO zero. The opera
lar hO/led feed to rhe process ond Shul down Ihe op-
eration per procedures. Inuestigalion imo he cause of
rhe evenr reveoled loot rhe beorings in Ihe pump setzed.
cousing the pump ro foil. JI was delennined Ihol rhe
bearings seized becouse rhe; were improperly installed
during rourine maimenance. Therefore, rhe causal fac-
ror idenlified in rhe CF chart was 'lmproper installo-
rion of rhe bearings during mainlenance. When
questioned, Ihe moinlenonce mechcmic stated lha! he
had followed rhe written procedures for me rask. When
rhe procedure was exomined. ir was found lO be Ol.Jr-
doted. A more recellt reviSlon should hove been uSd.
ond its use mighl halle prellented the beodng prob-
lem.
Srarting o( lhe lop of Ihe RCM, rhe investigalor con-
duded lhal the source of lhe difficully was an equip-
ment problem. Therefore. the (rSI node coded is
Equipment Difficulty. Next. Ihe problem calegory 15
delermined lO be Equipmenr ReliabiJity Program Ptob-
/em. Because the wrong version of Ihe procedure was
used. Ihe next nodes lo be idenlified would be Proce-
dures. WrongJlncomplete, and final1y, Wrong Reuision
or Expired Procedure Reuision Used In addilion. Ihe
procedure administralion system faile<! to provide Ihe
proper revision of rhe procedure to maintenance per-
sonnel. Therefore, lhis causal factor could also be de-
lermined to have Documenr ond Configl.Jrotion Control
as a near rool cause and Controlo/ Officiol Docu-
ments L.ess Than Adequate as a root cause. under lhe
calegory of Adminislrolive/Monagement Syslems.
Table 4-2 illUSlTates Ihe palhs folJowed Ihrough Ihe
RooI Cause Map. '
Presentation of Results
For the inciden! reporto each causal faclor and item of
note should be presented usmg a three-column table
such as rhat presenled in Figure 4-4. As discussed in
Chapter 3, he frsl column is used lO describe Ihe
causal factor or ilem of note. The palhs through Ihe
RCM used to categorize a particular causal factor are
presented in the second (olumn. The enllre path
through Ihe map should be !isred wilh Ihe 10p level
nade Usted firsl and Ihe bortom level nades liSled last.
Hmulliple root causes are identiued for the causal fac-
 RooT usr IOrNTIFICATlON __

Table 42 The Pump Failure: Paths Coded Through the Root Cause Map

~~:;~s~ Examples

least
o F'ersonnel Dr!hcully
Detail

o EQurmenl Relrablhly
Company El"ployee
Plogran F'robJem

Q Proceaures
AdmlnlstratlVe
Management SySlems

DOcumenl and
Wlo~g Incam! ele
Conhgurallon Conllol

Wrong Revrslon or COll1fol al Otlrclal

Most E~pllea F'raceaure Documenls Less Tilan
Detail Revlslon Used Adequale

lar. then aU paths through the map should be shown.
A solid line 10 the middle coJumn should be used lo
separale the informalion about different paths.
Surnmary
Rool causes are identified for each causal factor. RooI
causes are he mosl basic causes thal can reasonably
be identified. hat management has control [O fix. and
for which effective Tecommendations fOT preventing
recurrence can be generaled. The Root Cause Map is
used to structure the identificallon process. The inves
tigalor starts al the top of the map and moves down
through the paths on the map lO idenlify rool causes.
Mulliple rool causes are identified for each causal fac-
tor. The results of Ihe rool cause ldentification process
are presenled using a three-column tableo

Tille 01 henr Inve5liguon Reporl

elunl Flelor ., Pllhs Th.ough ROOI elUn Mlp Recommtndl1lonl

,t o ""I'~'CI ,::,~ ... " o," ro;: .. 1
'"o (I.IIII'C'O' 11 II;:U'I '. t".
p",.,.'):" <,'tj lo."e
P'OO"" :ot',o"
"'"'1 t,I",""
" o' 'e'","c,
'"
,.tt""" "0'1"'"0 ':. e.o "O~ "O, rO
:ILIII flelO' :'I~ ~oo' <1.11 CI"~"""
NU' 'ocl 01,..
"'1'OIuo"'''.'nl,o, 'o 1::'"11
Il.I.CKGIIOU,,"O
1" 11~t:' O'O,,~11 o'.al
~o:'u"lI

1" '"' '~I<I '11 '"1 ." '"'o.;, ". -.~

n'~ 'ooIU.U

o'''il:" 'C 'III'o "1 l'. 0;1"SI tOIOO:<I."

'1:1, '1'.: '"O'... ~"g ""c.",";
'1IIa"S _"1 '., CI ... U '1"'" a,,~.a
J' "liJo"': to" 1I :.'1 'ClCI
.0" o .,.o:t "Ita ,e 'HClt. =" '".
''''0' 11_' CI.... Ilc'o'
. '.. U
,'111""'" 11"11
~ O' '". : "'1 ", 1"1 o:'" 'oc' ' n, 1
P'''""', O" (",. lO,,'" ~ s' C' '."'1"'. 11:0"""'01' O"'
'0: t~ :It.;:" lo 1::'tU t". a:'" '001 CI ....
UO.C I'ta _., "'O CI,u' IIcm
11001 :1.0. CIIt~O'r
Ntl' 'oo' eI.U
flool tiLO.

Figure 4-4 Roo! Cause Summary Table: Presentation of Palhs Through the Root Cause Map

RECOMMENOATION GENERATION ANO IMPLEMENTATION
Perhaps the mast significanl aspect o r001 cause analy-
sis is Ihe final slep. Following the identificarlon of roor
cause(s) ror a particular causal fador, recommenda-
liaos for preventing its recurrence mus! be generaled.
The identificalion of effective correclive adions is ad
dressed explicitly in Ihe definition of root causes. Roo!
causes are defined as rhe most bask causes rhar can
reasonably be identified, which managemenl has con
troJ lO fix and for which effective recommendorions
for preuenting recurrence can be genercned. The em-
phasis is on correcting Ihe problem so tha! il will nOl
be repeated. The following crifena for ensuriog Ihe
viability of corrective actions are suggested.
Willlhese corrective aetions preven! recurrence of
Ihe coodilioo ar event?
Is Ihe corrective action within the capability of the
organization lo implement?
Are me recommendations directly related to!he root
causes?
Can we ensure that implementation of lhe recom-
mendation will not introduce unacceptable risks?
The eorrective aetions developed should address nol
only the spedfic drcumslances of the event thal oc-
eurred, bul also syslem improvements aimed al the
incident's root causes. They should address options
for reducing Ihe rrequency. minimizing the personnel
exposures. andlor lessening Ihe consequences of one
or more of the root causes.
In general. Ihree types of recommendalions should be
generaled for eaeh rool cause:
CHAPTER 5
Corred Ihe specific problem
Corred similar existing problems
Correet the syslem tha! created Ihe problems
For example, if a procedure error is diseovered. Ihe
following three recommendalions may be generaled:
Corred me spedfic procedure mal caused the prob-
lem under investigallon
Correet olher procedures that have Ihis same type
of problem
Corree! the proeedure-generalion process lo pre-
venl the crealion of more problems
A suggesled forma! for recommendations IS lo pro
vide a general objeetive to be accomplished. followed
by a specific example of how il could be accomplished.
Ths will dearly stale the inten!ions and provide l spe-
cific method tha can be used to accomplish lhe goal.
If management wants lo implemenl this suggested
solution Ihey mayo However. they may also have l
bener. more effective way to meet the objective.
For example. l recommendation may stale:
Provide a means fOf operalors lo deled slow
changes in tan\< levels. For example. a strip chan
reeorder hat shows trends over 8 hours could be
provided in the control room.
Managemem may decide to provide tan\< levels on
lhe plan! process computer so that operators can
change Ihe time seale to whatever they need. from
minutes lo days.
11Im ROOT CAUSE A....AlYSIS HANOBOOk
The recommendations should seek lo rnake improve.
menls in management 5!,.'stems and/or inheTeol safety
by,
Reducing the inventarles of hazards
Making subslitutions for hazardous chemicals or
siruations
lncreasing the number of events required lo gener-
ale an inciden!
Finally, ensUTe thal me recommendations are based
on the conclusions fram the data analysis results. The
faets discovered duriog he investigation should tead
lO causal faetors aod TOO! causes, which. in turno should
lead to the recommendations. Facts are relevan! if they
lead 10 a recommendation. Facts hal are nol required
lo understand the sequence af events af Ihal do nol
suppon a recommendation should not be nelude<! in
he invcsligation reporto Ukewise. al1 of lhe recom-
mendations should be derived from Ihe circumslances
of Ihe event 21nd its rool causes.
Checklist for Developing and Imple-
menting Corrective Actions
In developing and implementing conective 21clions.
consideration of Ihe foJlowing questions can help en-
sure Ihal Ihe criteria listed above are met:
o Is Ihere al leasl one conective aclion assodated
wilh each rool cause?
o Does the correclive action specifically address Ihe
rool cause?
o Wil1 lOe conective action cause delTimental effects?
o Whal are lhe consequences of implemenling the
conective aClion?
o What are Ihe consequences of not implementing
Ihe correclive action?
o What is Ihe cost of implemenling Ihe corrective
aclion?
o Will lTaining be required as pan o implemenling
Ihe correclive action?
o In what time frame can Ihe corrective action rea-
sonably be implemented?
D What resources are required for successlul devel-
opmenl 01 Ihe correclive aClion?
o Whal resourcs are required for successful imple-
menlation and conlinued effectiveness of lOe cor-
recllve action?
o Whal impad will the developmenl and implemen
talion 01 Ihe corrective action have on other work
groups?
o Is implemenlation of the corredive aciion mea-
surable?
Presenlalion of Resulls
For the event reporto eacn causal factor and item 01
note should be presenled using a thn?e-column tab!e
such as Ihal presenled in Figure 4-4. As discussed in
previous chapters, lhe firsl column is used to describe
lhe causal faclor or item 01 note. The paths through
the Rool Cause Map are presenled in Ihe second col-
umn. The Ihird column should be used lO present rec-
ommendalions lor correclive action. U multiple
identification has becn used lO calegonze a causal fac-
lor or item of nOle. !hen alleasl one recommendation
for cach root cause should be presenled. The
recornrnendation(sl for preventing recurrence of the
causal faclor should be presenled adjacenl lo Ihe cor-
responding rool cause. The person(s) or
organization(s) responsible for implernenting a given
recornmendalion should be Usted in parenlheses im-
mediately after mal recommendation.
 R!COMMENOATlON GENfRATlON . .

5ummary
Recommendation generation is the final step in the
SOURCE root cause analysls process. When this slep
LS fimshed. the documentanon of the root cause analy-
sis is complete The final product wiU be a CF chart
and a rool cause summary table for each causal fac-
lor or ilem of note identified during the root cause
analyslS process.ln generating recommendations. it is
importan! for me investJgalOf to be confident thal (1)
the corrective actions ",iU prevenl recurrence af me
evenl ar condll1on. (2) each carreCllVe aeon is "mhm
Ihe capabilily 01 Ihe organizallon lO implement. (3)
the correetlve aetlons alJow the organization to meel
its primary objective. aOO (4) aU assumed risks nave
been consldered (and staled. ir appropriate)
 CHAPTER 6

REfERENCES

American Institute of ChemicaJ Engineers, Center lar Chemical Process So/elY Guide/ines for lnuestigoring
Chemica/ Process lncidents, New York, NY. 1992.

Department of Energy, Acddentllncident Investigo/ion Manual, 2nd ed., OOE/SSOC 76-45127,

Deparrment of Energy, Euents and Causal Faetors Chorting, DOElSSOC 76-45114, 1985.

Department of Energy, Roo! Cause Analysis Handbook, WSRC-IM-91-3, 1991 (and earHer versions).

E.I. duPonl de Nemours & Ca., Ine., User's Guldefor Reactor Inciden! Roo! Cause Coding Tree. Rev. 5. OPST-
87-209. Savannah River Laboratory. Aiken, Se. 1986.

Ferry. Ted S.. ModernAccident Investigaton and Analysis. 2nd ed.. John Wily and Sonso New York. NY. 1988.

OccupationaJ Safety and Health Administraton Accident Investigatan Course. Office of Training and Educa-
'tion. 1993.
 APPENDIX A

ROOT CAUSE MAp,. NODE DESCRIPTIONS

This appendix is designed to help you use the Rool
Cause Map in a consistenl manoer. lt cont8ins a lisl
of'typical issues, typical recommendations, and
examples for each nocle on the map. The appendix
covers Ihe nocles on the map fram leh to nght and
tram IOp lO bottom. Te help you find information on
a specific nocle, two node listings are provided.
The firsl lisl is organized by aTeas o Ihe map. This
Iisting is useful if you are interested in examining a
particular portion of the map.
A thiTd ndex is actually contained on the Root
Cause Map in Appendix B. 00 the map conlained
in Appendix B. each nade has a number in the
graphic following the tex!. The number in the
gr1lphic indicales Ihe page number in Appendlx A
ha! corresponds lo ha! node. By using this version
of the map, a user can directly detennine the appro-
priale page in the handbook withoul he need far a
separale indexo

The second lisl provides an aJphabetical listing af

Ihe nocles. This lisl can be used lo lacate informa-
tion concerning a specific nocle.
 ApPENDIX A - Roer CAuse MI4P NODE DESCRIPOONS .EII!I
Inde. of Rool Cause Map Nodes by Area

Prlmary DljfJculty Source J

Equipmenl Difficulty 2
Personnel Difficulty . 3
Other Difficulty . , 4

ProbJem Category
Equipment Design Problem 5
Equipment Reliabllity Program Prohlem 6
Inslallatiorv'Fabrication . .. 7
Equipmenl Misuse 8
Company Employee 9
Contrae! Employee 10
Natural Phenomena 11
SabotageIHorseplay 12
External Events.. . 13
Olher 14

Major Root Cause Catl!'gory

Oesign InputlOutput 15
Equipment Records 19
Equipment ReJiability Program Design LTA ' 21
Equipment Reliability Program lmplementation LTA 28
Administrative/Management Systems 55
Procedures . . 111
Human Factors Engineering _ 138
Training 163
lmmediate Supervision 180
Communications 192
Personal Perlonnance .. 208

Deslgn InputlOutput 15
Design Input LTA 16
Design Output LTA 17

Equlpment Records 18
Equipment Design Records LTA . 19
Equipment OperatingIMaintenance History LTA . 20

Equlpment Rellabllity Progrom Deslgn LTA 21

No Program .. 22
Program LTA 23
AnalysislDesign Procedure LTA 24
~ RO()'1 CAUSE ANALYSIS HANOBOOIC

Index of Rool Cause Map Nodes by Area (conlinued)

[nappropriat Type of Mainlenance Assigned 25

Risk Acceplance Criteria LTA _ _ 26
A1location of Resources LTA 27

Equlpment Rellabllity Progrom Implementado" LTA 28

Correcllve Maintenance LTA 29
TroubleshootingCorrective Aetion LTA 30
Repair lmplementation LTA 31
Prevenlive Maintenance LTA 32
Frequency LTA 33
Scope LTA 34
Aetivuy ImpJementalion LTA.. . 3S
Prediclive Mainlenance LTA 36
Deteetion LTA _ ,.... 37
Monitoring LTA . , __ _ 38
Troubleshooting Corrective Action LTA 39
Aetivity Implemenl3110n LTA 40
Proactive Malnlenance LTA 41
Evenl Specification LTA 42
Monitoring LTA 43
Scope LTA _ 44
Activity Implementation LTA . 45
Failure Finding Mainlenance LTA , , 46
Frequency LTA................................................... . 47
Seo"" LTA ... .. . 48
Troubleshooting Corrective Action LTA._ _ ,_ _ 49
Repair Implementatlon LTA _ , , 50
Rouline Equipmenl Rounds LTA 51
Frequency LTA _....................................... . , 52
Scope LTA _................................. . 53
Aetivity Implementation LTA. . _ 54

AdmlnlsrrativelManagement Sysrems 55
Standards. Polides. or Administrnlive Controls (SPACs) LTA 57
No 5PACs 59
Nol5tricl Enough , , 60
Confusing. Contradldory, or lncomplete . 61
TechnicaJ Error 62
Responsibility lor Item/Acrivity No! Adequately Defined 63
Planning. Scheduling. or Tracking of Work Aetivities LTA 64
Rewardsrlncentives LTA................... . 65
Employee Screening/Hiring LTA 66
 ApPENDIX A- Roor CAUSE MAP NaoE DESCRIPnONS ED
Inde. 01 Root Cause Map Nodes by Area (continued)

Standards, Policies, or Administralive Controls (SPACsl Nol Used 67

Communication 01 SPACs LTA 69
Recently Changed 70
Enforcement LTA _ 71
SafetytJ-Iazard Review _ __ 72
Review LTA or Nol Performed 74
Recommendations Nol Ye! Implemented 75
Risk Acceptance Criteria LTA . 76
Review Procedure LTA . . 77
Problem Idenlificalion/C9ntro! 78
Problem Reponing LTA 80
Problem Analysis LTA .._ 81
Audits LTA 82
Corredive Aclion LTA 83
Corrective Actions No! Yet Implemented 84
ProductlMaterial Control... 85
Handling LTA 87
Storage LTA 88
PackagingiShipping LTA _. 89
Unauthori2ed M~terial Substitution 90
Product Acceptance eriteria LTA 91
Product [nspections LTA . . 92
Procurement Control.................. . 93
Purchasing Specifications LTA 95
Control of Changes to Procurement Specifications LTA 96
Material Acceptance Requirements LTA .. 97
Material Inspeclions LTA ,................. . 98
ContraClor Selection LTA 99
Document and Configuranon Control 100
Change NOlldenlified 102
Verificaton of Design/Field Changes LTA (No PSSRl 103
Documentation Content LTA or Not Kept Up-toDale 104
Control of Offlcial Documents LTA 105
Customer Interface Serv1ces 106
Customer Requirements Nolldentified 108
Customer Needs Not Addressed 109
Implementation LTA 110

Procedures . 111
Nol Used 112
Not Available or Inconvenient lo Oblain 113
Procedure Difficult to Use 114
EIII Rcxn Cws( A.~lYSIS HAND800K

Index 01 Root Cause Map Nodes by Area (continued)

Use Nol Required bUI Should Be 115

No Procedure for Task .. .... ,............................. 116
Misleading'COnfusing......................................................... ............ ............................................ 117
Formai Confusing or LTA . '............................... . 118
More Thao One Actien per Step ................................................................................................. 120
o Checkoff Space Provided but Should Be 121
lnadequale Check1Jst............... ,...................................... H 122
Graphics LTA _ _ _ 123
Ambiguous or Confusing InstructionsIRequirements _.. 124
Dllta/Compullltions Wrongl1ncomp1ele 125
Insuffidenl or Excessive Rererences 126
Idenlification or Revised Steps LTA... . . . .... .. 127
Le'Vel or Det!l~ LTA 128
Difficult lo Identify 129
Wtongllncomplele ....................... .. 130
Typographical Error .._._ 131
Sequence Wtong. . . 132
Faets Wrong ReQulremenls NOI Correet 133
Wrong Re'ViSion or Expired Procedure Re'Vlsion Used 134
lnconsisle:ncy Between Requiremenls .. 135
Incomplete SiNation Nol Covered . 136
Overlap or Gaps BelVJeen Procedures .. . . 137

Human Factors Englneer-ing ........................................................................................... 138

Workplace Layout.......... 140
Conrrols"Displays LTA , ,.................................................... 141
Control/Display Inlegrarion Arrangemenl LTA _............................ 143
Location or ConrrolslDisplays LTA J44
Conflicting Layout , 145
Equipment Localion LTA , , _ 146
Labeling of EqUlpment or Locatians LTA , 147
Work Environmenl 148
Housekeeping LTA 149
Tools LTA . 150
Prateetive Clolhing'Equipment LTA _ 151
Amblenl Condilions LTA 152
Other Environmenlal Stresses Excessive _ _ _ 154
Warkload .. . .... 155
Excesswe Control Action Requirements 156
Unrelllisllc Monitoring Requirements 157
Knowledge.ba~ Dec:ision Rl2'quirecl 158
Excessive Calculatian or Dala Manipulatioo Required .. 159
 ApPfNDIX A - Roer CAUSE MAl' NOOE DESCRIPTlONS llDI

Index 01 Root Cause Map Nodes by Area (continued)

Inloleranl Syslem 160

Errors Nol Drecrable 161
Errors Nol Correctable 162

Tralnlng 163
No Training .. _ _ 164
Decision Nol lo Train 165
Training Requirements Not ldenlified 166
Training Records System LTA _ 167
Training Records lncorreet _.... .._......... 168
Training Records Not Up-ro-Date _ 169
Training LTA " 170
Jobrrask Analysis LTA 171
Program DesignlObjectives LTA . 172
Lesson Content LTA 174
On-the-job Trainiog LTA 175
Qualificalion Testing LTA .. _........... 176
Continuing Training LTA _ 177
Training Resources LTA 178
Abnormal EventsIEmergency Training LTA 179

Immedlate SuperlJlslon ISO

Preparation . 181
No Prepararon 182
Job Plan LTA _........................................................................................................ 183
Instruetions ro Workers LTA 184
Walkthrough LTA lBS
Scheduling LTA 186
Worker Selection/Assignment LTA .. _... . 187
Supervision Duriog Work 188
Supervision LTA 189
Improper Performance Nol Comcled 190
Teamwork LTA 191

Communlcatlons _ 192
No Communication or Nol Timely 194
Melhod Unavailable or LTA 195
Communieation Between Work Groups LTA 196
Communication Between Shifts and Management LTA 197
Communication with Contradors LTA 198
Communicalion wilh Customers LTA 199
E'I!D!II Rom USE ANAlYStS HANDBOOK

Misunderstood Communicalion 200

Standard Terminology Not Uscd 201
VerifcationIRepeai-back Not Used 202
Long Message , 203
Wrong lnstructions . 204
Job Turnover LTA 205
Communlcalion Wilhin Shlfts LTA 206
Communication Betv.'een Shifts LTA 207

Personal Perfonnance 208

Problem Detectlon LTA 209
Sensory!Perceprual Capabililies LTA 210
Reasoning Capabilities LTA 211
MOlor/Physical Capabilities LTA . 212
AtlirudelAtlenlion LTA 213
ResVSleep LTA (Fatigue) 214
PersonalfMedication Problems 215
 AppeNOIX A - Roor CAUSE MAl' Neoe DESCRIPnONS ~

Alphabetized Index 01 Root Cause Map Nodes

Abnormal EventslEmergency Training LTA 179 Customer Needs Not Addressed 109
Aetivity lmplemenlation LTA Customer Requirements No! ldentified lOS
(Predictive Mainlenance LTA) 40
Aetjvity Implementation LTA DatalComputations Wrongllncomplele 125
(Preventive Maintenance LTA) 35 Decision Nollo Trajn 165
AClivity Implementalion LTA Design Inpul LTA 16
(Proactive Maintenance LTA) 45 Design InputlOutput 15
Activity Implementanon LTA Oesign Outpul LTA 17
(Routine Equipmenl Rounds LTA) 54 Deleetion LTA 37
AdministrativeIManagemenl Systems 55 Difficult lo ldentify 129
Allocation or Resources LTA 27 Document and Configuration Control 100
Ambient Conditions LTA 152 Documentation Content LTA or
Ambiguous or Confusing Nol Kepl Up-to-Date 104
InstruetionsIRequirements 124
AnalysisIDesign Procedure LTA 24 Employee Screening1J-liring LTA 66
Attirude/Attention LTA 213 Enforcement LTA 71
Audits LTA 82 Equipmenl Design Problem 5
Equipmenl Design Records LTA 19
Change Nol ldentified ~ 102 Equipmenl Difficulty 2
Communication Between Shifts and Equipment Location LTA 146
Management LTA 197 Equipmenl OperatingtMaintenance
Communication Between Shifts LTA 207 Hislory LTA 20
Communication BetVJeen Work Groups LTA 1% Equipment Records 18
Communicatjon of SPACs LTA 69 Equipmenl Reliability Program Design LTA 21
. Communicalion with Contractors LTA 198 Equipment Reliability Program
Communicalion wilh CUslomers LTA 199 lmplementation LTA 28
Communicalion Within Shifts LTA 206 Equipmem ReJiability Program Problem LTA 6
Communicalions 192 Errors Not Correclable 162
Connicting Layout 145 Errors Not Detectable 161
Confusing. Contradictory. or Incomplete 61 Event Specification LTA 42
Conlinuing Training LTA 177 Excessive Cakulations or Dala Manipulation
Contractor Selection LTA 99 Requred 159
ControVDisplay Integration/Arrangement LTA 143 Excessive Control Aclion Requirements 156
Control of Changes to Procuremenl
Speci(calions LTA 96 Faets WrongIRequirements Not Correct 133
Control of Official Documents LTA 105 Failure Rnding Maintenance LTA 46
ControlslOisplays LTA 141 Format Confusing or LTA 118
Corrective Action LTA 83 Frequency LTA (Failure Rnding
Corredive Aclions Nol Yel Implemenled 84 Maintenance LTA) 47
Company Employee 9 Frequency LTA (Preventive Maintenance LTA) 33
Contraclor Employee la Frequency LTA (Routine Equipmenl
Customer Intenace SelVices 106 Rounds LTA) . 52
~ Roor uSt ANAtVSIS H.o.NOllOOk

Alphabetized Inde. 01 Root Cause Map Nodes (continued)

Graphics LTA 123 No Checkoff Space Provided bul Should Be 121

No Communication or Nol Timely 194
Handling LTA o 87 No Preparation 182
Housekeeplng LTA........... 149 No Procedure for Task .. _ __ 116
Human Faetors Engineering " 138 No Program 22
No 5?ACS 59
Identificaran al Revised Sleps LTA 127 No Training 164
lmmediate Supervision 180 Not Available or Inconvenient to Oblain 113
lmplementalion LTA 110 Nol Strid Enough 60
lmproper Performance Not Correded 190 Not Used 112
lnadequllie Checklist 122
lnappropriate Type of Maintenance Assigned 25 Onthejob Training LTA 175
lncamplelelSiluation Nol Covered 136 Other 14
lnconsislency Between Requirements ._. . 135 Other Difficulty . 4
InstallalionIFabrication 7 Other Environmental Stresses Excessive 154
Instruetions lo Workers LTA 184 Overlap or Gaps Between Procedures 137
Insufficient or Excessive References 126
Intolerant SYSlem 160 Packaging/Shipping LTA 89
PersonalfMedication Problems 215
Job Plan LTA 183 Personal Performance 208
Jobrr<'Jsk Analysis LTA 171 Personnel Difficulty 3
Job Turnover LTA 205 Planning. Scheduling. or Tracking of
Work Adivilies LTA 64
Knowledge-based Dedsion Required 158 Predietive Maintenance LTA 36
Preparation 181
Labeling of Equipment or Locations LTA ] 47 Preventive Mainlenance LTA 32
Lesson ConTenl LTA 174 ?reactive Maintenance LTA 41
Level of Detail LTA 128 Problem Analysis LTA 8)
Location o( ConrrolslDisplays LTA ]44 ?roblem Deleetion LTA 209
Long Message 203 Problem IdentificalionlControl 78
Problem Reporling LTA _ 80
Material Acceplance Requirements LTA 97 Procedure Difficult to Use 114
Material Inspections LTA 98 Procedures 111
Melhod UnavailabJe or LTA 195 Procurement Control 93
Misleading or Confusing _ ] 17 ProdUCI Acceptance Crileria LTA 91
Misunderstood Communicalion 200 Product lnspections LTA 92
Monitoring LTA (Predidive Mainlenance LTAl 38 Program DesignJObjedives LTA 172
Moniloring LTA (Proactive Mainlenance LTA) 43 Program LTA 23
More Than One Action per Step 120 Protective ClothingfEquipment LTA 151
MotorlPhysical Capabilities LTA 212 Purchasing Specificalions LTA 95

Natural Phenomena 11
 ApPENDIX A - ROOT CAUSE MAl' NaDE DESCR1/1r10NS .-JE!II

Alphabetized Inde. 01 Root Cause Map Nodes (continued)

Qualificalion Tesring LTA 176 Training Records [ncorreel _._.._ 168

Reasoning Capabilities LTA 211 Training Records Nol UploDate 169
RecenlJy Changed . 70 Training Records Syslem LTA 167
Recommendations Nol Yet Implemented 75 Training Requirements Not [denlified 166
Repair Implemenlation LTA (Correclive Training Resources LTA 178
Mainlenance LTAl 31 TroubleshoolinglCor~ctiveAction LTA
Repair Implementation LTA (Failure Finding (Corrective Maintenance LTA) 30
MainlenMce LTA) ._ __ _ , 50 TroubleshootinglCorrective Action LTA
Responsibility for ItemlAetivity Not Adequately (Failure Finding Mainlenanee LTA) 49
Defined 63 TroubleshoolingfCorrective AClion LTA
Rest/Sleep LTA (Faligue) 214 (Predictive Mainlenance LTA) 39
Review LTA or Not Perforrned . 74 Typographical Error 131
Review Procedure LTA ' 77
Rewardsllncentives LTA 65 Unaulhorized Material SubstiNlion 90
Risk Acceplance Criteria LTA (Program LTA) 26 Unrealistic Monitoring Requirements 157
Risk Acceplance Crileria LTA Use Not Required bul Should Be 115
(Safety/HazardIRisk Review) 76
Rouline Equipmenl Rounds LTA 51 Verification of Design/Field Changes LTA
INo P55RJ .. .. ...... 103
Sabotage/Horseplay 12 VerificatiorvRepeatback Nol Used . " 202
Safety/Hazard Review _ 72
Scheduling LTA 186 Walklhrough LTA . 185
Scope LTA (Failu~ Finding Maintenance LTAl 48 Work Environment . .. . . 148
Scope LTA (Preventive Maintenance LTAl 34 Worker SelectionlAssignmem LTA ]87
Scope LTA (Proactive Maintenance LTAl 44 Workload _ 155
'Scope LTA (Rouline Equipmenl Rounds LTA) 53 Workplace Layout.... . ... 140
Sensory/Perceptual Capabililies LTA 210 Wrongilncomplete 130
Sequenee Wrong 132 Wrong Instructions ... " .. .. 204
Standard Terminology Not Used 201 Wrong Revision or E"plred Procedure
Standards, Policies. or Administrative Controls Revision Used . . ... 134
15PACsI Not Used 67
Standards. Fblicies. or Adminisb"alive Controls
15PACsI LTA 57
Storage LTA.. . .. 88
'Supervision During Work.. . 188
Supervision LTA . . 189

Teamwork LTA 191

Teehnical Error 62
Tools LTA 150
Trainin9........ . 163
Training LTA 170
 ApPlNOIX A Roo, CAUSl MAP NoOf. DfSCRlfflONS . .

Typical Issues
Stan here wjth each causal factor. See the following pages for attribules of each of lhe next three nodes,
which wiU help you choose me correet one.

Sta" here wllh ea eh

eausallaetor

~ ~
EQII'Olmlnl P'lsc"~.1 Ott-II
OIffil:",1ly Olf1ltlllly Olllic""y

PItJ.\Wt\' DIFftaJtTY SouIlCI

_ _ RoO! CAUSE ANAlYStS HAND80QK

Eq.II;... "1
P,.~ ..",
e..... re""'....' P,.u.'r
P~;,"" PreDIO.,
. ...
, , ,,,.
fID''''!''"

Typical Issues
These inelude problems with quipment design, fabricalion. installafion. maintenance. and misuse. Prob
lems with Ihe equipmenl reliabiJiry program aTe also identlfied/categorized under this node.

Typical Recommendation
See lower level nocles.

Example
A spill lo lhe environmenl occurred because a valve failed. The valve failed because il was nol designed f~r
the environment in which i' operated.

PRlfMRY DlfflCUlTY SoURCE

 AppeNOIX A- Roo1 CAuse MAP NOOE DfSCR1PTIO/'lIS ~

(;0'''":1
E.. pIoJII

B
Typical Issues
Problems relaled lO the "runmng~ of (he plantfprocess are identified/calegorized under Ihis nade. This
neludes Ihe administralivelmanagemenl systems to control (he process (e.g.. standards. pelicies. proce
dures), training of personnel. communications. and communicalions among individuals and groups.

Typical Recornmendation
See lower level nocles.

Examples
A tank overflowed. resulting in a spilllo the environment. The operator filling Ihe tank was using Ihe wrong
revision of Ihe procedure. which had an ineorreel ealibration chart ror the lank.
A mechani, doing maintenance in a confined space was nol allowed to take a wri!ten procedure wilh him.
As a result. he had to review the procedure and commit it lO memory. During performance of the lask. he
omined an importanl slep. This resuhed in lhe failure al a key piece of equipment.
An operalor made a mistake performing a calculation. The dala used in the calculation carne from mulliple
steps in the procedure. He made a mistake in transferring one of the data poinls fram an earlier step in Ihe
procedure to he slep al which Ihe calculation was performed.

PRlMARY DIFflCU1TY SOURCE

_ _ Rom USE ANAt.VSIS HANDBOOk

~.I",
P~.".""c,
SOO"'.'
h'''fr:t,
o....,

Typical Issues
These nelude problems relaled lO natural phenomena. sabotage. externa! events, and evenls Ihal canna! be
categorized elsewhere.

Typical Recommendalion
See lower leve! nodes.

Examples
lnventory in the warehouse was damaged when the warehouse was flooded following a heavy rain.
A mechanic intentionally damaged a Jalhe. He was disgruntled abaul being placed into a new assignment.
A release 01 chlorine from an adjacent lacility affected the operalors in your facility.

PRlMARY OlfFICUITY SouRa

 ApPENDIX A - Roor CAUSE MAP Noor DESCIlIPTlONS . .

Slall hele wilh each

causallaclot

<~,"'.""IR"'~iI<lV 1n,"IIaIlOM
P,..,,,, P'.~I.'" Foc'''''l,".

Typical Issues
These ndude problems related lo Ine design process, problems related to Ine design and capabilities of Ine
equipmenl, and problems re1aled to Ine spedfication of parts and materials.

Typical Recommendalion
$ee lower leve! nocles.

Examples
A va!ve failed because tne designer used obsolete materials requirements.
A process upset occurred because one 01 me f10w streams was out of spedfication. The design inpuI did nol
indicale aH tne possible flow rales for me process. The pump was incorrectJy sized for Ine necessary f10w
requirements.
A line ruptured because a gaskel failed. The gasket was construcled ef tne wrong material because Ine
design did net censider aJltne possible cnemicals !hat would be in Ine line during dlfferent operating condi-
lions. A chemical Inat was nol considered caused the gasket lO lail.

PRIM.4JlY OlfflCUlTY SOUJtCE

aiII ROOT USE AAAlY5IS HAND800K

Slarl here WltI\ each

causallaClor

E~,;:~ ."'
~ 'r~_,

Equ,pme"l
E~.""T~"'" Il.,,,n'''l\ 1'109"'''' 1"'1110"'"
~'o~.. ~
P'~n"'" "~''''''''

Typical Issu.s
These nelude problems relaled lo lhe design and implementalion af Ihe mainlenance programo Was Ihe
Wfong type af mainlenance specified for the equipmem' Are there problems wilh the analysis process used
lO determine Ihe apprapriate mainlenance requiremenls? Are Ihere problems retaled to perlorming lhe
mainrenance aetivilies? Are monitoring acllvities implemented lO delecl deteriorating equlpmenl? Does Ihe
repair activity cover Ihe required scope?

Typical Recornmendations
lmprove equiprnent oper<'ltional and mainlenance reeords lo enable seleclion af Ihe proper rype af
maintenance
Assign addltional resources lO equipment with a demonslrated history of problems
Reduce mainlenance on equipment Ihal has no significant impacl on praduction or safety and that
can be easily repaired or replaced
Provide mainlenance procedures and training appropriate lO Ihe experience level of personnel

Examples
During Ihe paSI year. the failure rale for the feed pumps has doubled. Maintenance re:cords are: inadequale
lO delermine why any of Ihe fHlures occurred. Work records jusI say "pump re:paired:'
A number of pump bearings have failed recently. Predictive maintenance was seleeted as the appropriate
type of mainlenance for the pump bearings. However, there is no requirement for monitoring of the pump
bearings. As a resull. the predictive mainlenance activity was never implemenled.
Prevenlive main/enance (a calibrafion) was being performed on a praduc! scale every 3 months. However.
operators requested additional calibrations aboul once per monlh as Ihey noticed the sc.ale drifting. The
frequency of Ihe calibralion was changed lo once per month.

PRIMARY D1Ff1CUlTY SOURC(

 ApPENOIX A - Roer C~usc MAP NODE DCSCRJPTlONS . .

Statl here wllh each

causallactor

h'';l~''IO.. ~" E~,IOIII..1R ~1lIy E~.1~-,"1

a,...... 'ro;".. 'ro~" 11 .1"

Typical Issues
These inelude problems with the fabrication and insla!Jation of equipment. Was the equipment fabricated to
the design specifications? Was there a problem with the installation? Was a fletd modification performed
that altere<! the performance of Ihe equipment?

Typical Recommendalions
Develop fabrication procedures tO help ensure that the fabricated equipment meets design specifica.
tions
nvolve design personnel in field reviews of me fabrication and installation of eQuipment
A1low field fabrication and inslallation personnel lo have access lo design personnel lo resolve probo
tems encountered in the fabrication and installation process

Examples
A pipe needed to be rerouted during inslallafion lo go around existing equipment, but this was not on Ihe
layout drawing. The reroute created a low point in the lme mal al10wed contaminants to accumulate. Later.
me pipe failed in this low sedion.
Field personne! could not determine from the installation package how to conneel the power lo a new dril1
press. They decided to conneel l' me same way the others in the facility were connected even lhough this
dril! press had a differenl manufacturer than the rest. As a result of the incorrecl connection, the drill press
control system was damaged.
A walkway col1apsed because a field moclficalion af Ihe suspension system resulled in a weakened support
system. The walkway collapsed when il was fu[) of people.

PRlMAll:Y DIFFICUlTY SOURCE

~ Rom o.USf ANAlYSIS HAND800K

Slarl here wllh each

causal faclor

h.;......'
O''''''O"f

EOo'O"'.lO ..O" E~u,o"'"' R.h......,

P'otl'," p,~Q't .. P'oo t'"

Typical Issues
Was equipment used tor an aClivity other han il was intended? Was he equipment used beyond its capac-
ity?

Typical Recommendations
EnsuTe tha! proper equipment is available for personnel to use
EnsuTe that personnel are aware o he proper use of equipment

Examples
To save money, a drill press was purchased lO mix chemicals in a lab. The slowest speed on the drill press
was still too fasl for proper mixing of materials. As a resull, technicians WE'r routinely splattered with
chemicals while using he drill press,
A technician in the field Tan oul of a waler-based deaner. Someone nearby was using gas to Nn a lawn
mower. lnstead o gaiog back to he truck lo gel he walerbased c1eaner, the technician pul sorne gas on a
rag and used it. The operator's hair was burned when the rag canladed l hal bearing, slarting a fire,

PRlMARY DIFflCULTV SoURCf

 AnENDX A - Roen CAUSE MAP NODE DcscRrPTlONs lIiII
$tarl here wllh each
causal factor

Flt10n"tI
D.I!O:~lly

"""'.'
f1<1...
.....U'.I.
f"Q"""'"Q SulO""""

Typical Issues
Was a eompany employee involved? Are me employees involved covered by the normal eompany rraining
programs? Are they supervised directly by eompany employees?
Note: Distingujshjng between company ond contrad employees can be important because o/ the difierenl
management sysrems that control he work performed by these fWO groups.

Typical Recornrnendation
See lower level nocies.

Examples
A company employee took a sample from pr~ucl lank e instead o producl tank B. The tanks are arranged
e
Tom left to righl: A B.
A company employee mllde a mislake using a sca!e lo weigh a pallel o material. lt was the firsl time the
operator had used the seale. He was told how lO use lhe seale as pan o training, bul had never actual1y
used il himself.

PRIMARY OIFFICUlTY SOURO

liIIiI Roor .uSf ANAt.VSIS HAND800k

Slaft he!!! wlll'l ea eh

causal taclor

p".onntl
DI"OC:~"'

Typical Issues
Was a contrad employee involved? Was the persan nvolved a transienl worker in your faciJity? Was toe
persan nvolved covered by the contrael employee lTaining program? 15 the persan nvolved direetly super-
vised by someone who does nol work for your company? Does Ihi5 persan have to meel different require.
ments than a Mregular~ employee?

Note: Dist:inguishing between eompany ond conlroet employees can be imporlant because o/ !he differen!
management systems chal COnlrol rhe work performed by these IwO groups.

Typical Recornmendations
Ensure !ha! contrae! employees nave sufficienl guidance lo perform their aclivities
Ensure thal work documents used by contrael employees hav suffienl detailto allow individuals
inexperienced with your operations and work methods lo adequalely perlorm the job

Examples
A worker for Ihe local vending company enlered Ihe facilily to refill !he vending machines. The individual
was nol aware of Ihe requirement lO wear a hard hat and safely goggles in Ihe aisle way that led lo the
lunchroom.

A contrao mechaoic inslalled the wrong type of gasket io a lioe duriog a scheduled maintenanc:e aoivily.
As a resul!, !he line failed when lhe process was restarted. The procedure did nol specify Ihe proper material
to be used. The in-house mechanic:s a1l knew the proper material. and, lherefore. il had never been a
problem even Ihough iI was not specifically covered in the procedure.

PRlMARY OlfflCUlTY SoURCE

 ApPENDIX A - ROOT CA.USE MA.p NaDE DESCRIPT'ONS DII
Slart lIefe wlln each
c~sal 'actor

s.e'lIgo
~"::'I

Typical Issues
Problems that result rrom tornadoes, hurricanes, earthquakes. lightning. f100ds. or other natural phenomena
are identified under this node.

Typical Recommendations
Ensure Ihat nahJral phenomena are cansidered in he design process
Ensure that natural phenomena are considered in the development of procedures and training
Ensure that risk acceptance criteria are properly set for natural phenomena events

Examples
A process upset OCCUfTed in (he facility because power was 1051 as a result of lighlning striking a trans-
former.
The plant site was f100ded when (he river overtopped the levee designed far a lOO-year flood.

PRlMARY DlfflCULTY SOUIlCE

liIIIiI 1\00' UUS( ANALYSIS MA."i0600K

Slaft IItlll .tlll UCtl

Cal,tSlllaClor

o~.,
o~..,

.....-...
~."'".
~ .. .
h .. -,
~
o

Typical Issues
MalK:ious aets thal cause Ol rontribute lO an incident are iclentified under mis nOOe. Malicious lack of
aetion thal contributed lO a problem is a!so Idenbfied under Sabotllge. Was the evenllhe result of horseplay
Ol ather. nonUJOrk-related activJties?

Note: Dual coding uoder Personal Performance Ol Administrative!Management Systems may be oppropri.
ate. The problem Ihat /ed he employee te commit sabologe/horsep/ay should be oddressed.

Typical Recommendations
Ensure thal seeurity plans aOO equipment are adequlIfe
Ensure hal inappropnate behavior. such as horseplay. is adclressed and correded by managemenl
and supervision

Examples
A mechanic intentionalJy damaged a piec!? of equipmem. He was disgruntlecl about being placed In a new
lIssignmenl.
As a practical joke. operators sen! a junior operator lo check out the e/ectricolzerts (there are no such
fhings) on the generalor. As a result of trying to find the electrlcol zerts, the junior opera!or accidentally shut
down me generalor.

PAlMUY OlfflCUlTY Soum

 A,.,.ENDIX A - Roor C."USE M.v NODE DESCR,,.nONS ID
SIal! t\trl Wllh nch
causal faclor

""'"'.1
O~OU,"O~I
SI'.'IOI
M.".~Ia~

Typical Issues
Was the event a result o problems at adjacent facilities? Was il the result of aclivities outside the facili!y thal
are nol under your control?
Note: Coding under AdminisO'ativeIManagement Systems: SafetyIHazardIRisk Review moy olso be appro
priale.

Typical Recommendations
Coordinate emergency response and planning wilh nearby facilities
Develop contingenq, actions for external events

E.amples
A chlorine tanker accident on a nearby railroad spur requires the evacuation of a portian of your facility.
A nearby accident on the expressway prevents shipments from leaving your faciliry for an S-hour periad. As
a result, sorne deliveries are nol rnade on time.
A key supplier's warehouse was struck by a tomado. As a resull, the warehouse was unable to supply your
facility with raw materials for a periad of 2 weeks.
The local ulility's power planl shul down, resulting in a S-minule power outage lo your facilily. It look 2
hours to restan the plant and stabilize lhe process.

PRlMARY DlfflculTY SOURCE

11II ROOT USE ANALYSIS HANDBOOK

Slan here Wilh each

causal faclor

Nllo'.1 SI~.tlIi.1
P"t"o",.". ,oplo,

Typical Issues
These ndude issues that canoat be coded elsewhere on he map (e.g.. problems tha! canoal be coded
because of insufficient informalion),

Typical Recommendations
Analyze the causal factors ha! aTe coded under this node. Determine if addilional nocles should be
added lo the map lo calegonze these issues
Determine melhods for gathering additional information for this rype of evenl when il rcuTS

Examples
A customer complained that the malerials sen! lo him were oul of specification. However, when Ihe lab
sample was tesled. il was acceptable. When the cuslomer retesled the material. his test also indicatecl he
material was acceptable. ProdUC1 manufactured from this batch was also acceptable.
A spurious shutdown of a computer in the order receiving department caused a delay in handling a
customer's request. The problm could nol b rCTated. lt could nol b dtennined whether it was equip-
men! failure or human error that Jed lO Ihe shuldown.

A rabid fax bit a worker who was checking sorne equipmenl in a remate locatian.

PRlMARY DlFF1CUlTY SouRCE

 ApPCNDIX A - Roor Cwsc MAP NODE DfSCRIPlIONS ID

D~"Qn
"'~U! O''' ..' o!

Typical Issues
Were alllhe appropriate design inputs eonsidered during the design phase? Was the design output. sueh as
drawings and specifications. complete? Was the design input and output eonsistenl and complete? Did the
design review process fail to delec! errors? Was the design review independent?

Typical Recommendalions
Conduct a feasibllity review prior to begmning design to ensure that the eriteria can be met and that
no conmding criteria exist
Develop a pre-construction planning and Teview process to help enSUTe thal allthe specifications are
in agreement

Examples
A valve failed because equipment condilions during operalion. such as corrosivity, were nol considered
during designo
A pump failed lo deliver enough cocling water in an emergency because emergency requirements were not
consiclered In Ihe deslgn.

OESIGN INPUT/OUTPUl
arI Rom USE ANAlYSIS HAND800ll:

Des!;n
InpuuOulpul

Dls-;n Outpul
la

Typical Issues
Were aH the appropriate design inputs considered duriog the design phase? Were the design crileria so
stringent !hal they eauld nol be me!? Were sorne crileria conflieting? Were requirements out-of-dale? Were
Ihe wrong standards o, bases used? Were Ine necessary codes aod standards available lo he designer?

Typical Recommendations
Conduct a feasibility srudy prior lo beginning design to enSUTe tha! he crilera can be mel and that no
conflictiog tritera exisl
Develop an ndependen! Teview process lO help enSUTe tha! appropriate standards are used in he
design
Develop a cracking system lo help enSUTe thal design problems and conflic1S are resolved prior lo
startup
Develop a tracking system lo help enSUTe ha! currenl design criteria are used
Develop comprehensive system design requirements

Examples
A valve failed because the designer used obsolete m;,terials requirements.
A process upSet occurred because ene of the Oew streams was out of specification. The design input did not
inclicate aH the possible Oow rales for lhe process. The pump was incorrect1y sized ror the necessary Oow
requirements.

An engineer did not account ror 2111 types of vehicles that would be required io enter the plant in the design
of the new guard house and gateo As a re5ult, some of the oulside responder's fire tnlcks can no Icnger enler
Ihe plant because they are wider Ihan the new entrance.

A Oow controller could nol adequalely control Oow during an infrequenl operaticn. The Oow requirements
for normal, emergency, and infrequent operation covered loo wide a range for a controller to operale
properly under all of the conditions.

OESIGN INPl1J/Ovnvr
 ApPENOIX A - Roor CAUSE M"p NODE DlSCR1PTlONS DII

D.,'gll
l"puIlOulpu!

OUlg" I"pul

'"

Typical Issues
Was Ihe design output. such as drawiogs aod specifications. complele? Were aH operating conditions
(normal. sfarlup. shuldowo. emergency) consdered in !he design? Were he design documents difficult lO
read or inlerpret? Did !he final design outpul include alJ changes? Were Ihere differences between different
oUlpul documents? Did the desigo OUtpUI address aJl requiremems specified jo Ihe desgo ioput?

Typical Recommendations
lndude salisfaction of design input critena as a specific review team item duriog desigo reviev.'S
lnclude experienced operalions and maintenance personnel m design reviews lO help ensure fhal aH
possible operaling condtioos are considered io lhe design
Include designers in coostrlictioo and pre-slatlUp reviews lO help ensure fhal design informalion is
properly inlerpreled
Conducr ao independent lechoical review of Ihe fioal desigo lO help eosure coosislency among vari-
ous design documents

Examples
A valve failed because the material specificalioos were iocorrecl. The specifications did 001 agree wilh he
design crileria. The crilena slated Ihat the valve must operate io a corrosive environment. bur Ihe specifica-
Iions did nol indicare mis conditioo. Therefore. Ihe valve was construcled of improper malerials.
A Une ruptured because a gasket failed. The gasker was constructed of Ihe wroog malerial hecause the
design did nol consider al1 the possible chemicals (hat would be In the lme duriog differenl operatng condi-
lions. Gne Ihal was 001 coosidered caused lhe gaskel lO fal
A pump did nol provide lhe oecessary ceoliog waler duriog ao emergeocy. The pump was siled incorreclly
because the final design specificatioos did not ioclude changes identified in Ihe safety analysis.

OEStGN INPUl/OVTPUT
aIiI ROOT USE A.'l/AtfSIS HAN0800K

Typical Issues
Does ao equipment records program exist? 15 il adequale and Up to dale? Doe.s il conialo the correet
information? Does il contajo aH the information necessary lO enSUTe equipment reliability?

Typical Recommendations
Develop a syslem ror tracking equipment histories
Calleel nfarmarion ftom other sources (e.g.. vendors) lO help complete exisling equipment histories

Examples
A lank overflowed because of faulty liquid leve! instnlmentation. The records indicated that a calibralion f
was called for and performed 3 months prior. bul did nol indicate how much adjustment was made duriog
calibration. A large adjustment might have indicated pending {ailure.

A pressure vessel was nol properly lesled after a modificalion. The design informarion for Ihe salvaged
vessel had been lasto

EQtlIPMENT RECOROS
 ApPENDIJe A - Roer CAUSE MAl' NODl DlScRIPnoNS Da

Typical Issue
Have problems with design records caused problems with lhe operation. maintenance, or modification of
equipment?

Typical Recommendation
Ensure that design information is relained on equipmenl and accessible lo personnel responsible for
operation. maintenance, and modificalion of the equipment

Examples
As part of a capacity upgrade, engineers artempled to determine Ihe design Ihroughpul of a blender. No
.equipment records could be localed to determine the design capacity of he equipment.
Mainlenance procedures were being developed for a new freezer. Lack of design information reQuired
extensive field verificalion of equipmenl configuralion lo develop Ihe procedure.

EQUIPMfI,,l RKORDS
1m Roor USE NAlYSlS H....NDeoolr:

Typical Issues
w",s the history far he equipment that malfunetioned complete? Oid the history conlain information aboul
similar equipment? Would knowledge af Ihe history o me equipment nvolved in he event and similar
equipment have prevented lhe inciden! or lessened ils severity?

Typical Recommendations
Collect a.vailable information from olher sources (12.9.. vendors) lo help complete existing equipmenl
histories
lmprove he syslem (ar tracking equipment histories lo hclp enSUTe lhal al! pertinem informalion is
relamed
Assign responsibiliry far mainlaining and analyzing equipment repair and maintenance records
Periodical1y aud! lhe equipment history files lo help ensure ha! lhe records system is being followed
Assess adequacy of operator rounds and lhe information collected on rounds
Assess adequacy of mamtenance tasks that collect information on the status of equipment ,
Ensure that informal1on collected on rounds is analyzed lO determine if problems exist with equipment

Examples
A tank overf1owed because of faulty liquid level mstrumentalion during a nonroufine mocle of operation that
failed lhe level device. Previous problems had occurred wilh the instrumentation under lhese conditians.
Thls was not known by current personnel because no equipment history was avaitable.
A flow meter in a product Jine failed. resulting in the wrong amount of material being sent to a customer.
Records indicated thal calibralion of the flow sensor had been performed three times in Ihe last monlh, but
did not indicate how much adjustment was made during calibration. A large adjustment, or larger adJuSl-
ments each time. might have indicated a pending failure.
Operators routinely performed rounds twice each shift. However, lhere were no guidelines provided on
what to lcok far or what data to dacumen!. Following a number of pump faHures. the equipment logs were
reviewed lO determine wha! was causing the failures. A1though the operalors had looked al Ihe pumps each
shift, they had nol collected any operating history on them.

EQUIPMENT RECOROS
 ApPCNOIX A - Roo, CAUSE MAP NaDE DESCRIPnaNS .El
[q".~",.",
q.1 ,t .1. Typical Issues
P",~ ..",
e 'q la These inelude problerns relaled lO (he design and irnplemenlation
of the maintenance program. Was Ihe wrong type of maintenance
specified for the equiprnent? Are there problems wilh the analysis
process used lO determine Ihe appropriale maintenance require
ments?

Typical Recommendalions
Improve eQuipment operaiional and mainlenance records to
enable selection of he proper cype of mamtenance
Assign additionaJ resources lo equipment with a dernon-
strated hislory of problems
Reduce maintenance on equipment that has no significan!
impact on praduction and that can be easily repalred or
replaced

Examples
Maintenance activities had been specified for the running compo
nents of a wood chipping machine (i.e.. bearings. bladesl but no
maintenance activilies had been specified for the safery interlocks
associated with the machine. The analysis procedure did nol
require safery interlocks to be addressed. As a resulto an operator's
arm was amputated when it was caught in the chipper and the
auto stop feature failed.
A number of pump bearings have failed recently. Predictive
maintenance was seJected as the appropriate type of mainrenance
for Ihe pump bearings. However. Ihere is no requiremenl for
monitoring of the pump bearings.
Correclive mainlenance was assigned lo an auger Ihat provided
raw malerials lo a foad process. This selection was based on a
very low expected failure rate and a Quick repair time. Actual
experience indicales the failures took much tonger to repair han
Ihe analysis leam estimaied. As a result. Ihe risk associaled wilh
Ihe failures was much higher lhan lhe leam Ihought.

EQUIPMENT RWA8IU1'Y PROCRAM DrSIGN LTA

aiI Rom Cwsf: A.N.uVSIS HAN08QOK

Typical Issues
Does an equipment reliability program exist for this piece of
equipment? Have the maintenance needs for this piece of equip.
men! been analyzed?
Note: 1/ !he maintenance needs were anolyzed and il was deter
mined rhat no mointenonce was appropriate, cade this under
Program LTA (Equipment Reliability Program Design LTA).

Typical Recommendation
Determine the appropriate level af rnllinlenance for al!
equipment in the racility that is important to safety ar reli-
ability

Example
Hydraulic hoses on he forklifts in the facility were failing once
every 2 months. A review of the maintenance program records
indicated that proper maintenance for these hoses had never been
determined.

EQUIPMEHT RfUA8IUTY Pa.OGRAM OEStGN LTA

 ApPENDIX A- Roor CAUSE MAl' NODE DESCRIPT/ONS El
Typical Issues
These inelude problems relaled to Ihe design and implementation
of the maintenance programo Was the 'WTong type of mainlenance
specified for !he equipment? Are there problems wilh the ana1ysis
process that is used lo determine he appropriale mainlenance
requiremenls?

Typical Recommendations
Ensure lhal lhe proper level of risk acceptance is used in
determining Ihe level and type of mainlenance lo perform on
equipment
Ensure that the analysis process addresses aU aspects of
equipment operation importanl (o safety and reliability
'" Improve equipment operational and maintenance records io
enable Ihe seleetion of the proper rype of mainlenance
Assign additional resources lo equipmenl wilh a demon-
strated history of problems
AIIc<ll<O" 01
Reduce mainlenance on equipmenl that has no significanl
~U r""tTA
impad on produdion or safety and Ihat can be easily
repaired or replaced

Examples
Maintenanee aetivities had been speeified for the running compo
nents of a wood chipping maehine (Le.. bearings, blades) bu! no
maintenance activities had been specified for Ihe saJety interlocks
associated with the maehine. The analysis procedure did nol
require safety inlerlocks lo be addressed. As a result, an operator's
arm was amputated when il was caught in Ihe chipper and Ihe
aulo stop feature failed.
A number of pump bearings have failed recently. Predidive
main!enance was selected as Ihe appropriate type of mainlenanee
far the pump bearings. However, there is no requirement for
monitoring of Ihe pump bearings.
Corrective maintenance was assigned lo an auger that provided
raw materials to a food process. This selection was based on a
very low expected failure rate and a quick repair time. Actual
experience indicates he failures lcok mueh longer to repair ihan
Ihe analysis leam eslimaled. As a result. the risk associaled with
the failures was mueh higher than he team Ihoughl.

EQUIPMENT REllABlllTY PROGRAM OESICN nA

mi RooT USE ANAlYSIS HANDBOOK

Typical Issues
These nelude problems related lO the design o he mainlenance programo
Was the process used to determine mainlenance tasks completed? Did the
process address al! equipmenl importan! lO safety, reliability, and quality?
Was he process consistently applied?
''''~'.",Ll~

Typical Recommendations
Ensure thal the analysis process addresses all aspects o equipment
operation important to safety, reliability, and quality
Ensure ha! personoel are provided with sufficient guidance lO select
appropriale maiotenance tasks for different types o equipment
Ensure that personnel who are responsibte for developing the equip-
men! reliability program have the proper training

Examples
Maiotenance activities had been specified fOT the running components of a
wood chipping machine (Le., bearings, blades) bul no mantenance activities
had been specified for Ihe safety interlocks a5S0Ciated with Ihe machine. The
analysis procedure did nol require safety interlocks lO be addressed. As a
resull. an operator's aon was amputaled when it was caughl in !he chipper
and the aula stop feature failed.
Predictive mainlenance had been selected for certain conveyors. However,
no monitoring program was developed. The equipmenl reliabiliry analysis
program did nol require !hat moniloring programs be dl?Veloped when
predictive mainlenance was a5Signed.

EQUIPMENT REUABILlTY PROGRAM OESICN LTA

 ApPENDIX A - Roor USE MAP NaDE DESCRIPTJONS Da

Typical Issues
Was the wrong type o mainlenance specfied for the equipmenl? Should
corrective mainlenance be used instead of proaclive maintenance? Should
predictive maintenance be assigned inslcad of proaetive maintenance?

Typical Recommendations
Review equipment failure records lo determine if he faHures OCcur at
specific intervals of operation or calendar lime. Assign preventive
mainlenance tasks if the riSK associated with equipment failure is high
enough
Determine if the failures can be predicted by moniloring a parameter
(Le.. pump vibration. temperature. flow). Assign predictive mainle
nance tasks if the riSK associaled with equipmenl faiJure is high enough
Determine if tailures occur shonly after certain events (Le., startup,
shutdown). AMign proaetive maintenance tasks ir the risk associaled
with equipment failure is high enough
If other types of maintenance are nol appropriate. or ir the risk associ
.'0<1100' 01
ated with the failure is low enough. assign corrective maintenance
"UOJrn lTA

Examples
Corrective maintenance was assigned lo an auger Ihat provided raw maleri
als to a toad process. This selection was based on a very low expected
failure rate and a quick repair time. Actual experience indicates the failures
tcok much ooger lO repair Ihan the analysis team estimated. As a result. the
risk associaled with the faHures was much higher than the leam thoughl.
Records indicated that tube failures were occurring in heat exchangers
shortly after planl stanup. The failures were determined lo be caused by hot
spots that developed when contamioants collected in portioos o( the heat
exchanger. Proactive mainlenance aetivities were implemented lo clean OUI
the syslem prior to startup. This removed the contaminants and prevented
the heal exchanger failures.

EQUIPMENT RWABll1TY PIlOCIlAM OESIGN LTA

_ Rom CUSfAN.uYSIS H.o8OOlC

Typical Issues
Were the wrong risk-acceplance entena used for analyzing the maintenance
needs? Was corrective maintenance assigned even thou9h Ihe consequences
o failure are very high?

Typical Recommendalions
EnsuTe that the proper level o risk acceptance is used in determining
the level and type o mainlenance lo perfonn on equipmenl
Provide guidance in the analysis procedure lo allow consistent assess
men! of risk
Provicle guidance in the analysis procedure lo aUow for consistent
application o !he risk acceptance criteria. Use spedfic examples

Examples
Correetive maintenance was assigned to a conveyor thal provided Taw
malerials to a foed process. Experience indicated thal failures fook aboul 16
hours to repair. The anaJysis procedure did nol consider repair times in !he
overall risk associated with a failure.
The analysis team ossigned predidive. proactive, and preventive mainte
nance activities lO equipment with failures tha! resuhed in large conse-
quences. They assigned corrective maintenance to equipmenl with failures
that ha<! only low consequences. However. the risk associated with !he low
ronsequence, high frequency events was larger !han thal associated with
some of the high consequence, infrequenl events. The risk acceplance criteria
outlined in the analysis procedure led them ta believe thallhey were assigning
Ihe corred type af mainteoance ta these different types of risks.

EQUIPMENT RElIAIlUTY PROGRAM DESIGN LTA

 AI'I'ENOIX A - Roo' CAUSE MM NODt DESCRII'nONS DiI
Typical Issues
Are rescorces assigned based on the risk analysis? Are. some high priority
tasks nol be.ing accomplished because other low priority tasks are being
implemenled instead?

Typical Recommendalions
Ensure thal resources are assigned in accardance with the priorities
detennined in the equipment reliability program analysis
Assign additianal resources lo equipment with a demonstrated
history af problems
Reduce maintenance on equipment that has no significant im~cl on
safety or production and that can be easily repaired or replaced

Examples
Maintenance activities were being conducted far the running components
of the wood chipping machine (Le., bearings, bladesl bul no maintenance
activities Wl?Te heing implemented for the safety interlocks associated with
the machine. The equipment reliability program required weekly checks af
the interlocks.
Mechanics were always being pulled fram scheduled work to work on
"emergendes. ~ The percentage of corrective maintenance was 80~. This
had nol changed since the developmenl of additional preventive, predic-
tive, and proactive maintenance activities.

EQUIPMENT RaLUIUTY PROGRAM OEStGN LTA

al Rom CAUSE ANALYSIS HANOBOOK

.......
h ...."'
.. .. ll~

Typical Issues
These ndude problems related to the implementalion of maintenance adivines. Was he repair incorrectly
performed? Was the troubleshooting less han adequZlle? Dd he monitoring aetivity faillo detecl a tailing
component? Was maintenance performed when il should have becn (Le .. following a shutdown, befare a
startup, when vibration reading5 reached a trigger poinll?

Typical Recommendations
Provide troubleshooting guides based on equipment {ailuTe analyses for diagnosis o failed campo-
nenls
Review he frequency of preventive maimenance. If the same activity routinely needs lo be perfonned
between scheduled inlervals. shorten he prevenlive mainlenance interva!
Ensure ha! equipmenl moniloring for predictive maintenance is appropriate for the component

Example
A number of pump bearings have failed recentJy. Predictive maintenance was selecled as the appropriate
type of mainlenance fer the pump bearings. However. moniloring of the pump bearings \.\.'as never per-
fonned even Ihough il was identified as a requirement in the equipment reliability progrnm. As a resull, the
pump failed befare the predictive maintenance activify was implemented.
Preventive mainlenance (a calibrationj was being performed on a produet scale every 3 months. However,
operators requested addilianal calibralions about once per month as they noliced the seale drifting. The
frequency of Ihe calibration was changed to once per month after (he company was fined far shipping
averloaded trucks.

EQUIPMEHT RfllA81UTY PROGRAM IMPUMENT....T10N LTA

 ApPENDIX A - ROOT CAUSE MAP NODE DESCRIPTlO/lJS &ID

Typical Issues
Was the problem misdiagnosed? Was Ihe corrective mainlenance repair performed correclly?
Note: Dual coding under Training or Procedures moy 0150 be oppropriate.

Typical Recommendations
Provide troubleshooting guides based on equipment faHure analyses for diagnosis of failed compo-
nenls
Review mainlenance procedures lo ensure that Ihey provide adequate guidance based on Ihe experi-
ence levelofpe~nnel
Provide training for personnel on Iroubleshooting processes
Provide training for personnel on repair lechniques
Perform post-mainlenance lesling lo ensure Ihal Ihe mainienance is properly performed and corrects
Ihe problem

Examples
Mechanics' job performance was judged by how many work reQuests they compleled. As a result. they tried
lo diagnose the problem as quiekly as possible. This led to rework when me original repairs failed to correel
the problem.
An inexperienced mechanic incorrectly repaired a pump sea!. which subsequently leaked. He inserted one
of Ihe rubber seals backwards. The procedure provided no guidance olner Ihan lO ~installlhe rubber seals.

EQUIPMENT REllA8111TY PROGRA.M IMPLEMiNTAnON LTA

IIDI Roor USE AwJ.YSIS HANOBOOK

Typical Issues
Was the problem ml.sdiagnosed? Was Ihe wrong problem corrected because
the troubleshooting was less than adequate?
Note: Dual coding under Training or Procedures moy olso be oppropriate.

Typical Recommendations
Provide troubleshooting guides based on equipment failure analyses for
diagnosis of failed components
Provide training for personnel on troubleshooting processes
Perform postmaintenance testing lo enSUTe the maintenance is properly
performed and CDrrects lhe problem.

Examples
Mechanics' job performance was judged by how many work requesls they
completed. As l result, they tried lo diagnose the problem as quickly as
possible. This led to rework when Ihe original repairs failed lo corred Ihe
problem.
The electricians were attempting to solale l ground in l feeder circuit. They
thought they had isolated the prablem ta a portian af Ihe drcuit, but they
were mistaken. They had misread the elecmcal diagrams and misinterpreted
their in!itrument readings.

EQUIPMfNT REUABlllTY P"ROGRAM IMPLEME"''TATlON LTA

 ApPENOIX A - RooT CAUSE MAl' NaoE DESCRwTlo:vs . . .

Typical Issue
Was the correclive mainlenance repair performed correctJy?
Note: Dual coding under Training or Procedures mayo/so be oppropriate.

Typical Recornmendations
Review maintenance procedures lo ensure that they provide adeQuate
guidance based on Ihe experience level of personnel
Provide training for personnel on repair lechniques

Examples
An inexperienced mechanic incorrectJy repaired a pump seal, which subse
Quent1y leaked. He inserted one of the rubber seals backwesrds. The proce
dure provided no guidance olher thesn to "instal1 the rubber seals. ~

During correetive mainhmance. mechanics idenlified a problem with a seal

on a pressure transmitler. To correcl the problem, a new rubber gasket
should have been installed. However, the mechanic would have had lo 90 to
Ihe warehouse lo get a new gasket and it was c10se lo quitting time. lnstead.
the operator applied a sealant to the gasket. This caused problems during
subseQuenl repairs when the old seal could nol be removed.

EQU1PMENT RfUA8ltllY PROCRAM IMPLEMENTATlON LTA

~ RooT CAUSE ANAlYSIS HANOBOOI(

Typical Issues
Was the rrequency o the preventive maintenance corred (Le., loo long 01 too shortl? Was he scope of he
preventive mainlenance activity appropriate (Le.. too broad 01 too narrow)? Was the activity incorreetly
perfonned?

Typical Recornmendations
Review Ihe frequency af preventive mainlenance. Ir Ihe same activity roulinely needs to be performed
between scheduled inlervals. shorten the preventive majnlenance inlerval
Review mainlenance procedures lo ensure thallhey provide adequate guidance based on ihe experi-
ence level of personnel
Provide training far personnel on preventive maintenance lechniQues

Examples
Preventive manlenance (a calibrarian) was being performed on a product scale every 3 months. However.
operalors requesled additional calibrations about once per monlh as Ihey noticed he sc.ale drifting. The
frequency 01 the calibration was changed lo once per month after the company was fined lor shipping
overloaded trucks.
Preventive mainlenance was being perionned on l furnace every week lo preven! a buildup of powdered
material. However. only the main chamber was being deaned. Perlioos of the furnace were nol being
c1eaned, ando as a result, the performance of Ihe furnace degraded over time.

EQUIPMEN'T REllAllUTY PRQCllAM lMPUMENTAnoN LTA

 ApPENDIX A - Roor CAUSE MAP NODE DESCR'PTlONS EID
f'h'''''O''
~I"'~"'"
P~9"'"
Typical Issue
I"'Qlo .. I.lItio.
Was Ihe frequency of lhe preventive mainlenance corred (Le., too afien oc
'" not afien enough)?

Typical Recommendations
Review the frequency of preventive mainlenance. If the same adivity
routinely needs to be performed between scheduled intervals, shorten
the preventive mainlenance nlerval
Review me frequency of preventive maintenance. Consider reducing
the frequency of preventive maintenance on components. Monitor
equipment perlormance lo determine the effecls uf a reduced frequency

Examples
Prevenlive maintenance (a calibrationl was being performed on a product
seale every 3 months. However, operators requesled addilional calibrations
aboul once per month as they noticed the scale drifting. The frequency uf the
calibration was chmged to once per monlh afler the company was fined for
shipping overloaded trucks.
Preventive maintenance was being performed every monlh on conveyor # l.
The mainlenance took 6 hours and accounted for 50% of the conveyor's
unavailability. Conveyor #2 in a similar service in another par! of the plant
had Ihe same preventive maintenance performed every 6 months. No faHures
had occurred on eaher conveyor in the past 3 years. The preventive mainte
nance interval for conveyor # 1 was changed to once every 6 months.

EQUIPMENT REllA8lUTY PROCRAM IMPUMENTATlON LTA

l1li Roer CAUSE ANAlYSIS HANOBOOk

Typical Issue
Was the SCOpe of the preventive maintenance aetivity appropnate (Le. lOO
bread ar too narrow)?

Typical Recommendations
EnsuTe tha! the scope of prevenlive mainlenance aetivilies covers al]
partiDns o Ine equipment that need repair ar service
EnsuTe tha! a1I af lhe components requiring preventive maintenance aTe
covered by the procedures

Examples
Preventive maintenance procedures require heavy pieces of inoperative
rotatiog equipment tha! are nol in operation (O be rolaled lo preven! Ihe
shafts fram warping. Equipment tha! is shut clown is scheduled lo be TatateO
once pe! week. However. equipment in the warehouse is no! covered by the
procedure. As a result, sorne heavy rolors fai! after installation.
Preventive mainlenance was being perlarmed on a furnace every week to
preven! a buildup o powdered material. However. only me maio chamber
was being c1eaned. Pertieos o lhe fumace were nol being cleaned. ando as a
result, the performance of the fumace degraded over time.

EQU1PMfNT RUlA8I11TY PROGItM4 IMPUMfNTATtON lTA

 ApPE,,"'DfX A - ROOT USE M,Ap NODE DaCRIPTJONS a:LJ
EQO'll",I"1
~I"'~""'" Typical Issues
P"'9'"'"
l,"ploOlI"UloO'
no Was !he preventive maintenance activity incorrectly performed? Were aH
required components serviced? Were sorne iterns included on the schedule
that were never performed?
Note: Dual coding under Training. Procedures, or Planning. Scheduling, or
Tracklng o, Work Activines LTA (Administrative/Management Systems,
SPACs LTA) maya/so be appropriate.

Typical Recommendations
Review maintenance procedures to ensure lhat they provide adequate
guidance based on the experience level of personnel
I Provide training for personnel on preventive maintenance lechniques
I Review the preventive mainlenance schedule 2lnd compleled work
orders lo ensure that aU required activilies are being performed
I Perform post-malntenance lesling to ensure that the malntenance is
properly performed

Examples
An inexperienced mechanic incorrect1y installed a pump sea!. which subse-
quently leaked. He inserted one of the rubber seals backwards. The proce-
dure provided no guidance olher Ihan to "install the rubber seals."

EQUIPMENT RUIABlllTY PROGRAM IMPlEMfNTATlON LTA

aiI Roer USE ANAlYSIS HANDSOOK

Typical Issues
Did Ihe monitoring activity {aH lo delect l failing componenl? Was the monitoring activay performed? Was
the correel parameler being monitored lO delecl aiJure? Was Ihe predictive maintenance incorrectly per-
formed?

Typical Recommendations
Provide guidance on the typical paramelers thal can be monitored lO predict failures tar differenl
types of components
Ensure Ihat equipment monitoring for predictive maintenance is appropriate for the componen!
EnsuTe thal equipment monitoring is being performed
Ensure thallhe scope of equipment monitoring 15 adequate

Examples
A number of pump bearings have failed recently. Predictive maintenance was selected as the appropriate
type of maintenance for the pump bearings. However. monitoring of the pump bearings was never per-
formed even Ihough il was identified as a requirement in the equipmenl re]ability programo As a result. Ihe
pump failed before Ihe prediclive mainlenance activity was implemenled.
Monitoring of a pump indicaled an upcoming failure (e.g.. (rom predidive maintenance monitoring). The
pump was repaired incarrectly.

EQUIPMENT RELlABILnY PROGIlAM IMPUMENTATION LTA

 "'''''~''''Ulit 11 - IfUUI \.AU~t MM' (VODE UESCIIII'TlO....S UiI

Typical Issues
Oid Ihe monitoring activity faH to detect a failing component? Was the
correel parameler being monilored lo delect failure? Is there sufficienl time to
deleet an impending failure before the failure actually occurs?
P"o"....
....,.'.".tTI
Typical Recommendatons
Provide guidance on the typical parameters tha! can be monitored lO
predic! faiJures for differenl types of componenlS
Ensure !hat equipment monllortng for predictive mainlenance is
appropriale for the componen!

Examples
Pump bearings were being monilored for failure. However. by the lime Ihe
impending faHure could be detected. Ihere was insufficient time to penorm
!he maintenance.
Turbine bearing temperatures were being monitored to predict impending
failures. However, failures occurred even though Ihere was no prediction of
failure based on lemperature levels. Vibration should have been monilored
instead, because it was a berter predictor of impending faHures.

EQUIPMENT RW.4JIIUTY PROGAAM IMPlEMfNTATlON lTA

 ApPfNDIX A - Roor USE MM> NOVE OfSCRIPTlONS a::EI
Typical Issues
Was lhe sc:ape af the work appropria!e? Did me mainlenance address the
problem? Was the $Cope broad enough 10 corree! the problem?
Note: Dual coding under Training or Procedures moy be appropriate.
~"I""'"
1I .... .-<.lT~
Typical Recornrnendations
Provide guidance on the typlcal failures that occur in various compo-
nenls
Provide troubleshooting guides based on equipment failure analyses for
diagnosis of failed components
Provide training for personnel on Iroubleshooting processes
Perform post-maintenance lesling [O ensure that me maintenance 15
properly perlormed and that it cOfTects lhe problem

Exarnples
Mechanics' job perlormance was judged by how many work requests they
completed. As a result, they tried to diagnose lhe problem as quickly as
possible. This le<! lO rework when the original repairs failed to corred the
problem.
High vibration readings generally indicated a bearing problem in the pump.
The mechanics replaced the hearing even mough it did not lcok wom or
damaged. When Ihe pump was restaned. the high vibralion readings were
still presento The pump impeller had been damaged and caused me hgh
vibranon. This was nol considered as a polenlal cause of Ihe high vibration.

EQUIPME."I1' R.Hl4BIUTY Pll:OGIotAfot IMPlfMEN'TATION lTA

aiI ROOT USE AAAlYSIS HAN0800K

Typical Issue
Was he predictive mainlenance incorrectly periormed?
Note: Dual codiog under Traioio9o Procedures, or P1anning. Scheduling, or
Tracking o( Work Activities LTA (AdministrativelManagement Systems,
p ~~ . SPACs LTAl moyo/so be appropriate.
....,"." ll.

Typical Recommendations
Review maintenance procedures lo ensure thal they provide adequate
guidance based on the experience level of personoel
Provide training for personoel on predictive mainlenance techniques
Review the preventive maintenance schedule and completed work
orders lO ensure that all required aetivities are being performed

Example
An inexperienced mechanic incorrectJy instaUed a pump sea!. He inserted
cne of the rubber seals backwards. The procedure provided no guidance
other than lO '"inslalllhe rubber seals."

EQUIPMENT RIllABlUTY PROGAAM IMPUMENTATlON LTA

 ApPCNDIX A - Roor CAUSE M"p NODC DESCR'PTlONS BII

.............
"'

.......
'1..
~

'"

Typical Issues
Was maintenance performed when it should have been (Le., following a shutdown, befare a startup. (he
heginning of winter)? Was the work incorreetly performed? Was the scope of Ihe activity broad enough?

Typical Recommendalions
Ensure Ihat triggering events for proactive maintenance are appropriate for the componenl
Ensure lhat monitoring is performed lo determine when triggering events occur
Revjew maintenanee procedures lO ensure lhal they provlde adequate guidanee based on the expert-
enee level af personnel
Provide training for personnel on monitoring and mainlenance techniques
Review the proactlve maintenance schedule and eompleted work orders (O ensure hat al1 required
aetivilies are being perfonned

Examples
Praducl barreIs were cleaned as they were returned from cuslomers. However. sorne praduet was contami-
nated by dust !hat accumulated in Ihose barreis thal were not used for an eXlended periad of time. Cleaning
.was switched lo shortly befare use instead of when the barreIs were retumed rram eustomers.
Cremes were supposed lO be inspeded and lift-Iesled prior to Iiftjng any item that was greater than 70% of
me crane's rated eapacity. These inspections and tests were never performed because (he erane operalors
were unaware oi this requirement.
Fumace crucibles were to be cleaned whenever the fumace was scheduled to be shul down for more lhan 8
hours. Operations never told maintenance when the scheduled Shuldowns would accur. As a result. the
deaning was not performed as required.

EQUIPMENl RHlAB1UlY PROGRAM IMPLEMENTAnON lTA

lI:fI Rom V.USE AAAlYSIS HAND8001C
1

Typical Issue
15 he COlTed rriggering evenl specified tar he proactive maintenance?

Typical Recommendations
Ensure thal triggering events far proactive mainlenance are appropriale
for he componen!

Example
Proc:lucl barreIs were deaned as Ihey were retumed from customers. How-
ever. sorne product was contaminaled when il was placed in the barreIs. In
barreIs that were nol used for extended periods o time. dust would accumu-
lale and conlaminate the producto Cleaning was swilched lo shortly before
use instead of when the barreis were retumed from customers.
Tubes in a heat exchanger were failiog premarurely. The tubes were riosed
prior to slarting l new batch, bul they Wr nol cleaned al the complelian of
each batch. As a result, the material remaining in the tubes caused the tubes
~c,""..,
to corrode.
I"'DIt"'N.toCl"
'"

EQUIPMENT RELlABlllTY PROCRAM IMPlEMENTATION LTA

 AI'I'CNDIX A - Roen CAUSE MAl' NaDE DESCR,.nONS .mi
Typical Issues
Was a monitoring program in place lo determine when these events oc-
curred? Was maintenance notitled when these events occurred?

Typical Recommendations
Ensure Ihal moniloring is performed to determine when triggering
events occur
Review the proactive maintenance schedule and completed work
orders to ensure thal alt required activities are being perlormed

Examples
Cromes were supposed to be inspected and lift lested prior lO lifting any ilem
!hat was grealer Ihan 70% of the crane's rated capacily. These inspections
and tests were never performed because Ihe crane operators were unaware
of this requirement.
Furnace crucibles were to be cleaned whenever the furnace was scheduled to
be shut dO'Aln for more than 8 hours. Operations never told maintenance
when the scheduled shutdowns would occur. As a result, Ihe cleaning was
not performed as required.

EQUIPMENT RHIA8I11TY PRQCRAM IMPLEMENTATION LTA

aII ROOT CAuSE ANA!.VSIS HANDIOOIC

Typical Issues
Was Ihe scope of lhe <Ktivity sufficient lo preven! he problem?

Typical Recommendations
'0''''''
11 ..... .. 1'
Review the scope of the proactlve maintenance procedures lo enSUTe
that they aTe broad enough lO address lhe issue
Perform po51-maimenance testing to enSUTe thal ,he maintenance is
properly performed and corrects Ihe problem

Example
Al the end of Ihe season. Il.lwn mowers o.wrE! supposed lO be u.rinterized lo
prevent damage while sitting dIe over Ihe winter. Maintemmce changed Ine
oil. bul f",led lo stabilize the gas. As a result, Ihe mowers' fuellines \Alere
gummed up in the spring wheo Ihe mov.oers were broughl out for use.
Cranes were $upposed lO be inspeeted and lift leste<:! prior lo lifting "'"Y item
rha! was grealer than 70% ol the enne's rated capacity. The lift tests were
only perfonned al ene boom angle even Ihough lhey should have been
perlonned al a number af different boom angles.

EQUIPMfNT RrllABllITY PROCRA!.4 IMPllMENTAT10N LTA

 ApPfflJDIX A - ROOT C.4USE M.4p NODE DESCRIPTlONS aJiI

Typical Issue
Was the mainlenance incorrectly periormed?
Note: Dual coding under Training. Procedures, or Planning, Scheduling, OT
Tracking of Work Activities LTA (AdministraiiveIManagement Systems,
SPACs LTA) maya/so be appropriale.

Typical Recommendations
Review maintenance procedures lo ensure Ihat rhey provide adequale
guidance based on the experience level of personnel
Provide training for personnel on Tepair techniques
Review the proactive mainlenance schedule and completed work
orders to ensure thar all required activities are being perfonned

Examples
An inexperienced mechanic incorrectly instatled a pump seal. He inserted
one of the rubber seals backwards. The procedure provided no guidance
other rha.n to "'install the rubber seals.'
An electrician was performing a mainlenance check on a pressure instru-
men!. During performance of lhe check. a high pressure signal was simulaied
in the instrument loop. Because !he loop Wl.S nOl properly isolated. it resul!ed
in l. pressure relief valve lifting l.nd a release to the environment.

EQUIPMENT RnlABIUTY PROGRAM IMPlEM~NT'ATION LTA

al Rom USE ANA!.VSIS HAND800K

Typical Issues
Did hidden faiJures contribule fa Ihe loss evenl? Could these hidden tailures have been detected by testing
the equipment?
Note: This type 01 mointenance is usually opplicoble to slondby sysrems or the detection af hidden foilures
in systems.

Typical Recornmendations
EnsuTe Ihal slandby syslems are periodically tested to detennine their operability
Verify thal installed spares are periodically used lo enSUTe tha! lhey aTe ready lo operale when the
primary components ar trains {aH ,
Check fault-finding lesting procedures lo enSUTe ha! lhey test !he entire system and nol jU5t a portion
of il
Ensure thatlhe frequency of lesting is corred (no! loo afien. bu! afien enough)

Examples
A slandby diesel generator was installed lo provide power lo vital components during a loss of power. No
lesting had ~en perforrned on the diesel generalor sinee it was installed. As a result, when there was a loss
of power, lhe diesel generalor did nol work.
A second cooling pump i5 inslalled as a spare. 11 is designed lo slart when the primary pump fails. The
slandby pump is smaller than the primary and so it is seldom used. The pump is lested when il is periodi-
cally placed in service (although lhis is nol done on any schedule). However. the aUlostart system is never
tesled. As a resuli. the standby pump failed to start following an emergency shutdown of lhe primary pump.
Routine lesting of a compuler backup power supply (an uninlerruplible power supply with batteries) was
performed once ayear. However, the batteries had an expected lifelime of 18 months. As a result, many of
the battery taHures were nol delected for monlhs after they occurred.
EQUIPMEN'T RUlABllITY PRCX;RAM IMPlfMENTATlON LTA
 ApPENDIX A - Roo, C,4.Use MAl' Nooe DESCR/PTlQNS DiI
Typical Issues
Was the frequency af faull-finding manlenance carrect? Was the mainte-
nance performed loo frequently? Was it not performed often enough?
Note: This type 01 majntenance is usua//y applicable to slOndby systems or
he detedion 01 hidden lai/ures in systems.

Typical Recornrnendations
Ensure that standby systems are periodically tested to determine their
operability
Ensure tha! Ihe frequency of testing is corred (not too ohen, but aften
enaugh)
Assess the ]mpad af faull-finding maintenance an the system. What
impad does Ihe maintenance have on the equipment? Adjust the
frequency accordngly

Examples
R.p.. A standby diesel generalar was installed to provide power to vital compo
lOOp......." .....
nents during a loss of power. Na testing had bE:!en performed on Ihe diesel
'" generatar since it was instal1ed. As a result. when there was a loss of power,
the diesel generalar did not work.
Routine testing of a computer backup power supply (an uninlerruptible power
supply with barteries) was performed once ayear. However, the batteries had
an expected lfetime of 18 manths. As a resulto many af the battery failures
were not detected for monlhs after they occurred.
An important contral system in a nuclear power plant was tested daily to
detect hidden faHures. The lest took about an haur to perform. As a resuJt, the
system was inoperable about 5% of the time for scherluled maintenance. In
arldilion, the maintenance aften introduced problems into the system mat
rendered it inoperable. The test frequency was modified so thal jI was per-
formed once per week.

EQUIPMENT RELlA81UTY PROGRAM IMPLEMENTATlON LTA

lI:IiI Rom CAuSE ANAlYSIS HAN0800K

Typical Issues
Did the testing nelude all applic.able portioos o Ihe syslem (i.e.. detection
syslem, control systems, actuation systems. and the actual components)?
Note: This Iype 01 mainlenonce is usuo/ly opplico.ble to standby systems or
the deredion 01 hidden oi/ures in sy.stems.

Typical Recommendations
Check fault-fjnding testing procedures to enSUTe that they test the entire
systern and nol jusI a portion o it. Check lO see ha! the foUowing
portions of the system are included:
- deteetion systems (Le.. a system Inat detects low valtage to start an
emergency generalar)
- aduation systems (Le.. lhe parl of the systern Ihal tells the standby
componenl lO start)
- the componen! !:se!! (Le. the diesel generalar)

Example
A second cooling pump i5 installed as a spare. JI is designe<:! to start when
!he primary pump fails. The standby pump is smaller than the primary and
so it 15 seldom used. The pump IS lestro when il is periodicaDy placed in
service (ahhough this is nol done on any schedule). However. the autoslart
syslem is never tesled. As a result, !he standby pump failed lO start following
an emergency shutdown of !he primary pump.

EQUIPMENT RtUABILlTY PIQGIlAM IMI'LEMENTATtoN LTA

 AI'PENDIX A - RooT CAUSE MAl' NODE DESCRll'nONS mi
Typical Issues
Was the scope of the repairs appropriate? Did the repair corred the problem?
Was the scope of the repair bread enough 10 COrTeel the problem?

f ...,.... '"i
MI"'I"Utl
Typical Recommendations
'" I Provide guidance on the typical failures that occur during testing
Provide b'oubleshooting guides based on equipment failure analyses for
diagnosis 01 failed eomponents
I Provide b'aining for personnel on troubleshooting processes
Perform post-mainlenance testing to ensure thal mainlenanee was
properly performed and corrects the problem

Example
During testing. a standby generalor failed to start. Troubleshooting revealed a
failure in the starting circuit. No posl-mainlenanee tesling was performed. As
a resulto a failed fuelline was nol discovered.
RI~U'

""~""'"t&IIl>.
".

EQUlPMENl' RfllABlllTY PROCRA~ IMPlEMEfIo'TAnON LTA

EtI ROOT CAUSE ANAlYSIS HANDBOOK
" .,.., . ~ . . . . . ,. 1ft
EQU1PMENT RELIABlllTY PROGAAM IMPlfMfNTATlON
Typical Issues
Was an error made in performing the repair aClivity? Were problems ntra-
duced as a resull ol performing the repair? Were hidden faiJures introduced
into he system as a result af performing the maintenance?
Note: This type o/ mainrenance 15 usually opplicable 10 standby systems O(
the delection o/ hidden foUures in syslems. Dual coding under Training,
Procedures. or Planning, Scheduling, or Tracking of Work Activilies LTA
(AdministraliveIManagement Syslems, SPACs LTA) moy olso be appropriate.
Typical Recommendations
Review maintenance procedures lO enSUTe hal Ihey provide adequate
guidance based on he experience level of personnel
Provide rraining for personnel on repair techniques
Perform cm analysis af procedures lO determine the types of errors Iha!
could be reasonably made. Ensure Ihal the procedures adequalely
address each of Ihese
Examples
A standby diesel generator (DG) was inslalled lO provide power to vital
components during a 1055 of power. To perform lesling of lhe OG. the mainle-
nance lechnician takes lhe DG off-linIO'. After testing. maintenance failed lo
return Ihe DG lO an online conditlon. As a resulto when Ihere was a loss of
power, !he di~1 generalor did nol work.
A secondary cooling pump is lnstalled as a spare. il is designed lo start when
Ihe primary pump fails. A failure in the aUlostar1ing system was found during
a test. However. Ihe pump was nol repaired lar several weeks because il was
nol pul on the mainlenance schedule. When Ihe primary pump tripped. Ihe
secondary pump was still inoperable.
lTA
 ApPENQIX A - Roor USE MAP NaDe DCSCRIPTlONS El

Typical Issues
Are routine inspections of equipmem perlormed? Are personnel aware of the types of problems they should
look for? Do they know how lo document the problem and feed it into the maintenance system7

Typical Recornrnendations
Develop guidance far operalor aOO maintenance rauneis
Ensure lhat personnel are aware of the process for initiating corrective maintenance
Make the process of reponng problems as simple as possible to encourage repartng problems

xamples
Operators are suppased to nsped he line for problems at the beginning of each shift. Often the operators
skip the raunels because they have loo much paperwork to complete.
Grounding straps on a pipeline were to be inspecied once per year. Most of the line was inspecled yearly.
bu! partions tha! were diff!Cult lo access were frequently skipped.

EQUIPMENT REUA8IUTY PROCIlAM IMPlEMENTAnON LTA

mi Rom CAUSE ANAlYSIS HAND800K

TypicaJ Issues
Was Ihe frequency oj he rounds corred {Le.. lOO ahen ar nOl ahen enoughl?

Typical Recommendalion
Review the frequency of Ihe rounds lo determine if they are perlormed
al he required frequency

Example
Qperators perlorrned equipment rounds in sorne aTeas of he plant onty once
A",,'Y
a day. FrequentJy, significant valve packing leaks were found by the ope:ralors.
....Io ...nI".. ~ More frequent rounds resulted in detectians olleaks while they were still very
". small.

EQUIPMENT REUABIUTY PRCX;RA.M IMPtlMfNTAnON LTA

 AI'I'ENDIX A - Roor CAusE MAl' NODE DESCRIPTIONS mi

Po.,.-,
Typical Issues
Eo.'I'",.,l
~O"~1IlU Was the scope of me rounds appropriate (Le.. too broad or too nal'l'ow)? Are
all partions of the planl covered by routine rounds?

Typical Recommendations
Ensure that 2011 eueas of the plant are covered by periodic rounds
Provide guidance on the activities that ate to be performed during
routine rounds

Examples
Operators were told to perfonn rounds in the steam plant bul were nol told
what activities they were to perfonn. As a result, the operators poked their
head in the door of the building and glanced around, but did nothing else.
A plan! was recently aulomated. The operalors did nol need to teave lhe
control room to operale the plan!. The operalors onty toured lhe atea right
around lhe control room. As a resull. no one routinely toured the entire plan!.

EQUIPMENT REUABlllTY PROCRAM IMPlEMENTAnoN LTA

mil Rom USF ANA.l'l'5IS HANOBOQl(

TypicaJ Issues
Are the rounds perfonned' Are they performed al Ihe spedfied frequency? Do
the rounds cava all aTeas tMl are specified?

Typical Recommendations
Ensure thal raunds are performed as required
Ensure mal a11 eqUlpmenl is covered on rauneis as required

Example
0pera10lS are supposed lO check fOl' IelIks In various portions of the plan!.
However. they usualIy only tourro the par! of the :Xanl mal was beluleen he
control room and the lunch room.

EQUI'MfNT RfUAIIUTY PltOGllA-\4IMPllME"''''''TlON LTA

 ApPENDIX A- Roor CAUSE MAP NaDE DESCRIPr/ONS 1m

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AOMINISTRAllVf/MANA.GfMfr-.'T SYSTEM5
1111 Roen CAus' ANAlYSrs HANOBOOK

Typical Issues
Do standards. policies. or admnistrative controls (SPACs) exisl? Are [hey madequate or inadequately mple-
mented? Od inadequate materiaL procurement. or configuration control contribute lo (he problem? Are
safery/hazard reviews inadequate? Are corrective actions identified and implemenled? Was there a problem
wilh IhE! cuslomer interface or cuslomer service?
Note: Standords. policies. ond administra!iue COn/mIs prouide guidonce on how on aetiuity should be oc-
complished, whereas procedures prouide a detoiled. step-bystep method for performing a speci!Jc rask. For
example, [heTe ore SPACs tha! describe the policies goueming scheduling 01 workers. There is o/so a proce
dure rhat prouides a de/al/ed. step-by-step process JaT performing Ihe lask, including fhe forms to complete
and dor.a to enter in the computer system.

Typical Recommendations
Provide wrinen documentation of SPACs
Ensure Ihat alllevels af affeded employees are aware of SPAC changes
Track and dorument the final resolution for all corredive adion recammendatians
Insped materials far damage upon alTival at the facility
Ensure that acceptance requirements are documented and match the design requirements
Review and approve field changes
Periodically salidt feedback from customers

Examples
A mechanic inslalling a cable tray drilled inlo a live wire within a wall because the facility drawings he was
using were nat up-ta-date. A management system for control of electrical drawings may have prevented this
occurrence by ensuring that the mechanic had up-to-date documentalion. A management policy/procedure
wauld also be required to ensure that such drawings are obtainedlreviewed as part of the work permit
system far penelrations af any wall.

The management of change policy requires safery reviews of a1l process changes. but during an overnight
emergency. a failed gale valve was replaced with a ball valve. The hazards of the change were not reviewqd,
and the valve subsequentJy ruptured when peroxide trapped in the ball decomposed.

AOM1NlSTJlATlVF1MANAGEMINl SYSTlMS
J
ApPENDIX A - Roor CAuse MAP NOOE O!5CRIPHONS &'IiI

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AOMINISTRATlvf/MANAGEMENT SYSTEMS
l'iIitI Roen USE AAAlYSIS HAND800k

Typical Issues
Was the error caused by (he lack or inadequacy al SPACs? Wer the SPACs naceorate, confusing, incom
plete. undear, ambiguous, nol stricl enough, 01 olherwise inadequate? Were the \AJTong actions rewarded?

Typical Recommendations
Provide IAlritten documenlation of SPACs
When errors are faund, modify SPACs aocordingly
Ensure thal policies regarding produclion, material control. procurement. security. etc.. do nol contra-
dict safety policies
Ensure Iha! the rewards and incentives are consisten! with facility objectives

Examples
An operator was unable to read al the level neroed lo understand faciliry procedures becaUSE' employee
screening slandards were nol high enough. As a resulto he made a serious mistake in operating a key piece
of equipmenl.

The surveillance testing for the fire prolection sys!em had no! been conducted for the pasl 2 years. The
maintenance and operations departments bolh thought the other group was responsible for the lest.

AoMlNtSTRATlVJ./MANAGEMfNT SVSHMS
 ApPCND/X A - Roor CAUSE MA.p Nace DESCRIPTlONS El
Typical Issues
Did a SPAC exist fa control me particular type af work ar Sltuatian invotved in
the incident? Was the work or situlllion significan! or nvolved enough to
warranl sorne type of SPAC lo ensure adequate job Quality lInd work control?

Typical Recommendations
Compile a list of SPACs mandated by regulatory reQuirements (OSHA.
EPA. etc.) and compare it to II curren! liS! of existlng SPACs. Develop
any missing SPACs
Provide wrirren documenlation of SPACs
Define. document, and communicate missing SPACs

Example
A maintenance worker was exposed to a pressurized release of a process
materiaL The Une from which the material was released had nol been depres-
surized and c1eared before mainlenance work began. The plant did nol have
a safe work pradicelpermit fer opening process equipment (Le., "Jine break-
ing-).

Ao""'INISTAATM/MANACEMENl SY5TEMS
lID Rom USE ANALYSIS HAND800K

Typical Issues
Were Ihe existing SPACs strict enough to provide adequate job quality ar
work control? Did vagueness allow violanon of Ihe intenl, ir nol he lener. of
Ihe SPACs?

Typical Recommendations
- Improve he leve] of detail of SPACs
lmprove the descriplion of accountabllities in SPACs (for resolving
ambiguities)

Examples
A safety limil was violated durios operation of a process because an a13rm
indicating a 1119h temperature \Alas bypassed. The first-line supervisor thought
the alarm was false and bypassed il. The SPACs were nol strict enough,
because they a1lowed the supervisor lo bypass an alarm without getting any
review ar approvais from management and temoica! support.
Operators were supposed lo check the operation of pumps by taking vibration
readings and checking temperatures. Inslead, Ihe operators jusI performed a
visual check of me pumps. The SPACs did no! specify how the operalors were
lo check the pumps, and the SPACs did nol require supervisors lo periodically
check on how the operators were performlng Iheir lasks.

AoMINISTRATM/MANACEMENT SYSTEMS
 ApPfNOIX A- ROOT CAuse MAP Nooe DESCRIPlIONS li.ID
Typical Issues
Were he SPACs confusing, hard lo understand or interpret, ar ambiguous?
Wete the SPACs incomplete or not specWc enough? Oid contradiclory re-
quirernents exist? Were sorne requirements violated or disregarded in order to
S!'"~I'~' foHow others? Was a SPAC nol followed because no practical way of imple
Po,<;." O'
&a ..",,,,,.,... menting Ihe SPAC existed? Would implementation have hindered produc
Co"'.I.[SP&C1
tion?
'"
NO $P&C. Typical Recommendations
Solicit comrnents and recommendations from operations/maintenance
personnel regarding ambiguous or undear language in the SPACs.
Resolve comments
Ensure that policies regarding production. material controL procure-
men!. security. etc.. never contradict a safety policy
Comrnunicate to operalors that safely should be given top priority
Ensure that SPACs retled management's decision lo make saJety top
priortty
SPACs that require specific authorization signatures should state alter
nate sources of authorization in the event the primary aulhorizer.; are
not available
Provide the necessary lools/equipment features to allow/encourage
personnel to follow Ihe SPACs

p""","g
Examples
S,-.O.",,; ., A key piece of equipment in a process safery system failed. The policy stated
r..<...,., ..... 0"
'<1"0100. l r& that the required mainlenance and inspeclions were lo be performed annu-
aUy. Because of the difficulty of scheduling [he work with procluclion and the
~ ....
I.".t.."
~. amount of work involved, the mainlenance/inspection cyde had gradually
slipped to 18 months. The policy did nol slate a maximum periad af 12
'" monlhs.

[""10'" A plant policy indicaled tha! aH "fatigue-related failures" be reported to Ihe

S"..-.. ~ .... u .. ;
Equipmem Reliability group. However, the maintenance organizalion had no
'" guidance on what sort of failures were "fatigue-related." In addition. a recenl
reorganization resulted in the eliminalion of the Equipment Reliability group.
and Iheir previous functians were splil among four other groups.
A release af a flammable liquid was larger than expected. averflowing lhe
tank's dike. AdministTative oontrals on the maximum inlended inventories far
the tanks in the dike were vialaled because of an anlicipaled shortage of the
material from the supplier. Produdion dedded lo ~sto<:k up" on the material
to prevent produdian outages.

ADMINI5TRATI\'uMANAGtMEI't,'T SV5TEMS
lID ROOT USf AAAlYSIS HAND800K

Typical Issues
Did technical errors aT ncorreel facts exisl in Ihe SPACs? Dd Ihe SPACs fail
lO consider all possible scenarios or conditioos?

Typical Recommendalions
lndude SPACs in Ihe scope/charter af hazard review teams
When erTors are laund. modify SPACs accordingly

hamples
A fire occurred \.Uhen hol work near a process unt ignited vapors leaking tram
N~I S',el a nearby fiange. The hol work policy for 1he plant erroneously indicated Ihal
E.o.;"
a hol work pennit was nol necessary because Ihe work was nol specifically on
equipment associaled wilh hazardous materials.
Drawings were not updated following modifications. The SPAC contralling Ihe
design process was ncorree!. Drawings were nol senl lo he corred individual
in Ihe drawing control department.

AoMINISTRATlVE/MANAC[M(NT SYSTEMS
 ApPENDIX A - RCXJr USE MAP NooE DESCRIPT/ONS aD
Typical Issues
Did the SPACs define che organization or group responsible for the item? Did
confusion exist over who was responsible far the activity? Did an activily exist
far which no one tcok responsibility?
S""~I",'
hile... "
A''''''''~'l''''
Co,uoIlISPl(;11 Typical Recommendations
'" Assign responsibility far items/adivities by including specific Job tilles in
SPACs
[nelude aocountability in job performance criteria (for job performance
appraisalsl

Example
A lechnkallimil far the [ength of time allowed between air flow checks on a
stack exhaust system was violated. The operations department considered the
checks lo be maintenance items. The mainlenance department considered
the chei:ks lo be an operations item. Responsibility for he checks was nol
defined.

AoMINrST~TM/MANAGfMENT SmEMs
lID Rom CAuSE NAI.'rSIS HAND800K

Typical Issues
Was he work scheduling system adeQuate? Was the work properly planned?
Was the work schedule use<! far implementing work? Was the work scheduled
based on safety and reliability impact?

Note: This node oddresses the scheduling o/ work oetiuities on/y, nOl !he
scheduling 01 personne1 ro accomplish Ihe work. ProbJems wirh scheduling o/
personnel are addressd under nade 186, Scheduling LTA (Immediate Super-
visiono Preparatioo).

Typical Recommendations
Update Ihe tracking system daily, weekly, or monthly, as appropriate, by
adding new action items andlor documenting Ihe currenl status of al!
aetion ilems
Conduet periodic, unannounced audits lO verify Ihat those aerion tems
documented as ~complele" are actually complete
Umi! access lo the trackinglscheduling system to aulhorized persannel
(e.g.. use a password ror an electronic syslem, lock syslem documenla
lion in a filing cabinel and distribule keys only lo authorized personnel)
Prioritize action ilems and assign reaJistic dales for completion
Develop and use Mindicators" lo help deteet problems in ongoing use of
managemenl syslems (e.g. how long does illake lo respond to a
request for change lO a standard operating procedure?)

hamples
A lank overflowed during filling because the aulomatic shutoff valve failed lo
clase. An earlier inspection found Ihat the level switch for the vaNe was
1I... ,e. defective, bullhe equipmenl deficiency had nol been resolved.
I.<t"~ ...

'" A scheduling system was developed by the mainlenance planner; however,

because there were too many panic repairs. the schedule was never followed.
t"'~lOy.t
No one actually used the scheduling system to determine the priorities of the
s""."'~''''''~ work that u/as performed.
'"

AoMINISTRATlVf/MANAGEMENT SYSTEMS
 ApPENDIX A - Roor CAUSE MAP NaDE DESCRIPrlONS 1m
Typical Issues
Were workers rewarded for improper performance? Were incentives consis-
lenl wilh the goals of the company and facility? Oid the reward system en-
courage workers tO lake short cuts or waste resources?
SII'~".'
010:'''.01
~G"''''lIr'''''
tOMro . SPAt'l
". Typical Recommendalions
Oevelop rewards thal are consisten! with company goals and objectives
Ensure lhal metrics and other measurements for performance are
consistenl with facility goats and objectives

Examples
Performance of cuslomer service represenlatives was measured by the num-
ber of cal1s they handled each day. As a result. they tried lo diagnose the
tO"'O' -
problem as quickJy as possible and provide a recommended soluDon. Be-
tO"~'OIC1.1"j 01 cause the representatives were trying lo diagnose the problem Quickly, Ihey
",.",,101'
afien misdiagnosed the problem. About 40% of the phone calls were repeat
cal1s from customers whose problems were misdiagnosed the first time.
fo'MUI
E".r One of the metrics for the maintenance organization was the percentage of
utilization for a cerlaln lalhe. This was measured by the percentage of time
Ihe lathe was operating. As a result, the operators turned on lhe lathe in the
morning when Ihey came in and let it TUn unlil lhey went home. They never
used lhe lathe far work because it would decrease the amount of time the
machine rano

AOMINISTRATIVUMANACEMENT SVST[MS
mi ROOT USE ANAtYSIS HAND800K

Typical Issues
Old ao effectlVe employee screening program exisl? Oid il corredly identify
requirements for particular jobs? Did il screen employees against those
requirements?

Typical Recommendations
Assess critical personal capability requiremenls for each job pasillon
Communicate alt required job lasks lO potential employees befare
exlending employmeni opportunities
Ask job interviewees ir they can perform job-relaled tasks
Consider requiring Ihe passing af a physical exam/drug-screen test as a
contingency of employment
Have prospective employees perform a test hai simulates he actual
work as closely as possble lo determine if they can perform the wark

Examples
An operator made a mislake operating a process on a color-coded distrihuted
control syslem because he was color blind. AJlhough a screening program
existed for the jobo II did nol specify the ability lo differentiale colors as a
requiremenl.

A mainlenam;.e technician made an error in repalring a mili. The technician

couta nol read the procedure Ihal he was supposed (O use.

AoMINISTRAllVf/MM"ACEMENT SVSlEMS
 ApPflllOtX A - ROOT CAUSE MAl" NODE DlScR/pnONs lID

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AnMINISTRATIvt/MANAGEMENT SYSTEMS
mi Rom USE ANAlYSIS HANDSOOIC

Typical Issues
Were SPACs or dlrecrives nol used. adhered to, or followed? Was communicalion or enfon::emenl of SPACs
inadequate? Were the SPACs recently revised or difficult lo implement? Od the SPACs provide for adequate
accountability?
Note: SPACs prouide yuidance on how on odiuiry should be accomplished, whereas procedures prouide o
detoiled, slep-by-step method Jor performing o specific task. Far exomple, Ihere ore SPACs hal describe [he
policies goueming ~heduJjng 01 worken;. There is also o procedure [ha! prouides a detai/OO, slep-by-slep
process lar performing rhe rosk. including the forms lO complete ond data ro enter in rhe computer sysrem.

Typical Recornmendations
EnsuTe thal alllevels af affeeted employees are a.ware af SPACs changes
Take appropriate actions concerning Ihose employees who do nol use the SPACs
Apply lessons learned from one unit to other units

Examples
A mechanic bypassed an imponant slep in calibraling a key saJety instrumenl because he did no! take a
primoul of the procedure Wilh him, as required. This was found to be an accepted praclice in Ihe faciliry.
A requiremenl was in place to have the operalors check instruments in Ihe tield once per shifl. The operalors
never performed Ihe checks. Supervision was aware of the situalion and never enforced the requiremenl.

AnMINISTRATM/MANAGEMENT SY5TEMS
 11,."tNUIA ... - nV\,JI "'''V;'I: 'I"Ar I"VUI; vut..KlrIlUIY) " . . .
tri"

Typical Issue
Were standards, directives, aT policies noi communicated from managemenl
clown through the Olganization?

Typical Recommendalions
lnclude SPACs conten! in intial and refresher formal training; determine
employee's understanding
Periodically stress he importance of using SPACs during shift change
meetings. safety meetings, etc.
Ensure that SPACs documentation is readily available to aH affeeted
employees al alJ times for referente purposes

Example
During an extended fadlity outage. routine surveillances of process alarm
panels were nol performed. As l result. l chemicalleak went undetected tor 2
days. Facility management had nol cornmunicated to first-line supervisors
that normal surveillance procedures remained in effect duriog the outage.

AOMINISTRATIvt/MANACEMENT SVSTEMS
mi Roen CAUSE ANAlYSIS HANOBOOK

Typical Issues
Had standards ar directives been recently changed? Dd informatioo concern-
og changes fail lo reach alllevels o !he organization? Had sorne confusian
been crealed by the changes?
S'o.""
P.IIe,....,
M"'''lolrn~.
eOOl'.'"
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ISP~C'1 Typical Recornmendations
EnsuTe that a111evels o affecled employees are aware of SPACs changes
Verify thal employees fully understand recent changes befare expecting
them lO implement the changes
Ensure that there is a process for communicating SPACs changes lo the
individuals whe need to MOW aboul he changes

Examples
A new policy on calibration of flow indicators was provided lo al! of the
(Mo" ....,' maintenance department supervisors, bul the mechanics were nol tald o the
'" chaoge. As a result, the policy was not implemented, as required.
A new policy was pUl in place to require personnel lo enter the time charge:d
against each work order into a computer system. No one was lold of the
requirement or taught how to enter the information in the computer.

AoMINISTRATM/MANAcEMENT SVSTEMS
Typical Issues
In Ihe past, has enforcemenl of Ihe SPAC been lax? Have faHures to follow
Ihe SPAC in Ihe pasl gane uncorreeted ar unpunished? Has noncompliance
been accepted by management and supervision?
Note: Coding under Rewardsllncentives LTA (SPACslLTA). or lmproper
Performance No! Correcled (Immediale Supervision, Supervision Duriog
Work) may be appropriare.

Typical Recommendations
Managemenl should sel 2m example by always fol1owing Ihe letter of Ihe
SPACs
Employees who do nol use Ihe SPACs should be corrected and/or
punished
Discipline needs lO be fair. impartial, pre.stated, sure, and swift
Enforcement needs to be consisten!

Examples
A mechani, made a mistake instal1ing a piece o equipmenl. He did nol refer
lo a procedure when performing the test. A1though policy is lO a1ways refer to
Ihe procedUTe, lhe policy had nol been enforced. Mechanics often did nol
take procedures to the work site. and their supervisors were aware of rhis.
perators were supposed lo lag locallank levels every 2 hours. However,
lhey would lypically lake Ihe readings only al the beginning of the shifl. They
used these readings lo fUI in the readings for the remainder al the shift. No
one ever lcok issue with this practice unlil after an accident occurred.

AoMINISTRATlVElMANACEMENT SVSTEMS
lID Rom CAUSE ANAlYSIS HAND800K

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AoMINlsTAAnVf/MANAGEMENT SYSTEMS
 ApPENDIX A ; RoOT USE MAl' NODC DlScRIPrION$ El
Typical Issues
Was Ihe error caused by an inadequate hazard review of (he syslem? Was a risk as5essmenl of lhe syslem
performed? Have the safely and reliability hazards been identlfied?

Typical Recommendations
Ensure that aH newly inslaHed andlor modified equipmem i5 included in a hazard review prior lO
slartup
Track and documenllhe final resolution for all recommendations
Ensure Ihal personnel, equipment. and environmentallosses are 2111 addressed in the review

Examples
A wastewater tank was overpressurized and faHed. During Ihe tie-in of a new lineo Ihe review leam recom-
mended the installation of a larger overflow line to handle Ihe largesl posslble f10w inio the lank. The results
of Ihe revielv were nol incorporated into the installation package. The new Une was tied imo (he lank wilh-
out a new overf1ow Une instal1ed.
A scenario for rapid overpressurizalion of an atmospheric decanter system was nol considered prior lo
startup of a process because the hazard review did nol address procedural deviations during an allowable
startup mode.

AOMINISTRATIVuMANACEMENl SYSTEMS
liJI Roer USE AN.u.VSIS HA.~DBCX>K

...."..j.",. Typical Issues

s,."....f_'
v"'i'~
Was the safety and hazard review complete? Did il consider al! modes of
operatiorVmaintenance. and were other required hazard review issues consid-
ered? Was the review done accarding lO aH applicable orders. regulalions. and
guides? Was a safetylhazarcVrisk review performed?

Typical Recommendations
Provide a safetylhazardlrisk review procedure lhal complies with al1
applicable orders, regulations. and guides
EnsuTe Iha! the hazard review procedure is readily available to person-
oel who IAlm conduc! the review
Periodically audl hazard review meetings and reports
Establish minimum training eriteria far hazard review leaders
EnsuTE' that all newly instaUed and/or modified equipment is included in
a nazard review prior lo slartup
EnsuTE' thal hazard revjew documentation is readily available to docu-
menl the content of the review and lo confirm that a review was per-
formed

Examples
An explosion occurred in a waste lank because incompatible materials were
mixed. The process hazards review had been performed. bul il failed lO
consider allthe possible SQUTCes of material that could be added lo the tank.

An explosion occurred in a waste tank after a new stJeam had been tied into
Ihe tank. No safety review had been performed prior lO tying in the stream lO
determine ir incompatible materials would be in the wasle lank after the lie in.

No analysis had been performed to determine the operational risks a5sociated

with a new conveyor syslem.
 ApPEND'~ A - Roo, CAUSl MAP NaDE DESCR/P'IONS Em
Typical Issue
Have me recommendations from the safetylhazardlrisk review been imple-
mented?

Typical Recommendations
Ensure that aJl hazard review recommendations are documented and
reviewed by managemenl personnel
Managemenl should address a hazard review recommendalions and
document lhe manner in which !he recommendation will be resolved
(i.e., assign a responsible party for completion or reject the recommen-
dalion with documented reasen for doing so)
Communicate hazard review recommendations to al! affeeted parlies
Documenl Ihe final resolution or implementalion of each recommenda-
tion
Publish periodic reports of resolution status for managemenl
Ensure !hal implementation of the recornmendations is assigned to a
specific group or individual

Examples
A release of hazardous material through a ruplure disk was discharged to the
dked area of the process. The hazard review had recommended installing a
ealeh lank. with a rain hoodlcover. to receive any discharged material. The
caleh tank had not been inSlalled because of scheduling conflicts wi!h OIher
construction in Ihe area. The released material reacted violently with rain
water in Ihe diked area, producing a large quantity of toxic gas.
As a result of a faeility risklreliabilily analysis. reeommendalions were made to
have a final inspection performed of unusual and parrial shipments io ensure
hat they are correcto This reeommendation had nol been implemented yet.

AoMIN1STlV.TM/MANAcEMENT SYSTEMS
a l Roen CAus( A"t4lY'S15 H~0800K

Typical Issues
Were the risk acceptance criteria use during Ihe safetylhazardirisk review sel
inappropriately? Were risks deemed acceplable tha! should have been re
duced?
Si"" .",'"
!l~. P.....
Typical Recommendations
EnsuTe Ihat a diverse learn (able lO reasonably as.sess risk) is nvolved in
Ihe hazard review
Develop more objeclive crileria for judging risll levels (e.g.. a simplified
risll scoring seheme ar listing required safeguards ror spe:cific situationsl
Previe guidance lo tearo members lO help enSUTe Ihat the reviews are
conducted properly

Examples
An explosion occurred when Ihe ncorred material was fed inlo the reactor.
The supplier had mislabeled he material. The hazard review had identified
this as a risk factor bUI concluded Iha! the risks associated with nol anaJyzing
the incoming materials were acceptable.
Campany CJiteria ar multiple layers o safeguards a110wed a large credit for
relief valves. As a result, insufficienl attention was given to reducing he
frequency o relief valve actu<Jtions.

ADMIN1STIlATIVf1MAN....GEM~NT SVSTEMS
 ApPENoix A - Roor CAUSE MAP NaDE DE5CR1PTIO.'l/S l:iIiIi
Typical Issues
Wa5 Ihe safetylhazardtrisk review procedure less than adequale? Does it
provide adequate guldance far the scope of the review? Are Ihe resources
needed to perform the revlew available? Are personnel trained In Ihe use of
the procedure?

Typical Recommendations
Ensure thal Ihe hazard review lechnique is approprlale for the complex-
ity of the process
Ensure Ihat aH newly instal1ed andlor modified equipment is induded in
a hazard review prior to starrup
Ensure mat hazard reviews comply witn al! applicable orders. regula-
tions. and guides (e.g., sorne provide specific checklists (or Ihe sa(ety/
hazard review)
Ensure Ihat Ihe revlew procedure addresses scope of analyses and
trainlng of hazard analysis leam leaders

Examples
A complex shutdown syslem failed lo mlligate a process upsel, resultlng in a
release of a hazardous material. The revlew procedure for the plant specified
that a HAZO? be performed for all new/modified systems: however. the
HAZOP procedure was nol well-suited fer analyzing this type of syslem (the
FMEA technlque would have been a better choice of technique).
A major spil1 violatlng an environmentaJ permit occurred at a process lhat
had recently undergone a hazard review. This type of spill. which had no
safety consequences, was nol addressed in the srudy because Ihe review
procedure did nol require evaluation of environmental halards.
A risk assessmenl was recentiy performed on a packaging operation. The risk
assessment did not address supply problems because the review procedure
did no! require Ihal lssue lo be considered. Laler. a fire at a key supplier's
facility led to a 4-week shuldown.

AOMINISTllAtrvMANAGEMENT SrSTEMs
mi Rom CAUSE ANAll'SIS HANOBCX>K

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AoMINlsTRAm'l/M.\NAC[MEN'T 5YSTEMS
 AI'PENDIX A - ROO1 CAUSE MAl' NOOE DEScIUP110NS &:1

Typical Issues
Was an event caused by failure lo provide corrective aClion for knov.m deficiencies or failure lo implement
recommended corrective actions before known deficiencies recur? Had Ihe problem occurred before and
never been reporled? Oid an audit faillo discover Ihe problem? Oid Ihe correclive actions implemented faH
lo corred the problem?
Note: JI the problemldeficiency could/shou/d haue been identified, or wos identi/ied In a soletylhazardlrisk
relJiew. then cade the elJent in that portion 01 the Map and nO! here.

Typical Recornmendatons
Track implemenlation o corrective aclions lo ensure timely complelion
Consider implemenling Ine same corrective aclions for similar situations allhis and other facilities
Measure Ihe effectiveness of corrective aclions
Periodically compare Ine results of audits with events thal occur in the facility io ensure thal audits are
effective in identifying problems

Examples
A lank overflowed because an operator ignored an audilory alarm in Ihe control syslem. The alarm, which
sounded spuriously about every 15 minutes. had been broken for more than 6 months. The problem had
been T:MJrted lo Ihe maintenance organization but ha<! nol been repaired.
A lank had overflowed when Ihe operalor started the wrong pump. None of the pump control swilches were
labeled. A corrective action Tom Ihis evenl was lo inslalllabels on [he pump swilches. Prior lo installation of
the labels, another pump was damaged when the operator siarted the wrong pump. The switches for these
pumps were notlabeled eilher.

AOMINI5TRATlvE/MANACiMENT SYSTEM5
 Typical Issues
Are personnel reporting events that have significam impacts on health, safety,
or reliability? Are personnel aware al the types of events thal should be
reported? Do they know how lO report Ihe events? Are employees punished
fer reporting problems?
Note: Coding lInder Rewardsllncentives LTA moyo/so be oppropriote.

Typical Recommendations
Develop evenlreporting guidelines
Provide training lo personnel on the types of events thal should be
reported. Make these examples as process specific as possible
Ensure hal Ihe evenl-reporting process is as simple as possible

Examples
An engineer noled oil dripping from a pump sea!. The process for reporting
and documenting Ihe problem required a 101 of forms lo be filled out. The
Corr..m.
engineer did nol wanl [O lake the time lo complete the forms. ~ a result, he
~,,,.~ (l'
did nol reporl Ihe problem.
An operalor reported a problem with Ihe drying oven he was using. The
Co"otl...
11.,1., ~.I".' lemperature control system had malfunctioned and a batch of product had
",. "'. been damaged. Company policy required individuals who reported problems
to help personnel correo lhe situation. As a result, Ihe operator was required
lo work overtime lo assisl wilh Ihe repairs and he missed Ihe college basket-
ball championship game on television. The nexl lime Ihe operalor discovered
a problem near Ihe end 01 his shitt, he did nol report il because he did not
wanl lo slay over paSI his shih.

AoMINISTRATM/MANAcEMlNT SYSTEMS
 ApPENDIX A - Roor USE MAl' NOVE DESCRIPTIONS lID
Typical Issu';S
Was. the problem misdiagnosed? Were knowledgeable personnel involved in
the problem analysis? Was proper emphasis placed on problem diagnosis?

Typical Recornrnendations
Develop generic methods for problem anaJysis such as the 5 Whys
technique. fault tree analysis. and/or causal factor charting
Train all personnello sorne level of troubleshooting. Provide appropri-
ate experts lo assist analysis leams
Have the results of the analysis reviewed by someone outside the
organization

Examples
An accident occurred in a reactor vessel. The incident investigation tearn
lhought the explosion was. caused by a lack of grounding on the tank. After a
second event, it was determned that the wrong malerials were being fed into
the tank and that this had triggered lhe explosion.
A root cause anaJysis team determined tha! spurious Shuldowns of a mixing
Une were caused by operalor errors. Subsequent shutdowns indicated lhat
electronic spikes were causing pressure spikes mat caused a safety systern to
actuale and shul down the lineo

AOMINISTRATlvE/MANAGEME"''T SVSTEMS
IJD ROOT CAuSE A ... AlYSIS HAND800IC

Typical Issues
Do audits find problems befare they cause safety, reliability. or Quality prob-
lems? Are audits performed al regular inlervals?

Typical Reommendations
EnsuTe tha! perjodic audits 01 systems important lO safety, reliahility. and
quality are developed
EnsuTE' thal audits are periodically implemented

Examples
An audir had been developed lO enSUTe hal personal prolective equipment
(hard hats. safety goggles. etc.) was being worn by plant personoe!. However.
the audt was only conducted once.
No audits hild been developed lo determine if quality assurance inspections
of final producls were being implementerl effeetively.

AoMINISTMTTVE/M.4.NACEMENT SYSTEMS
 A'PPfNOIX A - Roor CAuse MM' NODe DcsCRIPnONS aD
Typical Issues
Were implemented corrective aetions unsuccessful In prevenong recurrence?
Should other corrective actions have been identified? Were corrective actions
focused on correcting Ihe root causes of the problem?

Typical Recommendations
Involve a multidisciplinary team in identifying correetive actions to
ensure that the problem has becn fully analyzed
Rerer design/development of correclive aetions to specialists when
leams have difficuJty identifying practical solutions
Develop measures to delermine Ihe effectiveness of correclive actions
Trend event causes and rool causes lo determine ir correetive actions
are effective in prevenling recurrence

Examples
A problem wilh operalors bypassing alarms had been identfied. The correc-
tive aetion was lo administratively control alarm bypasses. After a couple of
years. the administrative control requirements were being ignored. Physical
changes to equipment may have been more successful in preventing bypass-
ing of alarms.
The procedure development process was modified to enSUTe that precautions
and warnings were placed in procedures where appropriate. However. an
audil of procedures performed ayear later identified hundreds of procedures
thal did nol have lhe proper precaulions and warnings.
An operator was fired for poor performance. The operator had produced a
number of bad batches. An experienced operalor was moved into this posi-
tion and also produced a number of bad batches. When the sysrem was
anaJyzed. it was determined that the control syslem was poorly designed and
could nol be easily controlled.
A gear looth failure destroyed the gear train of a printing press. Only those
gears with visibly damaged teelh were replaced. The press faHed again aboul
6 months later when another gear tooth. overstressed but nol visibly de
formed by the firsl incident. failed.

AOMINlsTRAnVf/MANAG[MfNT SVSTEM5
ai:iI ROOT USE AAAtYSIS HAND800K

Typical Issue
Was a recommended correctlve aetion for a known deficiency nol imple
menled (because of deJays in funding, delays in projecl designo normallength
af implementation cycJe. tracking deficiencies. elc) before recurrente 01 the
p.,~ .~ deficiency? Are correcllve aclions assigned lo specific groups ar individuals for
'''''':1';-
(t""O
implementatlon? Doe5 managemenl monilor the implementation of corrective
aClions?

P-;t ...
At"""il IA Typical Recornmendations
Ir a system is defidenl and requiTes correetlv!!: actions Ihal canoal be
implemented immediately, interim measures should be taken limpie
menling a temporary operatiog procedure. process parameler changes.
shuning equipmem clown. etc.)
Corrective acllons affecling safery should not be delayed because of
lack of funding, delays in projeet design, or normallength of the imple.
mentation cyele
The COSI of implementing corrective adions with significant impacts on
reliability and quality should be balanced 1gainsl lhe anticipated savings
from implementation
Ensure thal management periodically revieo..vs lhe status of corrective
actlOns
Reward personnel for completing correctlve adions

Examples
A tank collapsed under vacuum. An earlier hazard analyss recommended
vacuum breakers for Ihis type 01 lank, but fhese devices had no! yel been
installed.
A roo! cause analysis of a quality problem recommended thal special orders
be packaged in differenl colored tmrrels lo highlighl the need lor special
handling. Sinee this recommendation was made. 16 more instances 01 mis'
lakes with special orders occurred. The recommendation had never been
implemented.
An incident investig2llion recammended that small drain holes be drilled in rhe
discharge !ine af 2111 fire monitors to prevent accumulation of waler that could
freeze and plug the monitor. This recommendation had nol been imple-
mented befare anather fire occurred. and twa of the three monitors failed
because Ihey were plugged wilh ice.
An audit recommended shape coding 01 eerlain controls on !he conlTol panel
to avoid selection errors. This recammendation had not been implemented
when anolher batch of produc! was ruined as a resuh of an operalor switch
selectian error.

AoMINISTRATIvt/MANACEMENT SYSTfMS
 ApPC"DIX A - Roor CAUSE MAP NODC DCSCRIPrlONS mJ

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AOMINISTRATlvE/MANAGEMfNT SVSTEMS
Typical Issues
Was Ihe problem caused by inadequate matenal handling. slorage. packaging. Ol shipping? Was Ihe shelf life
for Ihe material cxceeded? Was an unauthonzed material subsmution made? Were spare parts inadequately
sloTec!' Was me problem caused by inadequate handling. storage, packaging, or Shlpping of finished prod-
Uet5?

Typical Recommendations
Ensure Ihal malerials are SlO,ed in a proper environmem
Inspect materials for damage uJX)n arrival al the facility
Provide proper packaging of finished products lO avojd damage duriog shipping
Provide proper environmenlal conditions fOl raw malerials and finished products lo ensure quaJity

Examples
As a result of improper abeliog. a grease was pli!lced mo inventory on Ihe wrong shelf in he supply room.
Sub:sequently, a pump falJed when this grease was use<! nslea<! of Ihe ene specified far thal pump.

Because of a snow slorm, prcxiuet could nol be shipped on schedule. The warehouse was full of finished
produet 50 il was lemporarily slored in nanow aisles in the process area. Some of lhe product was damaged
when an operalor ran inlo lhe skids wilh a forkhft.

AoMINISTR4TM/MANAGlMENT SYSTtMS
 A""EfYDIX A - Roo, CAUSE MA" NooE Dc.SCRIPnoIVS aiI
Typical Issues
Was maleriaVequipment/product damaged during handling? Were items
"mixed UpM during handling? Was Ihe equipment used for moving materials
appropriate for the items?
p.. do,1I
11I'1",,1
CO"I,OI
Typical Recommendations
Consider the size. weight. and hazards associated with transporting
materials, and choose a mode of lransport Ihat is approprale
Consider laooing equipment befare transporting it lo the field to ensure
that similar ilems are nol inadverlenuy swilcned

Examples
The wrong pump was insla!led in a [ine. The mecnanics were installing
Pl<hG"'G'
severa! pumps and had them aH on a cart. They were "mixed up" and in-
S~'~~J,';
staJled in the wrong localions.
'" Machined plates were p[aced in a cart for transport from one station lo the
U".'",nllC next. Recently, the cart had been repaired with screws thal were too long. As a
"'." ..1
h~OI'M ..n
result, some of the plates were scralched as they were p[aced on or removed
from Ihe cart.
~Kld,,<I A conveyor Ihat was used lo move brass fixtures to a packaginglocation
-.",11'<0
C,e.o.lU moved continuous[y. This caused Ihe fixtures to rotate fer long periods of time
while lhey were bunched up near the end al Ihe canveyor. As a resuh. Ihe
P"'''I
finish on some of the fixtures was marred.
l ,""

'"

AOM1NlSTRATM!MANAGEMENT SVSTEMS
1m Roor CAUSE ANALY:SIS H..v.:08001C

Typical Issues
Was material slored improperly' Was il damaged in storage? Oid il hlaV
weather damage? Was it S!ored in an environment (heal. cold. acid fumes.
etc.)lhat damaged II? Was produet properly stored? Were ffill.leriaLequip-
mentJpans issued aher Ihelr shelf Jire was exceeded? Oid malerials coolinue
~t~_",
... ".,
'0"'0
., lo be used after Ihe shelf Ife was exceeded? Were spare parts and equipment
slored properly? Was adeQuate preventlve maintenarx:e (c!eaning, lubrica-
tians, ele.) performed on spares?
...,,,,....,
Typica\ Recommendations
Ensure Ihat malerials thal require a controUed environment for slorage
are nol exposed lO Ihe weather
Befare stacking malerials in a warehouse, enSUTe tha! the contents and
Ihe packaging arE! compatible with this storage conliguratlon and wilJ
nol be damaged
Promptly COlTeel problems affecting slorage in controlled environments
(faHures of healinglcooling syslems, humidity control systems, elc.)

... ...
l!'c':.,
\j
~
S.U'._
'
Ensure lhal me proper environmenl is provided fer finished produet
For malerials with a shelf life. develop a system to document me
materiars shelf life. dale of manufl'loctuTe, and dale of distribulion
Assign stores employees lhe respensibility of ensuring lha! the shelf life
Prc:.l1
"'u"';' has nol been exceeded
t ... .~u
Ensure thal spare parts are nol exposecllO adverse welllher conditions
Promptly correet problems in equipmem storage conditions or envlron-
p .... u menlal control!> in warehouses
,",
I,,"~.:<o~.

Examples
An absorpbOn column inslalled lo remove contaminants from salvenl did nOI operaie as designed. Investiga- ,
lIon revealed lhal the absorben! matenal use<! to pack Ihe column had been stored outslde and uncovered.
The damage<! material reduced Ihe efficiency of Ihe column.

The air conditioning ~'Slem in the finished product slorage area al a glue foetory wos Inoperable for aboul a
week dunng ,he summer. The warehouse reached lemperarures of over 120 DE Some of the glues \A'ere
damaged (rom lhe excessive heat.

Rubber rubing use<! m the cooling syslem of penable generators cracked and failed The shelf life of me
rubber tublng IOslal1ed had been exceeded and me tublOg had become bnttle.

A pump failed shortly after installation. which was much earlier than anticipaled given the life expectancy of
Ihe pump. Invesligation revealed Ihat the pump had been !>tored in spare parts for a long lime Ouring the
storag;'. no preventive mainlenance. such as c1eaning and lubrication. had been perfonned as specified in
me manufacturer's in!>tTUetions for slorage.
 ArPENDIX A - Roor CAUSE MAP NODE DESCRIPr/ONS D11I

..
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.
" ,.;""1.'
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S,&I'''''
Typical Issues
Was material packaged properly? Was il damaged because of impropcr
packaging? Was equipment exposed fo adverse conditions because the
packaging had been damaged? Was the malerial transported properly? Was it
damaged during shipping?

Typical Recommendations
[nspecI malerials for damage upon initial alTival at the facillty
Ensure that packaging specifications are documcnled. communicated,
and dearly understoocl by the vendor
Provide directions for unpacking items so lhey are not damaged by the
customer
Ensure thal proper packaging memods are used for the final product

Examples
An electronic system incurred water damage because il was nol packaged in
waterproof packaging as specified in the packaging requirements.
An electronic device used far chemical analysis provided incorrect analysis
results. As a resull. 10,000 gallons of producI were laler found lO be unaccepl-
able. lnvestigalion revealed thal the electronic device had becn dropped off of
a forklift. Secause [here was no obvious physical damage. me manufaclUrer
shipped the device.
A waterbased coaling material was peeling off within several days of being
applied. This shipment of the coating material had frozen during rransport by
truck. Freezing changed lhe adhesiveness of he coating material.
Motorcycle windshields were packaged in cardboard boxes that were held
shul with large melal staples. Jf the staples were nol complelely pulled out of
the box, lhey would scratch the plastic wndshield when it was removed from
the package. making me windshield unusable.

AOM1NtSTRATIVf/MANAGEMENT SVSTEMS
mil Rom USf ANAlYSIS HANDOOOK

Typical Issues
Were nCOlTee! malerials substituted? Were material ar parts substituted
without authonzation? Did the requirements specify no subslitulion? Did
substitution of different materials adversely ",Hect he quaHty of he final
produc!?

Typical Recommendations
I Implement a management of change program
Train employees lo use tlle managemenl of change system
EnsuTe that lield!warehouse personnel understand the maoagement of
change system's importance lo them
Assess Ihe impao of maTerial subslitutions on he quality of the produd
produced
EnsuTe that materials are properly labeled lo preven! inadverlenl substi-
tulion
Artempt to design the process so mat only the corred item will fil

Ex.mples
A valve failed, causing a spill to he environmenl. The valve was not the one
specified fer Ihis service. Because the specified one was nol C1vailable. CI
substitute had been installed wilhout Ihe proper review and authorization.
A drawing indicated that 2" bol15 would be needed to instan a brackel. When
the mechanic actually performed the installation, 2.5' bolts were needed.
". ,."
""QI<I"'''
Instead of going back to the warehouse to gel me nghl size 00115, the me-
". chanic use<:! the 2" bolts wilh the nu15 only partially mreaded and no lock
washer. Later, lhe bracket fell off when the nuts vibrated off the bolts.

AoMINISTRATlVf/MANAGEMENT SYSTEMS
 , ApPENDIX A - Roen USE MAP NOOE DESCRIPT10NS DII
Typical Issues
Could the acceptance crileria for manufactured parts and finished products be
understood and implemented? Were the acceptance crilera clear and unam-
biguous?
Note: This node only opplies to produd (things made within your jadlity)
acceptance criterio. Acceprance criterio for purchosed materals (items re-
ceiued from our.side your faciliry) ore specified as part 01 the procuremenr
process ond are oddressed under Material Acceptance Requiremems LTA
(Procurement Control).

Typical Recommendations
Develop acceptance aitera for rnanufaetured parts, rnalerials, and
finished products
Ensure thal product acceptance tests can be reasonably implemented

Example
lnspection of loilet paper rolls ndude<! cheeks of the dirnensions of !he roll.
the adequacy of the paper rolling process, and the fragrance added to the roll.
Acceptance entena were specified for the roll dimensions and adequacy of the
Tolling process. No aceeplance erileria existed ror the adeQuacy of the fra-
granee leve!. As a result, sorne batches were shipped without Ihe required
fragrance.

AoMINISTRATIVf/MANAGEMENT SYSTEMS
DZI Rom USE ANAlYSIS HAND900K

Typical Issues
Was inspecllon of malerials performed in accordance with (he acceplance
requirements? D,d a lack of inspection lead to safety. reliability. or quality

.",.,,,
..."" ..1
C.'loo'
problems? Were manufaetured parts, materials. aod final products inspected
prior lo shipment? Can the inspection requirements be reasonably imple
mented' Do intellecn.tal produets (Le., reports. analyses. dala) mee! require-
ments?
Note: This node only appfies to materials ond work products produced wilhin
your adltly. Jnspections o/ 0/1 molerio/s ond work products receilJed from
outside lhe jacilily ore addressed as par! 01 the procuremenl process under
Material Inspections LTA (Procuremenl Control).

Typical Recommendations
EnsuTe lhal materiaVproduet inspections are performed in i'lccordance
with requirements
Provide dear inspection specificalions and melhods for producl tesling
Provide personnel wilh the capability lo implemenl lhe inspection
requirements

Examples
Acceplance crileria specified thal a moiSlUre lSt should be performed on a
sample of each shipmenl of powder. The warehouse was nollold who was
supposed lO do he lest. As a result, lhe matenal was shlpped withoui the test
being performed.
ProdUCI iospeclion requirements specified thal 10% of aH items be inspected
before shipmeol. When ooe of the quality assurance inspectors was gone
(e.g.. sick. in training), only 5% could be inspeeted wilhoui holding up ship-
ments. As a result, a number of bad lots of material were shipped.

AoMIN1STRATM/MANAGIMfNT S\'STfMS
 ApPENDIX A - Roor CAUSE MA.p NODE DESCRIPTlONS mi

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AoMINISTAATM/MANAGEMENT SY5TEMS
lID Rom USE AN...lYSIS HANOBOOIC

Typical Issues
Was the error tne resull 01 inadequate control 01 changes lo procurement specifications ar purchase orders?
Od a fabricaied item failta meel requirements or was an ncorreel item received? Oid produCl acceptance
requirements fail lo match design requirements or were lhey otherwise unacceptable? Were proper specifica-
110ns and evaluations used to selecl contractors?

Typical Recornmendations
Procuremenl specifications should not 00 changed without review and approval by knowledgeable
personnel
EnsuTe that acceplanc:e requirements are documented and match the design requirements
EnsuTe [hat Ihe contraetor SE!lection process considers Ihe mpac! on overall cost, reliabiliry, and quality

Example
A large tank was fabricated using an ncorreel grade 01 stainless steel because the buyer made an unaulho
rized change lO Ihe purchase arder, and the personnel who signed off on the arder did not detecl Ihe
change.

AoMINI5TRATIVl/MANAcEMENT 5YSTlMS
 ApPCNDIX A - Roor CAUSE MAP NODE DtsOUpnONS aa
Typical Issue
Oid the purchase specifications inelude (1) a schedule for delivery of the
materials. (2) m.nerial packaging and shipping requirements. (3) safety
requiremenls. (4) liability clauses, and (5) payrnent schedules?
Po..."", , Note: This node applies lo HOW items are obtained, nol WHAT is obCoined.
Con".1
See Material Acceptance Requirements LTA lar prob/ems re/oled to speci/ica-
tion o/ what was purchased.

Typical Recommendalion
Develop purchase spedfications wilh input from the technical contacts.
procuremenl spedalists, attorneys. and others in your company to
ensure ha! all contractual requiremenls are addressed

Example
A contracllo purchase logs from a supplier did nol inelude late delivery
penallies. As a result, the supplier was routinely a week or two behind sched-
ule.

AoMINISTlUTlvt!MANAGEMENT SVSTEMS
aD Roor USE ANAlVSIS HA.N0800K

TypicaJ Issues
Were changes made lO purchase orders 01 procurement specifications without
(he proper reviews and approvals? Did (he changes result in purchase o the
1,l...rong maleri",ls? Did changes in contrad language cause safety, reliability,

, ......!
qua]ry. or legal problems?
te,uol

Typical Recommendations
Inelude procurement control procedures in he management of change
program
Provide receipt inspection thal compares the malerials supplied againsl
the original plan! request

Examples
A pump made from Hastelloy e was ordered for use in a hypochlorite Jiquid
plant. Purchasing went out for bids on Hastelloy pumps (and did not specify
Hastelloy el. A Hastelloy B pump was received. and lailed after only 4 days
of service because of chemical attack.
During the purchasing process, the procurement speeialist bought
unformafted diskettes beeause they were eheaper. As a result, eaeh disk had
to be formaned by the user. This resulted in about 40 hours of wasled pro-
duetion time while the disks were formaned.
A contrad lo hire subcontraetors originally reqUlred the eontraetors to supply
hazardous material handling training to their personnel al Ihe contractor's
expense. This requiremenl was subsequently dropped. As a result. the com-
pany had lo pay for the training and pay the contrador for the time their
personnel spent in the training.

A batch of producl was ruined because of improper mixing of the compo-

nents. Purchasing had switched suppliers lo reduce costs. The feed material,
was now purchased at twice the concentration as befare. The management of
change s\lStem did not identify it as a change because the same material was
purchased fmm bolh suppliers.

AoMIN1ST1lATlVE/MANAGEMENT SVSTEMS
 Apf'ENDIX A- Roor CAUSE MAP NODE DESCRIPrlONS 1m
~~~ I$"f~.t
I.'f")'8"-
Typical Issues
5.m~.
Were acceptance crilena for raw malerials. spare parls. and process equip-
ment adequ8le? Was it easy lO determine if the material received was accepl-
able?
~'O"_'8'_' Note: This node applies lO problems re/ored lO WHAT wus purchused. Probo
Ce. 'e'
/ems associated wirh rhe process o[ obtoining. poying for, and deliuering rhe
material IS cauered under Purchasing Specificalions LTA.

Typical Recommendation
Develop acceplance criteria for raw materials. spare parts. and process
equipmenl
Have the warehouse personnel assist in the developmenl of he accep-
lance criteria lo ensure that they are clearly understood by mase who
will use them

Examples
Acceptance criteria specified that the bolts should have a Rockwel1-C hard-
ness oi 30. Warehouse personnel did not know what lhis meant or how lO
determine if the bolts met this specification.
Acceptance criteria specified Iha! the powder should nol contain excessive
JTloisture. Warehouse personnel did not know exactly whal lhis meant As a
result. they accepled matenal [hat was unusable.
Acceptance criteria had nol been developed for rubber gaskets used in a
process. The gaskcrs deteriorale rapldly lf they are nol individually sealed in
plastic. Without any acceplance criteria. the warehouse accepled a shlpmenl
of gaskets tha! were not individually wrapped and sealed

AOM1NISTRAflVf/MANAGfMENT SVSTEMS
 Typical Issues
\AJas the inspeetion of malerials performed jn accordance with the aceeptance
requirements? Old a lack of inspedion lead lo safety, reliability. or quality
problems? Were manufacrured parts or materials inspected prior to aeeep-
e, ,
tanee or use in your proeess? Can the inspection requiremenls be reasonably
C.,,. implemented? Do inteHectual produets (i.e.. reports. analyses. data) meet
requirements?
Note.: This nade only opplies ro moteri(lls ond work products prodlJced
ourside your jocility. lnspeetions oj 0/1 molerais ond work produas produced
wirhin your jociliry ore oddressed os port oj lhe producl material con/rol
process under Product lnspections LTA (ProductlMaterial Control).

Typical Recommendations
Ensure that material receipt inspections are performed in aecordance
with requirements
Provide elear inspection specifications and methods fer material aceep-
tance.
Provide personnel with the eapability to implement the inspection
requirements

C."",I.'
SIFt" l"
Examples
'" Aceeptanee criteria specified that a meisture test should be performed on a
sample of each shipmenr of powder reeeived frem a supplier. The warehouse
was not told who was supposed to do the test. As a resulto the material was
aceepted and used withouI the tesl being performed.
The acceptance criteria for a raw material specified that a lengthy test be
performed befare the material would be transferred from the tanker lo the
supply tanks. Another, less ngorous. test was often substituted to save time.
An outside contraclor was employed to perform a safety analysis of a sysleljll
in aecordanee wilh DSHA requirements. No one reviewed he contractors
repon prior lo dosing out the contrae!. The contractor failed to analyze a1l of
the partions of lhe system thal were In the $Cope of lhe contrae\.

AoMINISTRATIVuMANAGEMENT SVSTEMS
 Ap/,lNDIX A - Root CAusE MA.p NODE DESCRIPnONS El
Typical Issue
Does the contrador selection process address the lollowing: (1) safety requite
ments, (2) rraining. (3) habLilty. and (4) scheduhng?

"0''''''''."1
cu.!
Typical Recommendalion
Develop purchase specifications for contraet services with input from
he technicaJ contacts, procurement specialists. attorneys. and others in
your company to ensure that al1 contra.ctual requirements are addressed

Examples
A eontrad to hire subcontraclors did nol specify who was responsible for
paying for hazardous material handling training lor the contrae! personnel As
a resull. the eompany had to pay for the training and pay he contractor for
time their personne! spenl in the training.
The contraet for supplying maintenance personnel did no! specify lhal equipo
ment supplied and used by the contractor be subject to approvaJ by the
company. As a resull, the contractor used ladders and other equipment thal
did not meet aSMA requirements.

AOMlN1STRATlVf/M.-.NACEMENT SY5TEMS
El ROOT USf ANAtYSIS HANDBOOK

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AoMINISTRATIVE/MANAGEMENT SVSnMS
 AP/'ENDIX A - Roor CAUSE MAP NODE DESCRIP110N5 mm
Typical Issues
Were drwings or documentation nol complete or up-Io-date? Was control of design.field changes inad-
equate? Was the error caused by improper control of asbuilt documents? Was an "unofficlar' copy of a
procedure/drawing used?

Typical Recommendations
Train all employees to understand the difference befWeen a change and a replacement-in-kind.
Reld changes should be reviewed and approved
Periodically audit lo verify (hat al! official copies are updated

Examples
A batch of procluct was ruined because of improper mixing al the components. Purchasing had swilched
suppliers lo reduce costs. The feed material was now purchased at twice the concentration as befare. The
management of change syslem did not identify il as a change because the same material was purchased
trom both suppliers.
An operator was using an outofdate process drawing in the field because it coniained a1l of his markups.
The markups wre required lo corred errors on Ihe drawing and (O add additional inlormation the drawing
did not conlain.

AOMINISTRATIVf/MANAGEMfNT SVSTEMS
liE RoOT CAUSl ANAlY51S H"NDBOOK

Typical Issues
Was the chaoge to Ihe system identificd? Was Ihe definilion of chaoge LTA?
Od personoel understand Ihe definilion of "chaoge" versus "replacement-in-
kind"?

Typical Recommendations
Ensur tha! aulhorizalion signatures are ohtained from key personoel
befare design1field changes can be implemenled
Tram all employees lO understand a (haoge versus <lo replacement-in-
kind
Train employees on how 10 initiat a reqUe5t fer change
Provide specific examples of whal is and is nol a chaoge requiring
review

Examples
An 502 release occurred because a stiffer gasket was installed. The gaskel
installed (Quid last longer in this chemical slVce. bul would nol sea! properly
using previous jorque settings. Th' managemenl or change system defined
"replacementinkind" as use of ~similar or bener" malerials. Because the
maintenance department considered Ihe new gasket material superior. a
change review was nal perforrned.

A new supplier was selected lo supply producl barreis la the facility. BarreIs
from lhe new supplier were cheaper but only came in one color (black). This
caused shipment problems because differenl colored barreis had been used
prevlously lO easily ldenlify Ihe barrel conlents. Purchasing did not realize lhe
importance of the color coding.
A field modlfication lO an instrumenl alr hne ha lo be made lO rQute the line
around a waler line lhat was nol on lhe drawings used by he deslgner. ThlS
reroule crealed a low pont in lhe air Ioe where conlaminants collected. Th
ficld modification was not identific as a changc that requircd a re\liew.

AoMINISlltAT1VMANAG[M(NT 5VSTEMS
 ApPENDIX A- ROOT CAUSE MAP NODE OESCRIPTlONS ~

Typical Issues
Were new equipment or inSlal!ations verified to (onform to specifications prior
lo startup? Were new or modified eomponents functionally tested prior to
startup?
00""'""1'-:
CO'-';"."c.
C."..I Typical Recommendalions
Conduct a pre-slarlUp safety review for new or modified facilities. and
ensure Ihal aH requirements of the review have been mel before highly
hazardous chemieals are inrroduced into the process
Conducl an assessment of field changes and new installations lo ensure
proper operation of the equipmenl folJowlng startup

Examples
A control valve failed lO the WTong pasillon upon loss of instrumenl airo A pre-
startup safety review was nol performed because Ihe valve was installed as
part of a replacemenl-in-kind.

COWO'O' A new air eompressor was installed. A pre-slartup review of the installation
Ofl", ..1
00'_"'"'." lH was performed to ensure that it was inslal1ed correctly. However. no opera-
tional tesIs of Ihe compressor were performed. As a result, the compressor
failed saon after slarlUp beeause of an insufficienl cooling waler supply.

AOMlNISTItATlVE/MANAGEMENT SVSHMS
III!II Rom USE ANAlYSIS HAND800K

Trpical Issues
Were drawings and documenls updated when changes \VeTe made? Did
documen~drawjngs reflect the current status? Do documents contain al! 01
the required informalion? Do documenls used in the fletd hav markups to
make them usefuP
Note: This nade app/ies primarily lO drowings and operarar aids. Procedure
contem problems are oddressed under Procedures. Problems associoted with
(he conten! 01 SPACs are oddressed under SPACs LTA.

Trpical Recommendations
Require authorization signatures for al] designlfield changes
lnelude the task 01 updating drawings aod procedures in the document
change tracking system
SeUci! input from documenl users on required changcs.
lnvolve the document uSrs in periodic reviews and updates 01 the
documents
Consider conducting mandatory walkthroughs in the field foJlowing
construction !o confirm that official documents accuralely reflecl actual
design

Examples
A senling tank was moved 4 leet from its original locauon to allow for proper
forkljft access to other equipment This field change was nol indicated in lhe
final design documenta!ion As a result. a skid-mounted demineraliler inslalla-
!ion had lO be field mocilfied because lhe settlmg lank took up par! of the
floor to be used tor mstallalion of the demineraliler Skld.
Two system modirications were being implemenled concurrently: however.
the design engineers did nol know this. The drawings did nol indicalE' that
changes were pending from lhese IVJO modifications. As l result. changes
lmplemented by he first modification were undone by implemenlalion o the
second modificalion.

An acid spill occurred during opening of a Une break. Lockouts had ben
made based on current drawings. The drav:ings were not up-lo-date and did
not show an acid stream lhal had been lied into the lne 3 months earlier. The
syslem lhal existed for controlling documenls was not adequale. The organi-
zation was 6 months behind on upclating marked-up drawings and distribul-
ng new copies to all official documenl holders.

AoMlNrSTRATlvE/MANACEMENT SVSTEMS
 ApPENDIX A - Roor USE MAP NODE DESCRIPTIONS am
Typical Issues
Did a system exist for controlling documents? Did the system provide melh-
ods for keeping documents up-to-date? Were aH necessary documents avail-
able? Were aH officiaJ copies of each document updated? Were al! unofficial
copies or outdaled copies found or disposed ol? Are procedures. standards.
policies. and other omcial documenls used in the field current?
Note: This nade applies to the distribution 01 documents. Problems re/oted to
the content 01 the document are addressed under Documentation Contenl
LTA or Not Kept Up-to-Date.

V"~~Il"" "1
On 'l'l/FItOll
Typical Recommendalions
C.'"'lutl.
(N"PSS~l Search and destroy" unoffidaJ copies Qf documents
PeriodicaJly conducl an audit lo enSUTe that al! officiaJ copies are up-
dated

Example
Maintenance personnel onen made printouts o( procedures tha! they kept at
their workstations. That way Ihey did nol need lO get a new copy of the
procedure each time. However, they dld not check (or updales each time
befare use.

AoM1N1S1RATlVE/MANAG[MENT SVSTEMS
~ ROOT USE ANAlYSIS HANDaooK

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AOMINlSTRATlVJ/MANAGfMENT SYSTEMS
 AnENDIX A- Roor CAUSE MA1' NOOE DESCRIPTIONS EI:I:ii
Typical Issues
Are there problems associated with the customer interface? Are customer needs identified? Are customer
needs addressed?

Typical Recommendations
Develop a system to solicit feedback from customers
Develop a system to aIlow customers to easily contad your company
Ensure thal euslomer requests are promptly addressed

Examples
A customer required special praducl packaging to allow it lo quickly load the praduct into its system. Sorne
shipments were made using the spedal container while others were not. This requiremenl was nol always
passed on lo !he planl personne!.
Customers ordered materlals from a catalogo Not aJl ilems in the catalog were heing manufactured. Customer
service sti1l accepted orders fer these items because they wer not lold that they were no longer being made.

AoM1NISTIlATlvE!MANAcEMENT Sl'STEMS
ami Roor USE ANAt.VSIS HANDSOOK

Typical Issues
Are cuslomer requirements for producIs identlfied? ls there a mechanism in
place lo solieil customer requirements?

c~.~ ...' Typical Recommendations

IOlOfoo"
S.. " ...
Provide incentives lo personnel to salici! and darify CUSfomer require-
ments
Provide l means lo handle special orders and requests

Examples
A customer initial1y ordered 20,000 pounds of material A. Later. lhe customer
changed the arder to 30,000 pounds of material B. Thi5 change was never
inpuI inlo he arder system. As l resulto he u,Tong material was deJivered fa
the cuslomer.
A printer used l standard blue color to produce pamphlets for a dient. A
CUSlomized blue color should have been used lo match other advertising
malerials used by the c1ient. The prinler jusI assumed Ih81 l standard color
{which is less expensivel was what Ihe client wanled.

AoMINISTAATrvtlMANAGEMENT SYSHMS
 ApPENDJX A - Roor USE MAP NODE DESClllPrlONS liIIim
Typical Issues
Ate cuslomer needs paSsed on through the organization lo mase who need to
know aboul them? Are there methods to produce products that meet unusual
requirements?
C"':OH'
,",.rt".
s....... Typical Recommendalions
Ensure that customer r2quirements are passed 00 to al1 those in the
organization who need lO know about them
Provde a rneans lo flag special orders lo make them easy lo dentify

Example
A custorner requred special product packaging lo allow illo quickly load the
product into its system. Sorne shipments were made using the special con-
tainer whJe others were noto This requrement was no! always passed on to
the plant personnel.

AOMINISTIlATlVl/MANAcEMENT SVSHMS
EiI RooT USE ANAtYSIS HANOltOOk

Typical Issues
Were tnere problems in addressing the customer requirements? Can all
customer requirements be addressed? Were customer selVice personne[
helpful? Were customer service personnel courteous?

Typical Recommendations
Provide a melhod lo clase the loop. Compare the product lO the origi~
nal cuslomer requirements
Develop a system to track special orders
When probtems are encountered. follow up Wilh the customer to cJarify
what wenl Wfong. EJ'sure ha! follow.up actions are taken lO preven!
recurrence

Example
Special cuslamer orders were taken by he cuslomer service center and
passed on lo the plant. The planl placed a iow priority on these tems because
they would inlerrupl normal production. As a resull, mQSt special orders were
delivered several weeks after he promised delivery dale.

AoMINI5TRATTVF1MANAcEMENT SVSTEM5
ApPENDIX A - RooT CAUSE M.4" NODE DCSCRIPTIQNS BID
Typical Issues
Was a procedure used to perform the job? Was
the procedure incorrect or incomplete? Was a
procedure developed far the job? Was a proce-
dure required lo perform the job?
Note: Procedures prouide detai/ed, stepby-step
direetions on how to accomplish a task. Guidance
documents thm prouide general guidance and
principies should be addressed under SPACs LTA
or SPACs Not Used {AdministrativeIManagemenl
Syslems}.

Typical Recornrnendations
Ensure thal copies of procedures are
avaUable far warker use ar alt limes
EnsuTe thal proceduTes are in a standard,
easy-to-read format
Perform a walkthrough of new and revised
procedures
Use lookup tables ins!ead of requiring
calculalions lo be performed

Examples
An operator failed to complete a crilical slep in
an operalion because the procedure he obtained
trom the procedure files was no! lhe most recen!
revision,
A new operalor faHed lO complete a crilical step
becaus the procedure was not detailed enough:
il was written as a guideline/reminder for experi-
enced operators.

PROCEDUlU5
liIiI Rcxn USE AAAlYSIS HANDIlOO"

Typical Issues
Was a procedure use<! lo perlorm he job? Was a
copy of the procedure available la Ihe warker?
Dd Ihe procedure system require lhal Ihe proce-
dure be used as a task reference or was il jusI for
rraining? Were personnel required lO take copies
of Ihe procedures lO Ihe (jetd? Should the use af
Ihe procedure be required even Ihough il was nol
in the past? Was a procedure written for this task?

Typical Recommendations
EnsuTe thal copies af procedures are
availabJe for worker use at all times
Dvelop procedures wilh sufficienl delail
for he leas! experienced. qualified worker
Supplement training and reterenee maten-
als with easylo-carry checklists Ihat parallel
a procedure

Examples
An operator made a valving error. He performed
he task without using the controlled procedure
because he wouJd have had to make a copy of
Ihe master.
A mechanic incorrectly performed a repair job on
a key pump withoul using Ihe procedure. Me
chanics were no! required lo use !he procedure in
Ihe fieJd because il was for training purposes
only. However. using the procedure in he fieki
would probably have prevented the error made
by the mechanic.

PROCfOUR(S
 ApPENQIX A - Roor CA.USE MA.p NaDE DESCR/PTlONS . , .

Typical Issues
Oid a procedure exist lar the job ar task being performed? WlJS the procedure
readily available? Was there a copy of Ihe procedure in the designated file,
shelf, ar rack? Was there a "master copy" of the procedure available for
reproduction?

Typical Recommendations
Place copies of operations and maintenance procedures in the appropri-
ate work areas so that the procedures are ALWAYS avallable for person-
nel use
Maintain master copies of al! procedures and control access to these
masters

Examples
An operator made a valvng error. He did not use the controlled procedure
because it would have required him to make a copy of the master. Instead he
used the procedure copy he had at his workstation. This procedure was oul-
Ho Pro<o~." of-dale.
I.,r...
An electrician was troubleshooling a large breaker. After determinjng what the
problem was. she should have obtained a copy of Ihe procedure (or replace-
ment of the chargng springs. Bul mat would have required her to return lo
the maintenance shop. So she replaced the spring based on memory. As a
resull. a plant startup was delayed when the breaker failed to close.

PROCEOURES
am ROOT USE AAAlY515 HAND8001(

Typical Issues
Considering the rraining aod experience o he user. was the procedure too
difflcult lo understand ar follow? Was sufficient information available lo
identify ,he appropriale procedure? Was the procedure designed far he "less
practiced" user? Was procedure use inconvenient because of working modi-
tiaos le.g.. tighl quarters. weather. protedive clothing)?
Note: Dual coding under Misleading/Confusing (Procedures) moyo/so be
appropriare.

Typical Recommendations
Di:!velop procedures such Iha! Ihe contenl provides he leas! experi-
enced employee with adequi'll direction lo successfully complete
required tasks
Choose a procedure formal hat is easy lo Tead aod follow
ChQOSl" a procedure formal that s approprial lo the leve! of complex-
ity of the task
If certain job lasks require an employee lo be in an awkward pasilion or
Ho pOU~"'
'01 tUl to wear uncomfortable personal protective equipment. make procedure
use as convenient as passible by posling applicable procedures at eye
leve! in an easy.lo.read fonnat in these specific locations
lf tasks require reference in me field to a procedure. ensure mal employ
ees are provided with a concise yet complete (with no references to
olher procedures) procedure (or checklisl) Ihal is easy lo carry and use
in the field Oike a one- or twopage printout of the perlmenl procedurel

Examples
An inexperienced mechanic made a mislake installing a piece of equipmenl.
The mechanic did not take a copy of the procedure wilh him because il was
long. it used lermino!ogy that he did not understand. and he fe!! he under:
stood the task well enough.
An inexperienced mechanic made a mistake inslalling a piece of equipment.
The procedure slated only to remove the old ilem and replace it Wilh a similar
unit. This WBS nol delailed enough for the inexperienced mechanic.
The operator did nol use Ihe procedure because 01 ils numerous cross
references to olher procedures. To carry all of them would have required a
large notebook.

PR<>CtOURES
 ApPENDIX A - Roor CAUSE MAP NaDE DrsCRIPJlONS 11m
Typical Issues
Was the procedure classified fer training and reference? Based upon the
significance or difficulty of the job, should the procedure have been classified
as a "use every time" procedure?

"01 U."
Typical Recornmendalions
Procedures classified as reference procedures should contain very few
steps. If the number of sleps is loo overwhelming for shorHenn
memory. il should be classifled as a "use every time" procedure
Training and reference manuals may need to be supplemented by:
- easyto-carry checklists that parallellhe procedure
- more detailed stepby-slep procedures for "use every time" if the
training and reference manuals are loo cumbersome

Examples
An operator made a valving error, resulling in a tank overflow. He did nol
take a copy of the procedure with him because il was for reference, and he
>lo P,... o...
lo< la"
Ihought he knew how lo perform Ihe valving operation.
A mechanic incorreetly performed a repair job on a key pump without using
Ihe procedure. Mechanics were not required lO use Ihe procedure in the field
because il was fer training purposes only. However. using Ihe procedure in the
field would probably have prevented Ihe error marle by lhe mechanic.

PROCEOURES
II1I:I Roer CAUSE AAAlYSIS HANDBOOK

Typical Issue
Was there a procedure far this task?

Typical Recommendations
Develop a procedure for the task
EnsuTe tha! aH modes o operalion, all maintenance aclivilies. aod aJl
spedal activities have wrirten procedures

Example
A mechanic under-torqued a flange. He performed the job without a proce-
dure because one did nol exist fOT he task.

PROCfOURES
ApPENDIX A- Roor USE MA.p NODE DCSCRIPrlONS a:m
Typical Issues
Was an evenl caused by an error made while
following or trying lo follow a procedure? Was !he
procedure misleading or confusmg?

Typical Recommendations
Ensure Ihal procedures are in a standard.
easy-lo-read forma!
Ensure tha! procedures use Ihe appropriate
level of detai] for he complexity and fre-
queney of a task
Use look-up tables inslead of requiring
calculalions lo be performed
Use specific component idenlifiers

Examples
An operator incorrectly completed a step of a
procedure requiring him lo open six vaJves. He
skipped one of the valves. The procedure did not
have a checkoff space for each valve.
An operalor overfilled a tank. The procedure
required him ro calculate the n.mning time of the
fitl pump. A look-up lable with the inilial lank level
and Ihe corresponding fill pump run rime should
have been provided.

PROCEDUIUS
~ ROOT CAUSE NALYSIS HANOBOOIC

Typical Issues
Od the layout of the procedure make jI difficult lo follow? Od the formal
differ from thal which the user was accustomed 10 using? Were the sleps of
the procedure logically grouped?
Do warnings ot cautions cantajo information that should be contained in
procedure steps? Ate importan! warnings and cautions embedded in proce-
dure steps?
15 me procedure formal appropriate for the task? ls a now charl used when a
checklisl is more appropriale? [5 a checklist used when a T-bar formal is mOTe
appropriate?

Typical Recommendalions
EnsuTe that procedures are in an easy-to-read formal. Use color codes
(ar chaoge paper color) when appropriate.
Avoid using the narrative ar paragraph formal; personnel tend lO gel
losl in a sea of print. The T-bar. nowchart. ar checklisl formats are
highly effective
Choose one or two effective formats and use these same formals
consislently Ihroughout the facility. The formal for a troubleshooling
guide may be inappropriate for a step-by-slep startup procedure
Ust procedure sleps in a logical. sequential order. A1so, be sure thal any
special precautions are lisled al he beginning of the procedure
Review procedures to ensure hat warnings and cautions are presented
in a consistent formal in a1l procedures
Involve procedure users in the procedure developmenl process. Have
an inexperienced user review the procedure lO ensure lhal sufficient
delail is provided
Use checklisls for verification processes and initial alignmenlS of sys-
lems
Use fiowcharts when decisions affect which part of Ihe procedure s
implemented fe.g .. a troubleshooting guide. or an emergency proce
dure Ihal requires diagnosis of Ihe probleml

PROCEDURES
 ApPENDIX A- Root CWSE MAP NODE OESCRll'rJOf'tlS mm
Examples
An opetator made a mistake while performing a slartup procedure. The procedure was confusing because it
required the operator to complele part of section A, then B, back to A. then to e, back lo A, then lO D and E.
The operator failed lo 90 back lo A after completing C.
Each step in Ihe procedure was numbered. Subsequenllevels of subsleps were numbered by adding a
decimal point and another sel of numhers. The procedure used too many levels on substeps (Le. a slep was
numbered 2.3.6.5.1.1.1.1.5). As a result, he operator skipped a step in the procedure.
A troubleshooting guide was developed using a checklist formal. The mechanics did nol understand how lO
move Ihrough the procedure: they jusi compleled Ihe ilems they thoughl were appropriale.
A procedure was developed by an engineer in a paragraph formal. Aboul half of Ihe informalion in the
procedure was design informanon Ihallhe operalors did not need.

PROCEDURES
El Roer CwSE ANA.LVSIS HAND8001C

Typical Issues
Od any steps in the procedure have more than one aclion or direction lO
perform? Oid sorne steps in the procedure state ene aclien, which. in prac-
tice, adual1y required severa! sleps lo perform?

.. '!"~"i
CO","fL'g
Typical Recommendations
Avoid bread procedure sleps such as "Charge the reactor." lnstead, use
this as a subheading and ndude allthe steps assodated with charging
the reactor below the heading
Do nol assume thal an employee will remember aU the steps associated
with an aetion item. Clearly communicate aH !he required sleps assod
ated with an actien item so ha! the least experienced employee can
successfully perform Ihe required job tasks

Example
An operatoT failed lo c10se a valve. resulling in a tank overflow. The instruc-
tion lO clase the valve was one of six aclions required in one slep 01 the
IttO'O.flt procedure. He complered rhe olher five actions bul overlooked dosing the
e' ....'
valve, which was he fourlh action in Ihe step.

PRQCEDUIUS
 ApPENOIX A - Roor CAUSE MAP NODE DESCRIPnON$ .mm
Typical Issues
Was an error made because each separate action in a slep dd nol nave a
checkoff space provided? ls the procedure complex and critical enough to
require checkoffs?
....."'....i'
C'.lu'''i
Typical Recommendations
For actions [hal require multple steps, ensure lhal aH [he sleps are
specifical1y deflned. When appropriale. inelude a checkoff space for
each of these individual sleps so that the emp[oyee can be certain Ihal
he/she has performed this step
11 is a 9000 praetice to design procedures Wilh enough ~white space" (by
indentation, ne spacing, etc.) lo aUow users ro keep ther place when
using Ihe procedure

Example
An operator failed lo open a valve. The procedure required him to open
seven valves. He missed one, opening Ihe olher six. A separale checkoff
1""";.11" space for each valve manipulalon was nol provided in Ihe procedure.
COto""

~'"''II"'"''
CoMu''"i
.'
11..",,,,,"",1
~f~,I""'.IS

PROCEDURES
mm ROOT CAUSE ANAL'rSIS HANDIlOOK

Typical Issues
lf el checklist was necessary, was it confusing? Was enough room provided far
th response ar did il require unique responses for each step? Od each
instruction (regardless of formal) c1early indicate what was required? Was a
detailed checklist required for a lask {ha! was no! very importan!?

Typical Recommendations
Develop a checklisl far al! safety-crilical tasks lo previde a quick refer-
enee far inexperienced and experienced users
Require iha! checklists be turned in if necessary for Quality assurance
Avoid using checklists inslead of supervision lO enSUTe ha! lasks aTE!'
performed correctly because checklists can easily be filled out before aT
after Ihe task: if supervision is required, Iheo providl2 a supervisor
lnelude the unique system response lo be expeeted when an employee
completes each step of a checklist
Provide enough white space on the checkllst so Ihat the employee may
record the system response so that expecled as well as unexpecled
responses can be documenled
Ensure thal checklists are only developed for critical tasks. Overuse of
checklists will reduce their effectiveness on critical rasks

Examples
An operalor failed to complete one step of a procedure. The procedure
~"~'i"O.' .'
required a check at the completion of each step. Because il did nol require
Cccl<''''i
"''''''b''t unique responses for the steps. the operator completed the procedure and
~oc ,..'(.
then checked off all the steps at one lime.
A checklist was designed so that the desirable answer to mosl questions (23
out of 26) was yes. As a resuJI. lhe Ihree remainmg questions were aften
answered incarreetly.

'''"~o<Ulo'
~'<O"fi'
~'I""<t.

PROClOURES
 AppeNDIX A- Roer CAuse MItP NODe DESCRIPTlONS mm
Typk,, Issues
Was an error made because graphics or drawings were of peor quality? Were
the graphics or drawings undear, confusing, or misleading? Were graphics.
induding data sheets, legible? Would a graphic (diagram, pieture, chart. elc.)
have made a significanl redudion in the likelihood of this error were it
provided?

Typical Recommendations
o For hard.copy graphics hat have been reproduced, ensure that the
copy is easy to read (e.g., nolloo dark, too light. or splotchy)
Indude color cocling on graphics when possible for easy use
o Ensure that the graphics accurately depict actual process operalions
ancVor equipment configuration
Do not overwhelm the user with too many graphics on one screen or
one sheet of papero Information should nol appear crowded
The texl should support the graphics
Rowcharts can be very effective graphics ror tasks that reqUlre decision
making and branching

Examples
A mechanic replaced the wrong seal on a large piece of equipment. The sea!
thal he was to remove was shaded on he drawing, bul he cauld not deter-
mme WhlCh seal was shaded because the copy was of peor quality.
An electrician incorrectly lerminated a wire. The wire lerminalions were
shown on Ihe installation diagram. The procedure copy he was using was nol
legible because it was made from a copy of a copy of a copy of the original.
An operator opene<.! Iwo valves in the wrong sequence during a complex
procedure to backwash an enclosed rotary filler containing highly reactive
peroxides. A diagram of Ihe filler (showing equipmentlabels) and proper
'"""fhr.,*", o, labeling of Ihe filler valving would have greatly cJarified Ihe procedure.
["".",
Roto'oo,..
An operator had lO determine if (he reaclor's temperature and pressure were
acceplable. The acceplable tempe:ralUre was dependent on the pressure. The
operator had a long set of !ook-up tables that listed the acceptable tempera-
ture (Or each pressure. A pressuretemperature graph indicating acceplable
and unaccepiable regions would nave reduced errors.

PROCEOURES
mm Rom CwS[ ANAlYStS HANOIlOOK

Typical Issues
Were the instructions in the procedure undear? eouJd they be interpreted in
more han one way? Was the language ar grarnmar undear complex?

Typical Recommendations
Have procedures vaJidaled by a team of subject matter experts (work.
ers) and by walkthroughs in the field
Te find difficult steps. have the newesl emp]oyee walk through the
procedure wilhoul coaching
A110w technicaJ edilors lo review procedures lo enSUTe tha! ambiguous
lerms have been avoided
Perform a hazard review 01 critical procedures lO determine olher
accidenl scenarios related lo errors in procedures and lo determine if
sufficienl safeguards are provided agains! employees nol following Ihe
wrinen procedures

Examples
,"U'Q. . t. An inslTUction called tor cuning XYZ rods ioto lO-foot-long pieces. The iment
C. ' .....l
was to have pieces 10 feel long. The person cuning Ihe pieces cut 10 pieces.
each a foollong.
A step in !he rool cause analysis procedure stated "Use Ihe RCM to assist in
determining the management syslem deficiencies [hat contribuled 10 !he
evenl." The supervisor assumed il meant lo use reHability-centered maime
nance nol the Roo! Cause Map.

PROaOURES
 ApPENOIX A - ROOT CAUSE MA,p NaDE DcscRIPnaNs lE
Typical Issues
Was the error made because of a mistake in recording or transferring data?
Were caJculalions performed ncorreetly? Was the formula or equation contus-
ng? Did it have multiple steps?
Note: Consider dual coding with Ambiguous ar Canfusing Instructionsl
Requirements or More Than One Action per Step

Typical Recommendations
Avoid procedures that reQuire employees lO make manual calculations.
Instead. pravide employees with pre-caJculated tables or warksheets
with easy-to-fill-in blanks and with thorough traning in their use. Or.
automate ca1culations within the syslem
Perform a hazard review of critical procedures lO determine ather
accident scenarias related lo errors in procedures and to determine if
sufficient safeguards are provided against employees nol fallowing the
written procedures

Example
A procedure required the operator to calculate the weight of produd in the
tank based on Ihe empty weight of he tank and Ihe curren! weight af he
tank. 80th af Ihese values were displayed on the computer. The operator
made an error in subtracting the numbers. The computer display could be
modified to display this number and eliminate the need for the calcuJations.

'",_Wi<.oIn. 0'
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A.'""...

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PROCEDURlS
a:rJ ROOT USE ANAlVSIS HAH0800K

Typical Issues
Oid the procedure Tefer lo en excessiv number af addilional procedures? Oid
he procedure cantain numerous steps of the type "Calculale limits per proce-
dure )0(2"? Was the procedure difficult lo fol1ow because of excessive branch-
ing olher procedures? Od the procedure cenlaio numerous steps of he
lO
type '"If X. heo 90 lo procedure ABe. If Y, theo 90 lo procedure EFG"? Oid
the procedure cantaio numemus references lo olher parts of Ihe procedure?
Oid il cantain sleps of Ihe type "If the malerial is acceptable. 90 lo Step 13,3.
Ir he material is unacceptable. 90 lo Slep 12.4. If Ihe test canoat be run. TedO
Slep 4 and contact your supervisor. ~

Typical Recommendalions
Ust 2111 information thal en employee musl have in arder lo perfonn a
specific task in Ihe procedure designated for this task. If the same infor~
mation is required lo perform different tasks. repeal Ihe information in
each procedure
Do nol branch (reference) lo more han one other procedure (module)
from a procedure
InUOQ".IO Procedures intended for slep-by-slep use in the plantlfield need lo
c,,",~r"l
conlain all required tasks; an employee is unlikely lO return to Ihe filel
manual to gel any referenced procedure
Perform a hazard review of critica! procedures to determine other
accidenl scenarios related lO errors in procedures and to determine ir
sufficient safeguards are provided againsl employees nOI following lhe
wrinen procedures
Use a flowchart lo determine the corred procedure steps io be imple-
menled. Avoid too many jumps within a procedure

Example
An operator exceeded an operaiing limil. The primary procedure did not
conlain the limits but referred to four olher procedures lo find the limits. When
checkmg his resulis against !he limiis. he looked 311he wrong limil in one of
the referenced procedures.

PROCEOUHES
 ApPCNDIX A- ROOT CAUSE MAl' NaDE DESCRIPTlONS EED
Typical Issues
Was the procedure user required to carry out actions different from those he
was accustomed tO doing? Did the procedure identify that the slep for the
adion had been revised? Oid the procedure user perform the action as the
previous revision specjfled rather than the current revision?

Typical Recommendations
Ensure that procedure changes are managed. and that al1 official copies
are updated and all unofficial copies desrroyed
Clearly idenlify (such as with a sidebar) which stepslinformation have
changed. and ensure that all employees are trained in or informed o
changes
Avoid the use of muhiple area references within a procedure

Example
An opera!or incorreetJy completed a step of a procedure. The operator was
experenced and performed the action as he always hado The new procedure
(which had been correctly updated) was not marked to indicate that the step
had recently been revised, and the operator did not realize tha! a change had
been made.

PROCEOURES
lIIi'i ROOT USf ANAlYSIS HAN0800K

Typical Issues
Do the procedures provide loo little delail lo ensuTe proper performance of
Ihe lask by Ihe mos! inexperienced operator? Do Ihe proceduTes have loo
mueh detail?

Typical Recommendation
Consicler using an audioe formal with high level steps for experil"nced
U5ers and delailed steps for ine:xperienced users

Examples
The instruclions fer a computer software program jusi stated "change Ihe
loading preferences lO user-<iefined values.~ No further directions were
provided on how this could be done.
An engineer developed a procedure in paragraph formato Aboul half of Ihe
information in Ihe proce<lure was design informalion Iha! Ihe operators did
nol nced.
An operations procedure for Ihe shutdown o Ihe cooling water syslem
included specific sleps on how lo clase manually operaled valves. This
information was no! needed in the procedure because i! was a common
operator skill !ha! did not require any task-specific knowledge.

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A.q ...... n"

PROaDIJRES
 ApPENDIX A - ROOT CA.USE MA.p NODE DESCRIPTIONS El
Typical Issues
15 il difficult to identify the corred procedure to use? Do many procedures
nave similar names? Are the procedures far differenl units dearly dislinguisn-
able trom one another?

Typical Recornrnendations
Inelude a header at the lop of each procedure page that indudes Ihe
procedure number, p<'Ige number. procedure revision. and unit number
Use different colored paper for each unit's procedures (Le .. blue for Unit
1. pink for Unil 2)
Provide dear, descriptive names for each procedure

Examples
An operalor osed the \AIl'ong procedure to slart up compressor 3A. There were
three procedures labeted "5tartup of Compressor 3~ (for compressors 3A. 38.
and 3C). The procedure he used was for compressor 3C.
A mechanic incorrectly calibrated a pressure transminer. A page from l
similar procedure was inadverlently substituled into his calibration procedure.
Individual procedure pages did not contain procedure titles or procedure
numbers. so Ihe subslituted page was difficu[t to distinguish fmm !he others.

PIlOCEOUItES
mm Rom USI ANALVSIS H"NOBOOlo:

Typicallssues
Was the procedure incorreel? Did he procedure
faillo address el situation that occurred during
performance o the task? Is the procedure consis-
tent with lhe installed equipment?

Typical Recommendations
EnsuTe hal procedures are technically
revtewed
Perform a walkthrough o procedures

Examples
A mechanic made a mistake calibrating a piece o
equipmenl because the procedure specified lhe
wrong limits.
An operalor ruined a batch o produet when he
incorrectly operated lhe computer control system.
New software had been installed. bul lile proce-
dure had nol been updated lo be consisten! wilh
lhe new software.
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5 1<1,
c "

.......
'oc"...

D.......... ' ..,

PROCfOURES
 ApPENDIX A - Roor USE MAP NODE DfSCRIPTlONS BID
Typical Issue
Was a rypographicaJ error in the procedure responsible for the eVll!nl?

Typical Recommendations
Use a word processor lo electronically spell.check the procedure imme-
diately after it has been typed
A1low a technical editor to review procedures for typographical errors
A1low employees lO revieo.v procedures for accuracy. 501icil feedback
from employees

Examples
An operator made a miSlake because the procedure containe<! the wrong
limil. The maximum temperalure was supposed to be 38 e, but the proce-
dure said 48 C. The mistake was made during typing and not caught by the
validators.
An operator overfilled a tank because of a procedure error. The procedure
should have stated "Hold the valve open for 34 seconds. ~ The typist inad-
vertently removed the hyphen (when the spell-checker in the 'Nord processing
software: nagged this polential misspelling) and the procedure then read,
Hold the valve open tor 34 seconds.'
1""'''''1
lo' ..
~ "'.,,,

PROCEDURES
liIID Rom CAUSf ANAlY$IS HAN0800k

Typical Issue
Were the ins01..lctions/steps in the procedure out of sequence?

Typical Recommendations
W'"O~<o"':"I.
Have procedures validated by l team o subjecI maner experts (wark-
ersl and by walkthroughs in the Aeld
Perform a hazard review af critical procedures to determine other
1 f~o~"P~".1
E"., accidenl scenarios related lo eITan in procedures and to determine if
sufficienl safeguards are provided againsl employees nol following the
written procedures

Example
An operalor made l mislake oocause he sleps were out o sequence in l
procedure. Step 5 directed the operator lo transfer material from Tank A lo
Tank B. Step 7 direded the operalor lo sample he contents o Tank A befare
transferring.

().. ,;a~., G.~<

Bu
0",",..

PROCEDURES
 ApPENO/X A- ROOT CAUse MAP NaoE DESCRJPTIONS EIIiI
Typical Issues
Was specific information in the procedure incorred? Djd the procedure
contajn current requirements? Oid the procedure refiect the current status of
equipment?

Typical Recommendations
Have procedures validated by a team of subject matler experls (work.
ers) and by walkthroughs in the field
Perform a hazard review of critical procedures to determine other
accident scenarios related to errors in procedures and to determine ir
sufficient safeguards are provided against employees nol rollowing Ihe
written procedures

Example
A safety limit was violated because the procedure did not contajn the current
limils. The Iimits had been changed. but the master procedure had not been
revised.

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B.I .
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I"'O,"~"I.I
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Co.. roa

PROCEOURES
am: Roer USE ANAlYS1S HANDBOOK

Typical Issues
Was specific information in the procedure ncorrect? Oid the procedure
cenlaio current requirements? Did the procedure Tenect the currenl status of
equipmenl? Was. an olcler version of the procedure used because il was too
difficult to obtain a currenl copy?

Typical Recommendations
EnsuTe tha.t only current copies of procedures are available
Seek out and desrroy old versions of the procedures
Consider incorporating nfarmarion added by operators lo their "per-
sona,)"" copies of procedures

Examples
A safety limil was violaled because the procedure did nol cootain the current
Jimits. The limits had heen changed, bul the master procedure had nol been
revised.
An operator liked lo use his markedup version of the procedure because il
containecl the syslem operating limits. which were contained in a differen!
procedure. The operalor always checked his personal version for updates. but
he missed adding a recent change. As a result, he shut down the process
when he performed the procedure incorrectJy.

PIlOCEOUIlES
 ApPlNOIX A - Roor CAUSE MAP NODE DESCRfPnONS .mm
Typical Issues
Did different procedures related to Ihe same task contain differen! require-
ments? Were there conflicting or inconsislent requiremenis stated in differenl
sleps of the same procedure? Were requirements stated in different units?

Typical Recommendalions
Have procedures validaled by a leam of subject matter experts (work.
ers) and by walklhroughs in the field
Tyoo~'"''''''
e"~r Perform a hazard review of critical procedures to determine olher
accident scenarios related to errors in procedures and to determine if
sufficient safeguarrls are provided againsl employees not following the
wrihen procedures

Examples
An operalor exceeded the environmenlal discharge limits. A caulion in he
procedure slated the flow rate limil in pounds per hour of material. The
procedure slep slated the limil in gallons per minute. The operator sel Ihe flow
rate based on !he gaHons per minute limil, which was less restrictive in Ihis
""".
The procedure said lO send Ihe eompleted form lo the PSM Coordinator. but
the forrn itseJf had a note on Ihe botiom Ihal said to send ilto Ihe operalions
manager.
A eaulion staled Ihal Ihe cover of the delector should nol be opened until
power was disconnecled (after Slep 12). Bul Slep 9 said, ''Afler removing Ihe
eover, push the red huhon to discharge Ihe capacitor."

PROCfOURES
 liIIIiI KOOT CAUSE NAIYSIS HANDBOQK

,ru..... Typical Issues

Were delails af the procedure ncomplete? Was sufficiem infonnation pre-
sented? Oid the procedure address all situaran! Ukely 10 occur during the
completion of the procedure? Was a critica! step missing?
Note: This node addresses specific issues that ore not included in o proce
dure 1/ procedures in general do nOC halle a sufficient leuel DI deuril, consider
coding under Level of DetaH LTA (Procedures, MisleadinglConfusing),

Typical Recommendations
Ensure that alI mode:s of operation. all mainlenance adivines, aOO all
special activities hllve written procedures
Perform a hazard review af critlcaI procedures to determine other
&Ciclenl scenarios re1aled lO errors in procedures and 10 determine if
sufficiem safeguards are provided against employees nol foUOIN'ng the
written procedures

Examples
A mechanic did nol correctly replllce a pump. The instnJction staled lo
"'replace the pump. ~ Numerous adian! were required lo replace the pump,
including en eleetricallockoUl, which was incorrectly performed.

Asevere decomposition and release of chlorine occuned when !he OperatOT

failed to check the strenglh of caustic in the neutralizer. The procedure did nol
nelude an instruction fer this step, a1lheugh most operators did perform this
check.

PROClDURfS
 ApPENOIX A - Roor CAuse MAl' NOOE DEScRIPnoNs fiIEi

TypicaJ Issues
Are lhere gaps between procedures thal are u.sed in sequence? Do multiple
procedures cover me same task?

Typical Recommendations
Develop a procedure development plan lO allocate tasKs between
procedures
Review procedures lo determine overlaps between them
T.Q'~"~"<l1
t,'o. Perform a walkthrough of the procedures lO idenlify overlap or gaps
between them

Examples
An operalor slarled up lhe planl air syslem using the slartup procedure. He
then checked (he normal operations procedure and it a[so contained a
sedion on starting up me syslem.
The operator started the cooling waler system using procedure CW-N-Ol.
Normal Cooling Water Syslem Slarlup. He then began Ihe startup of three
feed pumps using procedure FP-N-Ol. Slartup of lhe Feed System. Gaps
existed belWeen Ihese lWO procedures. Key steps were missing that were
supposed to be performed after startup of the cooling water syslem and
before startup of the feed system.
A booster pump on a pipeline was nol included in lhe mainlenance or
operations procedures. The divisions upstream and downstream of the pump
each thoughl (he pump was the responsibility of the other division.

Pll:OCEDUll:ES
EiI Rom USE AAAlYSlS HANDBOOI(

Typical Issues
Were. the capabiities and limitations of humans considered in he designo development. production, and
control of systems? 15 the layout of me workplace adequale' 15 me work environment excessively noisy, ho!.
ar cold? Does he task impose an excessive physical ar mental workload? Can the system tolerale faults?

Typical Recommendations
Locale relaled controls and ndicallans together
Provide employees with adequate per!>Onal prolective c10thing such as hearing protection. gloves. and
safety glasses. Ensure ha! they are available in differenl si2es lo ensure a comforlable f1t
Reduce Ihe complexity of control systems
Provide feedback lO (he operator so [hal he/she can lel! if actions are performed correctIy

HUMAN FAaoltS ENGINURINC

 ApPENDIX A - Roor CAUSE MAP NaoE DESCRIPTIONS EJ

hamples
An operator. assigned the responsibility of monitoring a compuler screen for an enlire 8-hour shift. failed lo
detect an important signa!.
An operalor failed lO control the flow rate in a process because the flow rale meter could nol be seen from
Ihe location where the f10w was controJled.
An operalor inadvertently swilched on Ihe VJl'oog pump because allthree pumps swilches looked the same
and were nol labeled.
An operator was supposed lo open cartens of materials. Jt was difficult to oblain ulility knives from the
warehouse (they never seemed lo have Ihem in slock!. so Ihe eperator eften used a screwdriver lo apeo he
packages. As a result, sorne of the items were scratched by !he Iip ef the screwdriver. .

HUMAN FACTORS ENCINE[RINC

. , Roer USE ANAlYSIS HAND800K

..........
5"""

,-
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Typicallssues
Did inadequate controls ar displays contribule lo !he error? Was poor inlegration al controls and displays a
factor? Oid differences in equipment between differenl processes ar aTeas contribute lo the problem? Oid
pooT ammgement or placemen! of equipment contrihule lo toe event? Was there a failure lo approprialely
and clearly label aH controls. displays, aOO other equipment?

Typical Recommendations
Ensure that operalors are provided with sufficienl information lo control the process
Locate relate<:! controls and indications te>gether
FoJlow expected norms in labeling and layout al conrrols and indications (e.g.. left lo rigol, lop lo
bottom progression, consisten! color cocles)

Examples
In cne processing plant, two units performed the same fundion. Each unit had a separale control room. The
control rooms were identical excepllhat they were mirror images of one another. An operator, normally
assigned lo the first unit. causcd a serious process upset when he was assigned lo work in the second unit.

The controller for an aulomalic valve was tOC<lled on the front side of a vertical panel. The f10w indication
for the line was on the back side of the panel. A mirrar was installed so Ihe operalar could see the f10w
indication while adjusling Ihe valve position. However, Ihe reversed image in the mirror caused problems in
selting the corred valve position.

HuMo\N FACTOIlS ENGINEERINC

 ApPENDIX A - Roor CAUSE MM' NaDE DESCRIPnONS mil
Typical Issues
Od jnadequale quipmenl controls ar control systems (e.g.. push-hultans.
rotary controls. Jhandles, keyoperaled cantrols. Ihumbwheels. swilches, joy
slicks) contribute lo Ihe occurrence? Oid Ihe control fail to provide an ad
equafe range of control for the function il performs? Was the control jnad-
equlllely proteeted from accidental activation? Were similar contrals
indistinguishable fram ane anolher? Oid one switch control a numher of
parameters or have differenl functions under diHerenl conditions?
Oid inadequate displays or display systems (e.g.. gauges, meters, lighl indica-
tors. graphic recorders. counlers, video display terminalsl conlribute to the
occurrence? Did Ihe display fan to provide all information aboul syslem slaNs
and parameler values needed to meel lask requirements? Dd Ihe configura-
tion of the display make informanon diHicult lo see or lO inlerprel? Was il
necessary for the user lo convert informalion presenled by the display prior
lo ...... 01 to using it? Did unnecessary or redundant information contribute to the
C.'''oI$.D''~''I
error?
'"
Note: Arrangemenr 01 controls is addressed by ControVDisplay Integralion/
Arrangemenl LTA. The location 01 controls is addressed by Location of
ControlsIDisplays LTA.

Typical Recommendations
Configure controls such thal il would be difficult lO accidentally activate
Ihem
ll~l"'g 01
t~O'll"".I.'
Ensure Ihal similar controls have dislinguishable features
l."'.. " l Tl Ensure thal he device/display allows Ihe necessary range of control
(e.g.. O-lOO GPM control dial would be inappropriale if the flow some-
limes required seltings as high as 110 GPM)
Ensure that sensinvity of controls allows an operalor lO quickly and
accuralely make process changes
Ensure thal displays provde enough nformalion about the process so
Ihat the operalors can adequately control it
Configure displays so Ihallhey are easy to read and interpret
Ensure Ihat similar controls have dislinguishable fealUres
Provide direcl display of Ihe necessary paramelers so Ihal operalors do
nol have lo convert the informaion for ji lO be usable
Display only he informalion thal is necessarylhelpful to safely and
efficiently controllhe process
Avoid he use of dual purpose controls. Provide one control for each
parameter being controlled

-
HUMAN F"CTORS ENG1N(ERING
liI:I:I ROOf CAUSE ANAtVSl5 HANDBOOK

Examples
The operalor o a remotely driven crane inadvertently dropped the load being ralsed. The keys on the
keypad he was using lo opera!e lhe crane were very small and close together. The operator's fingers, even
though they were average size, were too targe to accurately press ene button wilhout inadvertently pressing
he surrounding keys.

During an emergency, an operalor made he even! worse by increasing flow inslead of stopping f1ow. AlI
f10w controllers in the plan! were moved counlerdockwise lo reduce flow excepl for the ene nvolved in this
even!. 1I was moved cJockwise lo reduce flow. This violated the standard practice al this planto
An operator made m error in reading a meter because of the unusual seale progression. Instead of a seale
with major markings divided by units ef five (Le .. 5. 10. 15, 20), the seale was divided into units of six (i.e.,
6, 12, 18, 24).
A digital display was used to monitor the flow rate of a system. The system responded slowly to control
changes. This required the operalor lo write down values at various times to create a time lag. A chart
recorder would have been a more appropriate type of display.

HUMAN FAaoRS ENGINEER1NG

 ApPt:NDIX A - ROOT CAUSE MAl' NaDe DlSCRIPTlONS EJ
Hu"'''
f.<t..
Typical Issues
~'9"''''"'i Was there a failure to arrange related controls and displays of the readouts of
these controls clase lo each other? Was a display arranged so that il was
obscured during manipulation of Ihe related control? Were controVdisplay
relationships undear to the user? Was he response of a display to control
movements inconsistent, unpredictable. ar incompatible wilh populaional
stereotypes or with the user's expectations? Was there difficulty with multiple
dlsplays being operated by a single control? 15 here a clear relationship
between !he conlrots and the displays? Were conlrols localed near the dis-
plays they affeded? Can the operator read me display while adjus!ing Ihe
control? Are controVdisplay arrangements consislent wilh populational
stereotypes?

Typical Recommendations
Configure the control panel so !hat it is easy lO locate relaled conrrols
and displays
Locale displays so Ihallhe relaled control can be manipulated while
watching the display
Ensure Ihat the control and ils displays are directly related ID one
another (Le., if pressure is displayed, the corresponding control should
direetly affect pressure as opposed to another parameleT. like tempera-
'me)
Ensure that each display re5ponds consislently with populational
s!ereotypes when the control is manipulated (e.g.. the display shows a
quantitative increase when a control is turned clockwise)
Ensute that one display is provided f or every control
Ensure thal there is dear mapping be.ween Ihe controls and displays

Examples
The temperature control had numbers on the dial !hal ranged Tom O to 100.
The lemperature indication also ranged Tom Oto 100C. However. setting
Ihe dialto 75 did nol result in a temperature of 75 OC.
An operator sellhe flow rale improperly. The procedure specified the flow
tale in gallons per minute. The display indicaled pounds per haur.
The operalor incarrectly started pump O instead of pump B. The pump
controls are all identical and arranged in reverse alphabetical arder from leh
e
lO right Iike this: E O 8 A This violates a slereotype that conlrols will be in
alphabetical arder from left lo righl.
The controls for Ihree pumps were arranged differently than Il1e pumps
Ihemselves.
There were three sections of lights in Ihe room (front, middle. and backl.
However. the [ighl switches were not in Ihe same arrangemenl. The light
switch far Ihe back lights was located clasesl lo lhe Tonl of he room_

HUAv.N FACTORS ENGlNEERING

II1II Rom USl ANA!.VS1S HANOB<X>tC

Typical Issues
Were there problems related lo the location of controls ar displays? Wer(! they
OUI of the noma! work area?

Typical Recommendations
l...ocate conb'ols in convenient locations lo encourage their proper use
Locale displays in convenient locations to encourage thE!ir use
Locate displays 50 thallhey can be read by the average perseo
Locale controls so !hat they can be easily ope:Tatecl by me average
pe<>cn
l..ocale controls so !ha! they are not accidently bumped

Examples
A 1.&rge control handle on a control panel stuck out beyond the edge o the
panel when the pump was running. Someone walking past lhe plInel acci-
dently bumped the switch and shut down me pump. This resuilec! in a pro-
cess upset.
The speed control lar a pump was located three f100rs below the normal
operating area. As a resolt, OperatoTS ignom:f oul-of-Iolerance conditions
~cause they did nol want lo 90 up and down me three f1jghts of stairs.

The onty open space on a control panel was near the f100r. As a result, a new
char1 recorder was installed 6 inches above the Ooor. To read the display, me
operntors had lo gel down 00 lheir hands ane! knees 5ometimes!he opera-
lors juSI looked at the display while standing cmd guessed at the readings.

HUMAN F"CTO~ ENCINURING

 ApPENOIX A - Roor CAUSE MAP NOOE DESCR,pnONS mm
Typical Issue
Oid differences in controls, displays, or olher equipmeni be[Ween differenl
processes or areas cOnlnbute to the event?

Typical Recommendations
Ensure that color codes consislently have the same meaning on al!
control boards in he facHity
Ensure Ihat denlical units have identical control board configuralions
Label similar componenls in sequenlial order: ASe nol ACS

Examples
Two compuler syslems, locaied side-by-side in the facility, were programmed
using differenl color schemes. On the firsl system. Ihe color red indicated an
apen valve and green mdicated a dosed valve. On the second system. green
indicated normal and red indicaied an abnOl'Tlal condition. Because of the
inconsistency In color coding be[Ween the two systems, an operator who
normally worked on Ihe first system al10wed a lank lO overflow when he was
temporarily assigned lo the second system. His mindset was that green indi-
cated lack of flow,
An operator inadvertently started the wrong pump. The cooling water pumps
are arranged alphabelically (A-O) trom 112ft to right However, the control
panel has the controls arranged as fol1ows:
A e
BD
In one processing plant. IWO unilS performed the same function. Each unit
had a separale control room. The control rocms were identical except Ihat
they were mirror images of one anolher. An operalar. normally asslgned lO
the firsl unit, caused a serious process upsec when he was assigned lO \VorK in
the second uni!.

HUMA.N FACTORS ENCINEERING

~ ROOT CAU51 MAlVSIS H.4.N0800K

Typical Issues
15 equipment (10015. work surfaces. supplies) that personnel need lO perform
their jobs conveniently located? ls il accessible by workers when needed?

w..~, Typical Recommendalions

lit""

Ask workers aboul problems they nave encountered in locating needed

tools
Locale 100ls and supplies so thal workers will have access lO them
when needed. Consider back shifts md weekend access
Review work slanons lO ensure tha! proper ergonomics aTe being
implemented

Examples
l.CI~." .' An o~rator needed lo make a copy of a procedure fa use in the startup o a
C."'.i''Olutal'
system. His printer was out of papero The paper supply was locked in Ihe
'" supply room. As a resull, he spent 45 minutes locating enough paper by
taking il from other prinlers.
AH tools were retumed ro a centTallool crib each night. As a result. mechanics
spent 30 minutes at he beginning of each day obtaining the tools they
needed for the day and 20 minutes returning them at the end of each da",.

A11 batch recipes were supposed lo be shredded aher use in !he field. How-
ever. the only shredder was on the olher side oi the plan!. As a resull, many
operators jusI threw them in the waste basket

HUMAN fACTORS ENGINWUNG

 AI'I'ENDIX A - Roo, CAUSE MAl' NOOE DESCRIPTJONS aIEJ

Typical Issues
Was there a failure lo approprialely and c1earl~' label all eontrols. dispJays, or
olher equipmenl items Ihal had lo be localed, idenlified, or manipulaled by
Ihe user during performance of a task? Did labeling fail lo clearly idenlify
equipment? Did labeling incorrect1y idenlify equipmenl? Were labels hard lo
read. incorree!, or rnisleading?

Typical Recommendations
Ensure Ihal aH controls and displays are labeled correctly
Ensure Ihal labels are made with an easY-lo-read Ion! and are color
eoded if necessary
Locale aH labels close lo the related eontroVdisplay
Mainlain labels d5 neeessary (elean. ensure reliable adhesive. etc.)
Ensure eQuipmenl locations or localions of malerials are properly
labeled
Ensure eQuipmenl bins in the warehouse are properly labeled

Examples
An operalor seleeted lhe wrong valv! from a eonfiguration of 20 valves
because more Ihan half of lhe valves in Ihe group were unlabeled. The
E~."'"'.'l
l.'IIIO" l. H
adhesive used lO attaeh labels to the valves was nol reliable in the acidic
environmenl in which Ihe valves were loealed: Iherefore, many of lhe labels
had fallen lo the naor. The operator tried to judge which was the correel
valve using Ihe labels Iha! remained altaehed.
An operalor opened Ihe WTong valve. ClIusing a transfer error. The rabel was
posilioned betv.,oeen tv.,oo valves. forcing Ihe operalor 10 ehaose betv.,oeen tnem.
A row of bins in the warehouse eonlained different rypes of bolts. The labels
for Ine bins had parl numbers on hem. bul no equipmenl descriplions. As a
resull. some items were ineorrectly reslocked after bemg returned to Ihe
warehouse.

-- HUMAN FACTORS ENClNEERING

rDiI RoOT CAL'S( AMlrsls HAN0800lC

Typical Issues
Dld stressors in he work enVlronment. 5uch as poor housekeeping. extreme heal ar cold. inadequate light
109. ar excessive noise. contribule lO me error? Was the problem caused by difficulnes associated wilh
protective c1othing' Were there olher streSsors present In Ihe work aTea thal may have contrihuled lO the
problem (12.9.. vihratlOn, movement constriction. hi9h jeopardy or T1sk)? Were (he right 10015 available lo do
the job'

Typical Recommendations
Remove unused equipment and plpmg
Provlde employees Wilh adequ.ate personal protec!ive c10lhing 5uth as hearing protection. gloves. and
~fety glasses EnSUTe hat they are availllble in differE'nt sizes to ensure a comfortable fit
Ensure hal he nght tool5 are available 10 do the Job

Examples
An operatar received a cut lO her head when she bumped inlo an overhead pipe. The lighting in he area
was nol sufficient ro delecl overhead obslacles.
A step was missed during performance of a job. The operalor humed through lhe job because jI required
hlm lo wear a resplrator and work 10 a confined space. None of Ihe available respirators fil comfonably.

HUMAN FACTORS ENCINHItI"llC

 ApPENDIX A - Roor CAUSE M.-,p NaDE DfSCRIPT/ONS EJ

Typical Issues
Oid poor housekeeping conditions contribule to Ihe event? Was the error
caused by a cluttered work environment? Was an unsafe siluaton erealed by
a sloppy workplaee?
>\".,
E-,~,-"""!

Typical Recommendations
Ensure Ihal work areas are mainlained in a clean, organized manner
Remove ldemolish) unused eQuipmenl and piping

Example
A mechanic received a puncture wound to his hand when he reached mo a
tool bex and came inlo canlael wilh an open pen knife, The 1001 bex was full
of old rags and crumpled papel. Iherefore. the mechanic was unable lo delecl
the hazard.
An operalor needed to check the operating records from a couple monlhs
ago. The records were s!<'red on magnetic tape carlridges. The cartridges
were labeled. bul were just lhrown in a drawer. As a resulto it look the opera-
lar 25 minutes lO locale Ihe corred tape.

Ot""
E','';"'"''''
s,......
1:,,,.. ,,

HUMAN fAoolls ENGINHII:ING

~ Rom CAusE ANAlYSIS HAN0800k

Typical Issues
Were the propeT lools supplied lo do lile job right? Were Ihe 10015 in good
condition?

Typical Recommendations
Provide the right lools lo do Ihe job righl
Ensure worn 10015 are repaired Of replaced

Example
A mainlenance helper was assigned the task of checking batteries in smoke
alarms in the affiee aTeas of Ihe plant. He was nol aJlowed to use ea voltmeter
lO check lhe condition of the 9volt baneiles (only eleetricians cauld use
vo]tmelers). So he stuck the batteries on his tongue lo see if they were sriU
good.
A carpenter was using ea hammer with ea wom handle. When he was pulling
out ea nail. the handle broke and the earpenter mjured hlS elbow.

HUM4N fAcrORS ENGINEUING

 ArPfNDIX A - Roor use MAr NODe DEScRrpnONS am
Typical Issues
Oid prOlectlve clothing or equipment (e.g.. plaslic suit. gloves. respiralor)
contribule lO the difficulty? Oid protective clolhing or equipment significantly
diminish any of the senses (i e .. sight, louch. smell. hearing. or laste) neces
sary to perform the task? Were personnel reQuired lO wear protective clolhing
or equipment for an uncomfortable length of lime' Were personnel required
to dress in and OUI of prolective clolhing an excessive number of times?

Typical Recommendations
Ensure that protective clolhing is available in differenl sizes so thal all
employees can be properly fiMed
If several consecutive tasks require that protective clothmg be worn for a
long time, investigate the possibilities of using more comfortable profec-
tive clolhing designs (e.g.. loaser or lighter fil) or prolective c10thing
made with more comfortable material (e'9" "brealhable~ fabric)
If prolective c10thing dimlnishes senses requlred lO complete ihe task.
investigate altering the c1othing, jf possible, so tha! personnel may
perform fheir dUlies effectively

Examples
An operator wearing a fullface respirator was injured when he walked into
Ihe palh of a forklift. The respirator reduced his perjpheral vision: therefore.
he did nol Se Ihe forklift coming trom his leh slde.
An operator using an overhead crane allowed the load to collide with operal-
ing equipmenl. The proledive gloves he was wearing prevented hlm trom
accurately manipulating Ihe crane's conrrols.
An operator splashed sorne alkalme catalyst onto his hands. causing asevere
chemical burn. while manually loading Ihe calalysl into a vessel. The operalor
was wearjng gloves. but the gloves were nol chemicalty resistant.

HUfoUN fAcrORS ENGINEfRING

DiJ Roer CAUSE AMlYSIS HAND800K

Typical Issues
Was the even! caused by excesslve exposure of personnel to a ho! ar (old
environment? Was poor ventilation O.e.. poor aiT quality or inadequClte air
velodty) a contributar lO (he event? Was Ihe effed af rain. snow. elc.. a
factor?
"e"
E",,,,.,,
Was the event caused because lIuminatian [evels were nol sufficienl tor lask
performance? Did the level of iIlumination vary greatly over a given work
stalion? Was he error caused by failure lO provide supplemenrallighling for
personnel performing specialized visuallasks in areas in which fixed iIIumina
tion was nol adequate? Was there snadowing af lahels. instruclions. er olher
written inform!ltian? Was there a problem with glare ar renectioo? lf he Venl
occurred during an emergency situation. such as loss 01 power. was emer-
gency lighting inadequate?
Was the evenl caused by diminished human performance caused by exces-
sive noise? Were personneJ unabJe lO hear auditory signals or aJarms because
of excessive background noise? Oid auditory distraction. irritation, or faligue
of personnel result from excessive noise?

Typical Recommendalions
Ensure thal indoar work areas are adequalely ventilaled and heated/
cooled
Allow personnel to take frequent breaks if they are required lo work in
an uncontrolled. uncomfortable climate for extended periods 01 time
Consider the need tor roafing or walls over work areas tar which
prolection from wind and precipitalion reduces the hazards of operatlon
and maintenance
Salidt comments from employees regarding work station lighting.
Address any comments received
Provide nonglare sareens for computer monitors
Conduct an emergency drill at night and uSe emergency lighting. Solid!
employee feedback to determine whether or not the Iightlng is adequale
for emergency operations.revacuation
InstalJ additionaJ equipment to diminish workplace noise when possibJe
(e.g., mufflers. sound enclosures)
Fbst danger signs in areas in WhlCh noise is in excess of 85 dB to alen
employees lO wear hearing protection in Ihose areas
Ensure Ihal emergency aJarms and the emergency public address
system can be heard throughout Ihe process area

HUMAN fAcrollS ENGINff~ING

 AN'fNDIX A- Roo' Cwsc MAl' Nooc DCSCtltPTlONS gm
Examples
During an extreme cold spell, a mechanic damaged an ex....?nsive piece of eQuipmem by dropplOg a 1001 inlo
lts moving parts. Even Ihough me medlanic v.'as wearing gloves. his hands were so cold !hal he was unable
to gel a fltm grip on the 1001.
A senous incidenl occurred v.:hen glare caused by improper overhead lighting prevented an operalor from
detectlng Ihal an important annuncialor tile was i1luminaled.
During a loss of power i!Venl. an operaror was inJured v.hile attemptlOg lO Iroubleshoot the emergency
generator. ughting levels frcm Ihe conrrol room [O !he generator v.ere insuffident. and he ran imo a forklih
on his way to the generalor,
A computer operator flliled to respond tO a syslem afatm because background noise from Ihe compurer's
cooling fllns masked Ihe audilory a1arm signa!.

--
HUMAN FACTORS ENGINHRI"'G
liIIiiJ ROOT USE NAlYSIS HANOBOOK

Typical Issues
Was Ihe error el resull o environmental stressors other han poor housekeep-
og. inadequale climale control. poor lighting, a noisy work area, or problems
with protective clolhing? Was Ine worker rushed to gel he job done? Was
'NO" there pressure to gel Ihe job done lo allow Ihe syslem lo be restarted? Od he!
EM"OO"'f'1
she perceive Iha! he/she was al risk?

Typical Recommendation
When possibJe. reduce cerlaln physiological and psychological stresses
5uch as:
- paio aT discomfort caused by seating, etc.
- hunger er thirst
- vibration
"',"<1'"
- movement constriction
C "'; disruption o circadian rhythm
h.' n' tlA
- high-risk job
- perceived threal (e.g.. of failure ar job 1055)
- monolonous, degrading. ar meaningless work

Examples
A jackhammer operator was injured when he dropped his jackhammer on his
foo!. He had been using the tool for severa! hours without relief. and the
constan! vibration caused his hands lo 'fal! asleep." This weakened his grip
and caused him to lose control of Ihe jackhammer.

Working m a confined space contributed to an event because pe:rsonnel

rushed ihrough the job to get out of the higher-risk environment.

HUMAN FACTORS ENGINEERING

 1 pPE.....DIX A - Rom USE MAl' NOD! DCSCR/PIIONS mm
"o"
'"" . o.
l; .".

Typical Issues
Were loo many tasKs required for the number of available operalors? Was the error caused by a siruation or
syslem being complex and requiring a decision based on specifc knowledge for a successful oUlcome? Were
syslem conlIols so complex thallhey contribuled lo user error? Did Ihe system impase unrealistic moniloring
or mental processing requirements?

Typical Recommendations
Provide 10015 lO make decision making easier and lO reduce the chances of human error
Reduce the complexity of control systems
Do not place workers 10 situalions requiring extended. unevenul vigilance

Examples
Eight maintenance lasks were in progress al the same lime. The control room operator had lO perform sorne
steps for each of these lasks. He was lO transfer Ihe contents of tank A lO tank B lO suppon one of the
maintenance lasks. While he was involved wilh another lask. tank B overflowed.
The audible alarm on the loxic gas detector was inoperable. An operator was assigned to watch the toxic gas
melers far an enlire 8hour shift to detecl a toxic gas release. The operator failed lO notice a release when il
occurred.

HUMAN FACTORS ENGINHRlNG

ami Roen USE NAlYSIS HANDBOOK

Typical Issues
Were the system ar equipment controls so complex thal they contribuled lo ar
cauSd Ihe event? Could the system have been designed with simpler controls
so ha! the chance of error was reduced?

WQ(.IoIQ
Typical Recommendations
Automate the syslem so thal an employee is nol required lo constantly
manipulat controls
Reduce the complexity o the control system demands on lhe operator
Make the syslem more stable lo reduce he number o control adjust-
ments required

Examples
A worker operating ao aulomalic Iift nside a glove box was required lo
operate two sets of hand controls simultaneously. These controls were localed
on he exterior of Ihe glove bax. One sel af buttoos. localed on the left of he
glove bax, controlled the up/clown molion of the lift. The other se!. located on
the right side. controlled side-Io-side motion. While operating the lift, it was
necessary for the operator to have one hand in a gloveport lo balance the
load. The load on the lift fel! when the operator momentarily removed his
hand from the glovepon ro operale the controls.
The thickness of a sheet material needed constant monitoring and adjustmem
by the operator (15 to 20 times an hour). When other aetivities required his
atlention, out-of-tolerance conditions could go uncorrecled for 5 or 10
minutes.

HUMAN FACTORS ENGINEERING

 ApPfNOIX A- Roor CAUSE MAP NODE DfSClllPnONS Ei
Typical Issues
Were personnel required to monitpr more than three variables alance. caus-
ing overload or failure to nOlice important mformation? Cou1d the error be
attribuled to 10ss of aiertness because of the excessive length of a monitoring
task?

Typical Recommendations
Automate the sysiem so that an employee is nol required to monitor
s~eral variables simultaneously. However. provide enough employee
interaction with the syslem to keep personnel alert
Do nol place workers in situalions requiring eXlended. un~entful
vigHance
Ensure that staffing levels are adequate

Examples
An operator given the responsibility far lemporarily monitoring the alarms for
anolher unil allowed a tank lo overflow. He acknowledged Ihe audible leve1
alarm for the tank. which resulted in muting o the horno He meanl to relurn
to the problem; however. an alarm from one of the other systems sounded.
and his immediate anention was required there. The lank assodated with the
firsl alarm overflowed before he was able to take appropriate aclion.
A radar operator was given the responsibility for monitoring a screen for blips
during an entire 8-hour shift. As a resull of a decrease in vigilance, me opera-
lor failed to identify an important signa!.
Because of reduclions in staffing [evels. an operator was given the added
responsibility of monitoring the operatlon of the fiare system that selVes
several units. including his own. The operator can easily perform these duties
during normal operalions: however, during nonroutine modes of operation
(e.g.. startup). the operator is unable to monitor the fiare syslem because of
increasing responslbilities in his own uni!. lnaftention (O the fiare system may
cause the fiare system to failto funcllon properly. allowing a release of un-
burned process material to the atmosphere.

HUMAN FACTOKS ENCINHIl:ING

a:m:iI ROOT USE ANAtVSIS HAND8001C

Typical Issues
Was the error ca\lsed by a situalion 01 system being complex and requiring a
decision based on specific knowledge ror a successful oUlcome? Could better
design have been reasonably expected lo eliminate Ihe error? Do personoel
have lo recal! infrequently used informarion lo adequately perform the task?
Wo,~IOIC
15 il reasonable fOl a persan lo remember the information. or should il be
provided on Ihe equipmenl or in a procedure?

Typical Recommendations
Modify system design lo eliminate knowledge-based dec:ision making
Ensure thal enough lime is provided lo complete Ihe knowledge-based
decision
Previde 10015 (such as decision trees or flowcharts) to make decision
making easier and lo reduce chances of human error
Provide adequate staffing lo reach a knowledge-based decision

Examples
During an emergency situation, more lnan 80% of tne annunciator tiles in the
control room illuminaled alance. The operalors on duty were usee! lo re-
sponding lo a single alarm at a time using very speciflc procedures. In tnis
situation, they did nol have enough specific knowledge of how Ihe various
systems interacted: therefore. they were al a 1055 in delermining the appropri
ale method of response. As a result, Ihe operators responded lo a few alarms
in the wrong priority, worsening the even!. In Ihis case, knowledge of the
overall system was required, and the procedures provided were useless.

The c10ck on a dala recording unil needed lo be advanced 1 hour for the
switch lo daylighl savings time. The process for doing this was not obvious as
Ihere were no time-set buttons on the device. No procedure or directions
were available for this task either. As a resull, the operalor bied a number of
different ways befare succeeding.

A line had lO be f1ushed lo dear out sorne contaminants. This process was
only performed a few limes a year. No procedure was developed for Ihis
process because it was performed so infrequently. The operator llsed his besl
judgmenl in performing Ihe Iineup bul failed lo clase one valve. The backflow
through this tine resulted in an exolhermic reaclion in one of the supply lanks.

HUMAN FAaoRS ENGINEERINC;

 ApPCIIIDIX A - Roo, C"'USE MAP NODE DESCRIPTlONS ID
Typical Issues
, Was the error due lo the need for excessive mental processing by personnel?
Were personnel required to work through complicated logic sequences or
olher wrinen instruetions? Did the task require thal personnel commit exten
sive amounts of information to memory? Were personnel required to carry out
mental arithmetic?

Typical Recommendalions
Provide workers with the information they need (e.g., procedures.
caJculated tables) instead of relying heavily on their mental capabilities
(e.g.. memory, mental caJculations)
Provide the informalion thal workers need in Ihe simplest form possible
Anticipale the types of conditions workers may encounter and provide
the information they will need under each of these conditions

Examples
[n arder to determine the amount of acid to add to a particular mixture, an
operator was required to take readings from three meters and perform a
mental eaJculation. The operatar made a mental error in periorming the
arithmetic aod added the wrong amount of acid lo the tank.
An operalor was attempting to determine if the present plant condition was
acceptable. To do this, the operator had to determine lOe pressure and tem-
perature of a vesseJ. then use a 6O-page table to determine if the vessel had
adeQuate subcooling by determining the saturalion temperature for the
pressure of!he vessel. Theo he eompared the vessel temperature to the
saturation temperature. This task could have been simplified by using a graph,
a job aid. or letting the plan! process eomputer perform the task.

HUMAN FACTORS ENGINEERING

EiI Roor USE ANAtl"SIS HA."'IDSOOK

...u.o_,
,...."

,..
C"""'~~' '1' !"'" N.'
O"""" ..

C".",Od"" r"" "

"lO,.."".,
.. -;.~'"' lH
e,,,,,,,,..

'.
l ........1
t'.U'N1ld''''I'
,
r"...",
"""""-1
, .. ',1
.......
C'~.~"'""'
0.........._

h'C""'I
."'0' ,-,

[,.",,,,,-,,,
" .....1 ..

lO",,"," H'

Typical Issues
Were personnel unable lo delect errors (by way of alarms or instrument readingsl during OT after 1he occur-
rence? Was the system designed such that personoel were unable 10 recover from eTTors befare a faHure
occurred?

Typical Recommendations
Ensure tha! important safety-relaled equipment is adequately equipped with error-detection systems
Provide feedback lo the operalor 50 tha! he/she can lell if procedure sleps are performed correclly
Design tasks and equipment to o31l0v..' time lo delect and corred errars far safety-critic:allasks and
equipmem

Examples
An operalor was simultaneously fil1ing two large vessels wilh gasoline. While attending {O one of {he vessels.
he al10wed the other one lO overflow because no level alarms or indicators were provided lo lel him know
that the vessel was reaching ils capacity.
An operalor lhought he dosed a valve on lhe feed !ine lO a tank. However. the valve slem was binding and
the valve was half-open. No position indicator was provided for the valve and no flow indication was
provided for he !ine.

HUMAN FAGOItS ENGINEERING

 ApPENOIX A - Roor CAUSE MAP NOOE DlScRIPnoNs azD
Typical Issues
Were personnel unable lO delect errors (by way of aJarms or instrumenl
readings) during or after the occurrence? Did a serious error 90 unnoticed
because no means were provided lo monilor system slatus?
I"I~I,,,", Note: Consider dual coding wilh ContTols/Oisplays LTA {Workplace Layout).
5"1'"
Typical Recommendations
Ensure Ihat important safety-related equipment is adequately equipped
wilh error detection syslems
Ensure (hat syslems importanl to reliabiJity and quality are equipped
with error deteclion systems

Examples
An operator intending to stop f10w lo a tank accidental1y turned the wrong
valvBS. No level alarm was provided on Ihe lank lO indicale Ihat overflow was
imminent; Iherefore. Ihe lank overllowed.
The alarm limits for cooling water now were sel very close to the normal
values. The alarm wenl off frequently. The operalors learned lo ignore lhe
alarm becau5'! il was par! of normal operatlons. As a result, when cooling
waler f10w stopped because of a failed pump. lhe operalors did nol respondo
A warehouse slock person oblained Ihe wrong bolts for a jobo The bolts were
in bins thal were only labeled wilh Ihe parl numbers; no parl descriptions
were included. SmaJl parts like lhese were not labeled wilh part numbers. As a
resulto the stock persan could nol check Ihat the materials in lhe bin were Ihe
ones thal were supposed be there.
An operalor anempted lO open a block valve underneath a reJief valve. The
gale separaled from he slem, so even Ihough lhe valve appeared open
(based on stem posilionl. lhe gate was sol1 closed and obstrUcting the pressure
reHef valve inJet.

HUMAN FACTORS ENGINHAING

BID Roen USE .LYSIS HANDBOOK

~" ~ Typical Issue

fo "
EO; ''''I
Was the system designed such tha personnel were unable lO recover from
befare a failure occurred?
E!rTOTS

I",.~'., Typical Recommendations

S,ll''''
Oesign safety-related equipment so thal the delected erTors can be
corrected befare syslem failure occurs
Design tasks and related procedures to allow employees time to detect
and corred errors for safety-critical tasks

Examples
A computer operarar started an automatic operariog sequence, controlled by
a distributed control system, befare the valving lineups in the process area
had been completed. Even though operators in the rield called in lo len the
operarar lo stop the operation. the computer was nol programmed lo allow
interruption of the sequence. As a resull, process f10w was rouled lo wasle.
A low tank alarm occurred, indicating insufficient level for the pump drawing
suction from the tank. By the time the operalor responded to the alarm. the
pump was already damage:d.

Samples were drawn of each balch prior lo shipment. However, the balches
were aften sen! out before the anafysis of lhe samples was complete. As a
resull, when a sample indicated an unacceptable batch, the delivery could
no! be stopped befare il reached he customer. The cuslomer had lO be calJed
and asked lo ship Ihe batch back.

HUM4N fAcrORS ENGINHRJNG

 ApPENOIX A - Roor USE MAl' NODE DESCIlI,.UONS l'iI:CEI
Typical Issues
Was tTaining provided on this task? Was me tTain-
ing sufficient lo perform the task? Od the training
correspond lO the actual work environment? Were
rraining records adequate?

Typical Recommendations
Provide traming in Ihe hazards of Ihe process
and ;oh tasI<s
Provide refresher trlloining in appropriate
a"""
SoIicit comments from Ihe trainees aher they
have been on the ;ob far 3 months lO deter-
mine "hales" in the training program
Ensure that instructors are properiy quahfied
Provide training on tasks criticaJ lO reliability
and quality

Example
A salvenl tank overflowed because the operator
had not been rrained on how to calculate me liquid
level of a solution with a specific gravity less than
water.

-- Tra.ining
El ROOT CAUSE ANA!.VSIS HANDBOQK

Typical Issues
Had trainng on the task been developed? Had
training been condueted? Od the individual(sl
nvolved in me evenl receive training? Had the
training requirements heen identified? Was a
decision made lo nol traio on the task?

Typical Recommendations
Previde training in the hazaros o the process
and job tasks
Provide refresher training in appropriate
a....
Provie a unirten description o the training
requirements associaled with a spedfic job
tille
Previde l:raining on tasks critical lo reliability
and qualiry

hamples
A salvenl tank overflowed because the operator
had nol heen trained on how lO calculate liquid
levels af tanks. Training was nOl required on this
task because il was assumed lo be a ~skil1 o the
trade. -, However. the operalors were nol experi-
encecl wilh solvents and solulions with specific
gravities less than water.
An operator made a mistake in weighing materials.
A nevJ computerized scale had been inslalled a
monlh befare. Training was nat pravided in Ihe
use of the new scale even though it was signifi-
cantly differenl from the mechanical type that had
been used in the past.

Training
 ApPENDIX A - Roer CAUSE MAP NODE DESCRIPTIONS am
Typical Issues
Was Ihe decision made lO nol provide specific tTaining an a lask? Were sorne
employees not required to receive training? Was experience considered a
substitule for training?

Typical Recommendations
Provide training in lhe hazards of the process and job lasks associated
wilh normal operalions. nonroutine operations. and emergency apera-
lions
Provide training for maintenance lasks such as inspection. lestng,
calibralion, prevenlive maimenance. repair, replacemenl, and inslalla-
!ion
Provide refresher training annually for all employees in heir assigned
dulies

Examples
A solven! lank overflowed because Ihe operator did nol know how lo calcu-
late Ihe liquid leve!. The operalor was not required lo receive training because
he had years of experience working in a similar facility. However. lhe previous
facility did not use solvent. and the operalor did nol have expenence wilh
solutions with specific gravities less than water.
Management decided lo orlly train one mechanic lo repal! a special digital
processor used in the lab. However, while this mechamc was on vacalian. Ihe
digital processor broke and anolher mechanic had lo fix il.

Training
EiI ROOT USE A....uYSIS HI\N0800K

Typical Issues
Was training on the lask part o he employee's training requirements? Had
the necssary training been defined far the job description?

Typical Recommendalions
Identify all o the specific duties associated with each job title. Inelude
pertioen! tapies associated wilh these duties within the corresponding
010"""
training module
No, lO T,.",
Previde a written description o the training requirements assodated
with a job title. Require tha! each employee complete he training and
Qualification assodated wilh hisfher job ,ide befare performing specific
job tasks unsupervised

Example
An operaloT overflowed a salven! lank because he did nol know how to
calcula!e liquid levels. The operater had transferred from a similar facility, and
the training required for his present assignment had nol been defined. Slnee
the other fae]ty did nat use salvenl, the operatar did nal have experienee
warking wilh solutians witn specifie gravlties less than water.

Training
 ApPENDIX A - ROCJT USE MAP NaDE DESCRIPT/ONS lm'D
Typical Issues
Was the training record system complete and up
Io-date? Did it accurately reflecllhe employee's
training? Were the records used to determine
worker selection and assignments 10 tasks?

Typical Recommendations
Documenl lhe rraining Ihat an individual is
required lo receive prior to qualification and
...,,,,... ......,
~

",""~I
,,~.,
to maintain qualification
Ensure that individuals are assigned respon
sibililies for mainlenance of training records

Example
A lank overflowed because Ihe opeTtllor had not
received training 00 how lo calculale liquid levels.
The training records were nol routinely updated:
lherefore, Ihe worker who was assigned lO the job
was assumed lO undersland Ihis lask.

Training

-
El Roor CAUSE ANAlYSIS HANDSOOI(

Typical Issues
Did he records show training ha! the employee hild nol recei'Jed? Old he
records correctly indicale he employee's quahfications?

T,... ",~ <1"0".' Typical Recommendations

~ll\t'" LU
Document he required rraining hal an employee is required lO com-
plete annually

-
Document aH inhouse. on-the-job, ad autside training hal an em
ployee completes. lnelude dates of completion. test scores. instructor
comments, certifications, etc., aod a description of how competency is
ascerlained. aJong wilh these records
T,""'''~ ~ItO~1
1<01 1J~IODI"

Example
An operator overflowed a solvenl tank. He had been given he assignment to
mi he tank because his records ndicated mal he had been rrained en calcu-
laling liquid levels of solutions with specific gravities less rhan water. The
operalor had nol received the training.

Training
 ApPENDIX A - Roor CAUSE MAl> Nove DCSCRIPnONs l'jD

Typical Issues
Oid the rraining records show the employee's current status for job Qualifica-
lion? Was the Qualification expired bul nol reflected in the traimng records?

Typical Recommendation
Establish a rraining records management system hat assigns certain
individuals Ihe responsibility for:
- natifying records managemenl personnel af emplayee rraining
completion dales
- recording training completion dates
- fanvarding materials lO recards management personnellhat verify
employee understanding of the rraining
- alerting employees and supervisors af upcoming training require-
ments
- scheduling employees and instructors for specific rraining modules

Example
An operator overflowed a solvent tank because he had nol received training
on calculating liquid levels fOT solvenl solulions. He had been qualified befare
Ihis training was made parl of Ihe Quahfications The training records slill
showed him as qualified because they did not reflect Ihe new requiremenfs.

Training
~ Roo! USE ANAlYSIS HAND800K

Typical Issues
Were jobltask analyses adequate? Were tne
program design and objeetives complete? Did Ihe
training organizatioo have adequate instructors
and facilities? [5 refresher training performed?
Does testing adequately measure the employee's
ability to perform he task? Does trainlng ndude
normal and abnormaliemergency working cendi
liaos?

Typical Recommendations
Perform job/task analyses for routioe jobsl
tasks
o...... ~,
""~II-' Salid! comments from he trainees after they
have beeo on he job for 3 monlhs lo
determine "hales" in the training program
EnsuTe ha! oMhejob training consists af
~doing" rather than jusi -watching"
Provide refresher training for nonroutine
tasks
EnsuTe ha! instructors are properly qualified

Examples
A solvenl lank overflowed because the operator
did no! know how to ealculate rhe Jiquid level of
solutions wilh specific gravities less [han water.
The rraining included instn!clion in how lo calcu-
late the [iquid level but did not indude testing to
determine if the operator could perform the
calculations.
An operator made a mistake in weighing material
because he used the seale incorrectly. The seale he
used in training was Ihe previous model and il had
key differences from the one used on the jobo

A mechanic made a mistake when repairing a

pressure transmitter. Sorne transrnitters had special
seals so they would work in very high humidity
environments. The jobltask analysis did identify
that training would be needed for these different
types of transmirters.

Training
 ApPfNDIX A- Roor- CAUSE MAP NOOE DEScN/pnoN$ am

TYl'ical Issues
Was a jobltask analysis performed? Did it correctly idenlify the knowledge
and skills necessary lO complete lile task? Oid il correctly identify al! me steps
required lO successfully complete the task?

Typical Recommendations
Do nol diseount the value o conducting a jobJtask analysis ror sorne
jobs/tasks tha! may seem trivial ai meaningless
nelude al! pertinent information in he job/task analysis, including job
skills required lo perform he lask, the sequence of task steps, and
hazards o performing each lask
Conduct a walkthrough of the job/task while performing he analysis in
arder to aigger thoughts conceming the skills required lO complete the
task and the corred sequence of completing the steps

Examl'les
, An operator made a mislake weighing maleriallo be added lo a solulion.
The operator had not received training on how to use the scale because Ihe
job/task analysis did not identify use of the scale as a skiU for perforrning Ihe
jobo
A technidan made an error when analyzing a sample of material. The jobl
tO"L'"'"9 tasI<. analysis did nol identify Ihe need to dry the sample as parl of Ihe sample
T'''''''tl U
preparation.

~~M,,,"I h."111
~""'t"<1
1'.""; LT'

Training
miiI Rom USE AAAllS1S HANOBOOII:

Typical Issues
Was Ihe training program deslgned lO eQuip the trainees 10 perform Ihe task?
Did il contam he corree! amoun! of classroom and on-the-Job instruction?

Od the objeetivi?S satisfy thl! needs identified in Ihe task ana!)'Sis" Did me
objtttives cover all the reqUln;>ments necessary to successfully complete he
task? Were the objectives wrinen al the corree! cognitive leve]?

Typical Recommendalions
Provide employees with classroom and on-the-job training. After
completion of the traiOlng. have me trainee physically demonstrale aH
lasks (without receiving direction) lO ensure that me employ has
received an adequlIte amouol of rraining
Aher cornpletion of a rraining module. have trainees evaluale the
program designo Sohdt comments lO improve Ihe progrnm design
Establish en overall training management system that assigns certaln
individuals the responsibility for:
- analyzing training needs for each }oh tide
- establishing training crilena for each job tide
- designing curricula to meet training needs
- continually assessing and improving the training program
Using the jobJtask analysis, define and documenl rralOlng objectives so
hal employees will be equipped wlth sufficient skllls lO perform their
assignments successfully
Ensure mal trainees understand naining obje(tives al Ihe start ef l?ach
new tralning module
Ensure objeetives are written al the corred cognilive leve!. For example.
Ihe objective should be IA,nnen as ~Use me leboratory scale lO weigh a
sampJe~ ralher Ihan -Explain now a sample is weigned.- The
lecnniclan's job is lO perform me lask. noi merely to explain now to do
il. Knowing and doing are on N.'O dlfferenl cognitivt" levels

Training
 ApPlNOIX A - ROOT CAUSE MAl' NaDE DlSCIU,.noNs liIIiJ
Examples
An operator made a mistake weighing material. His formal training had contained instnJction about using
the seale, but on,thejob lraining on the use of the seare had nol been required.
An operator opened Ihe wrong valve during <'In emergency. In training, the operator had Tead the procedure
bUI had never performed lhe procedure in the plant or on a simulator: nor had he performed a warkthrough.
An operator made a mislake weighing malerial because he used the seare incorrectly. The task analysis
idenfified mal training was required on Ihe use 01 Ihe seale, but Ihe craining objeetives did not ndude il;
therefore training did nal stress this skill.
An operator overfilled a tank. The training objectives for Ihis system required the operalor to lisl the compo
nents in Ihe syslem, but did not inelude an objective lO e:xplain (he function and operation of me control
system.

Training
a;g RooT USl A:'<.AlYSIS HANDBOOK

Typical Issues
Oid lhe lesson contenl address aU the training ob;eetives' Did the lessons
contaio all of the informallon necessary lO perform Ihe job? Was the lesson
material consisten! with (he curren! system configuraljon aod procedures'
Note: This node oddresses rhe comen! ollessons led by rraining personnel or
formol fraining awoy from rhe Job (such as dassroom, labororory, or simulolor
rroining). Problems wlth Ihe conten! o/on-rnejob rraining are addressed
under Me On-the-}ob Training LTA node.

Typical Recommendalions
Ensure that the lesson conten! for eaeh traimng module addresses a1l
Ihe necessary tapies io guarantee a complete understanding of the
required tasks
Indude workshops or demonstralion techniques as part of Ihe lesson
conlenl lo provide a umgible and practical means of communication

E.amples
An operalor made a mistllke weighing material because of ncorred use of
Ihe scale. The lesson plan did nol address traming on the scale. although it
was in the objectives.

An operalor made an error In determining the amounl of material to add lO a

batch. The scale he used was instaJled 6 months before. The training he
received on the system the previous month had nol incorporated !he ne'oN'
scale lOto the lesson content

A clerk incorrectly entered a customized order into the computer. Dunng

training. me ins(]'Uetor had sho.....n her the wrong way lO perfonn the task.

Training
 ApP(NDIX A - Roor CtUse MAl' NaDe DcscRIPrlONS liIIiJ
Typical Issues
Oid the on-the-job training provide opportunities to leam the skill.s necessary
lo perform the job? Was there sufficient onthejob training? Oid Ihe on-the-
job training cover unique and unusual situations or equipment lo avoid
surprising the operator laler on?

Typical Recommendations
Ensure Ihat on-thejob rraining consists of actually "doing" rather Ihan
only "watehing"
Match trainees with experienced personnel who can explain nol only
hO\\t lo perform certain tasks, bul also why certain tasks are performed
Ensure Ihal on-thejob trajning covers unique and unusual situalions or
equipment

Examples
An operalor made a mistake weighing material because of incanecI use of the
scale. He had received classroom instruction but no on-the-job experience in
the use of the seale.
An operaror made a mjslake weighing malerial because of inconect use of the
scale. He had receved c1assroom and lab instruction on rhe use of the scale,
but the scale used in the lab was the previous model and operaled somewhat
djfferently from the one used on the jobo No onthejob training was provided.
Four furnaces were inSlalled in a boiler house. Thcy had each been installed
al differenl limes as Ihe plant expanded. The control syslems were similar. bul
had significant differenG!s. Ouring on.lhejob training. Ihe operalor only
operaled two of the four furnaces. As a result, the operalor accidently shul
T". _1 down one of the furnaces shortly aher he was qualified."
R.".'''Ol T~

.." .... h,'ul

f""""<J
1"""'1,1'

Training
lIIZ'iI RoOT USf ANAt\'5ts HANDSOOIC

Typical Issues
Did the testing cover aH of the knowledge and skills necessary to do the job?
Did the testing adequately Tefied the trainee's ability to perform Ihe Job? Was
on-the-job demonstration part of qualification and was Ihe demonstration
thorough enough?

Typical Recommendations
Verify thal Ihe trainee fully understood Ihe training in sornE! tangible
manner (such as a c1assroom exam, physical demonstralion wilhoul
direction, oral exam, warking with an experienced employee who is
able lo evaluale Ihe trainee's performance)
EnsuTe that all areas of the lesson conten! are verified for understanding
(including both complex task skills and rudimentary skills)

l ... ~. tO"""
m
Examples
An operatof made a mislake weighing material because af ncorreel use of a
seale. He had received instruction on the use of the scale but had not been
o'"In' o~ tesled on his ability to use the scale.
TlliIIlIl;L~

An operalor failed lO dose a valve in an emergency because he could not

find il. Qualification testing consisted of a discussion of ihe procedure. A
walkthrough evalualion should have been performed.

Training
 ApPENDIX A - RooT CAUSE MAP NODE DESCRIPTlONS am
Typical Issues
Was continuing training performed to keep employees equipped to perform
nonroutine tasks? Was the frequency of continuing training adequate?
Was training provided when the work methods for this task were changed?
Was training provided on changes to the procedure for the task? Was training
provided on new equipment used to perform the task?
Note: Prob/ems with refresher training on obnormol ond emergency opera-
tions should olso be ceded under Abnormal EventSiEmergency Training LTA.

Typical Recommendations
Provide all employees with refresher training for routine and nonroutine
tasks associated with their job assignments at least on an annual basis
(for operations, this would inelude training on startup, shutdown,
troubleshooting, emergency shutdown, and safe work practices)
Consult employees regarding the frequency of training. Should the
training be conducted more often? Less often? Should refresher training
content be revised?
Provide additional training for new procedures, procedure modifica-
tions. and process modifications involving new equipment
Ensure that the new work method training ineludes instructions that
relate to nonroutine tasks (changes to startup, shutdown, emergency
operations, etc.)
Verify understanding of the new work method to the same degree that
is required for verifying understanding of initial training (e1assroom
exams, physical demonstration. etc.)

Examples
An operator made a mistake weighing material because of incorrect use of a
scale. The scale on which he was trained had been replaced with a newer
model. and no training had been provided on the new model.
A mechanic had trouble reading a graph with a logarithmic scaJe. The graph
had been recenUy added to the procedure. The training departrnent had not
been notified of the change and did not identify the need to provide training
on this topie.
A member of the fire team had trouble getting the foam system actuated. He
received training on the system when he was hired 5 years before. but had
not received any refresher training since (hen.

Training
lI:iiI ROOT CAUSE ANAlY5lS HANOBQOk

Typical Issues
Was the training equipment adequate? Were simulalors or demonstratiorV
example components used? Was the equipment used in training the same as
that used on the job? Were the instrudors and otner personnel providing lhe
training adequale? Do the instructor qualifications require the instructor to be
able lo perform the task? Was !he instructor who performed he training
qualified on this task?

Typical Recommendations
Use simulators when possible to provide personnel with hancls-on
experience
P'o~'". tltJogol
O~IO<\N.. lTA If simulators are nol a viable aplioo, use moclels (perhaps computer
models) instead. Ensure thal the models are similar enough to he real
equipment to avoki confusion (e.g., if a control button is actually red on
loo.o" C"nton. the control panel, make sure it appears red on lhe cardboard model)
". When possible, use the same equipmenl in training Ihal will be used on
Ihe jobo PPE is a good example
On"IIlI,o.
Ensure thal proper facilities and training equipmentlsupplies are avail-
lt""""glTA able for training and conducive to leaming:
- video equipment
overhead projectors
- inleractive workstations
- distraction-free c1assrooms
Provide guidance for determining instructor qualificalions
Review current instructor qualifications far adequacy. Address any
deficiencies that are found

Examples
An operalor made a mistake weighing material because of incorrect use of a
scale. The scale he had used in training had key differences from lhe one
used on lhe job.
A mechanic had trouble repairing a transmitter. The repair required the
operator to wear gloves and a respiralor. When he had practiced in training.
he did nol wear any prolective dothing because lhe training deparbnenl did
nol have any of Ihe required prolective dothing.

Training
 ApPfNOIX A - RooT CAUSE MAP NODE DfscRIPnONs ~

Typical Issues
Was training provided on abnormal and emergency events? Od it inelude alJ
lhe necessary elements? Was the frequency o( the training adequate?

Typical Recommendations
Inelude abnormaVnonroutine job tasks as part o( the initial training as
well as part of lhe continuing training. Ai a minimum, the lesson content
should inelude startup/shutdown procedures, emergency shuidown
procedures, and emergency evacuation and response
Provide refresher training for these evenls FREQUENTLY to give em-
ployees confidence in dealing wilh Ihese stressful activities
Establish a frequency for providing training for Ihe abnormaVemergency
events and consuli employees regarding the frequency
Ensure that Ihe training mimics Ihe anticipaled events/emergencies as
c1ose!yas practica! (e.g., ensure Ihai employees are wearing the PPE
prescribed for Ihe event when walking through Ihe tasksl

O....-I'D Examples
TI'''''''O LU
An operator opened the wrong va!ve during an emergency cooling waler loss.
He had becn trained on the emergency response during his training, bul did
not have to perform the task while wearing the neeessary proteclive clothing
and while responding lo many alarms.
An operator opened the wrong valve during an emergency cooling waler loss.
He had received dassroom Iraining on the procedure, bUI had no! performed
a walkthrough or performed lhe procedure in the plant.
A member of the fire team had trouble getling he foam system actualed. He
received training on the system when he was hired 5 years befare. but had
not reeeived any refresher training sinee Ihen.
During plan! emergencies, management personneJ were supposed lo contact
local authorities lo coordinate evacuation of surrounding areas. During an
actual evenl, Ihe phone numbers that were to be called eouJd nol be found.
No tTaining had ever been provided on this lask.

Training
mJ ROOT uSt ANAlYSIS H4NDBOOIC

Typical Issues
Oid immediale supervision fai! lO provide adequate preparation, job
plans. or walkthroughs for a job? Were polential problems identificd

S'W.d'"
~.,"'; .. ~
befare the work began? Were appropriate personnel selected and
schedule<! far the task? Did immediate supervision faH to provide
adequate support, caverage, al oversight during job performance?
Did supervisors corred improper performance? Did personnel work
S,......... L:. together as a coordinaled leam?

.......' Typical Recommendations

....."..
....... " " MI
~ Adopl a standard job plan formal
Distribute duties equal1y ameog similarly skilledJtrained per-
,,,~,,"~l'
sonnel
Far nonroutine jobs ar jobs thal require specific safety precau-
fians. encourage supervisers to oversee [he job aod provide
job supporl as necessary
Encourage supervisors lO provide more supervision lo less
expe:rienced workers
Ensure Ihal supervisors correet improper performance

Examples
An ope:ralor failed to respond prope:rly to an alann because he was
covering for two uni! operators simultaneously. This was required
because his immediate supervisor did not schedule enough control
room operalors lo cover the shif operations.

Ope:l<llors were supposed lO perform plant rounrls al leas1 once per

shift and generate work requests lar any equipmem thal was inope:r
able or needed repairs. Often the operalors skipped the rounds
when it was cold or raining even Ihough the rounds were slill re
quired. Supervisors knew whal was oceurring and did nothing lo
correcl Ihe situation.

lMMEDlATE SUPEIMSION
 ApPENDIX A - Roor CAUSE MAP NODE DlSCRIPTIONS EII:D
Typical Issues
Did immediate supervision fail to provide adequate preparation. job
plans. or walkthroughs for a job? Were potential interruptions or
special circumstances idenlified befare lhe w,ork began? Were
appropriate personnel selected and scheduled for the task?

Typical Recommendations
Ensure that supervisors undersland Iheir role in providing a
job plan for subordinates
Adopt a standard job plan format
Distribute duties equally among similarly skilledJtrained
personnel
Verify thal Ihe employee has Ihe credentials to complete the
task befare assignment

Examples
Late in the shift, a first-line supervisor instrueted a mechanic [O
repair a valve in a confined space. However. his supervisor failed to
schedule anyone else to assisl wilh Ihe entry. To gel the job done
befare the end of he shift. the mechanic entered the confined space
alone and died.
A job required Ihe coordinated effort of the operalors. mechanics,
and electricians. The electricians were !he lead group on Ihe project.
The electrical supervisor falled to arrange for suppOrt from the other
two groups.

IMMEDIATE SUPEIlVISION
li1IIiI RoOT ,un ANAlVSIS HAND800K

Typical Issue
Oid immedate supervision failta provide any preparallon (eg.. instructions.
job plan. walkthrough) for the lask performed?

Typical Recommendations
EnsuTe thal superviSOr5 understand mal jI is their responsibitity to
provide suborrlinates wlll1 instructions andlor a job plan. and lo conduct
\....'alkthroughs when appropriate (lO shO\.l.' workers the lacalion af equipo
men! ar lO discuss lhe proper sequence af steps, etc.)
Provide supervisan with wrinen Job descripllOru so thal me above
responsibilities are c1early communicated and documented
Provide coaching lO supervisers whose job preparation skiUs aTE! less
than adequlIte

Examples
An irnmerliate supeTVIsor sen! his crew out to paiot stripes in a parking 101. No
instructions were given for Ihe jobo As a result. the crew used the Wfong color
paio! to stripe me 101. In aciditioo. Ihe resulting parking places were nol of
arlequlIte size lO Zlccommodate anything other than compad cars.
A job required lhe coordinated effort of the operators, mechamcs, and eleet:ri
ciaos. The eteetrlcians were the lead group on the projecL The electrical
supervisor failed to arrange for support from lhe other two groups

IMMEDIAT( SUPfRVlSION
 ApPENDlX A - ROOT USE MAP NaoE DE5CRIPrIONS lIiI:IiI
Typical Issue
Did immediate supervision prov\de an incorred, ncomplete. or otherwise
inadequate job plan for perfonnance o Ihe work?

Typical Recommendations
Establish an adminisaative procedure that requires alJ supervisors
{including contraet supervisors)10 provide Iheir subordinates with a job
plan thal includes instrUCllons necessary for completlOg nonroutine job
""lo;
Establish a faciJitywide job plan format lO ensure that all necessary
informarion is included in Ihe job plan

E.ample
A new unu was undergoing iu first turnaround. Ouring the tumaround,
maintenance personnel rontaminaled the replacement catalyst because of
handlingfloading errors. The new catalyst required special handling precau-
tions tha! the crew was nol aware of. The tumaround plans were the same as
tor me old unit that was replaced and did not provide tor special handling of
the new catalyst.

IMMEOIATE SlJPflMSION
m:II ROOT USE AAALYSIS HAND800K

1"'''''. ". Typical Issue

S.~ ..... ",n
Did immediate supervision provide incorrect. ncomplete. aT otherwise nado
equale job instructions befare he beginning af wark?

Typical Recommendations
Encourage <lo culture that is feedback orienled (Le., repealing instrudions
back lo the instructor lo ensure understanding)
Traio supervisors on how lo give instructions aod how to verify tha!
instructions are undersloocl

Examples
An electrician was instrucled lo check the potential transformer on the majo
generalar. His supervisor meant la tell him to check the potential transformer
on ao emergency generalar. When the electrician opened he access panel on
the majo generalar. the plan! shut down.

A captain of <lo commerdal cargo plane ordered his copilol lo se! the throttles
to he ful! position. The copilo! thought aplane was still taxiing on their
runway and lhat they should nol lake off. But, the caplain was the captain,
and me copilol felt he should follow his ordel'5 without question. As a resulto
lheir plane hit another plane and more than 500 people died.

IMM1DiATE SUPERVISION
 ApPENDlX A - ROOT CAUSE MM NOOE DESCRIPTlONS mm
Typical Issue
Did immediate supervision fail to perforrn an adequate walkthrough (show
workers the location of equipment, discuss operalion of the equipment and
the proper sequence of steps, etc.) with lhe workers before they started lheir
job?
Pr,paral1on

Typical Recommendations
Encourage supervisors to show workers the location of equipment
involved in the job task
Encourage supervisors to discuss operation of the equipment and the
sequence of steps involved in nonroutine job tasks

Example
A team of expert mechanics was assembled to instail a special piece of
equipment in a new facility. AJlhough lhese were experienced mechanics,
lhey were unfamiliar wilh bolh lhe facility and the specific piece of equip-
ment. The immediate supervisor assumed that, because these mechanics
were experts in lheir field, they did not need to be "stepped through" lhe jobo
However, lhe job required some special precautions, and the mechanics
damaged the equipment because lhey were not shown lhe specific problem
areas before starting the jobo

Wor~"Seltclionl
AS5lgmenllTA

IMMEDIATE SUPERVISION
~ ROOT un ANAlYSIS HANOBOOK

Typical Issues
Was scheduling of workers inadequate? Did immediate supervision arrange lo
have enough personnel available lO effeetively carry OUI the task? Were loo
many conculll!nt tasks assigned lo workers? Were duties nol well distributed
among personnel?
~"O"OI"'"
Note: Ttis node addresses rhe scheduUng 01 personnel cn/y, nor rhe schedu/-
Ing 01 Ulork oaiuities. Prob/ems with scheduling 01 work aetiuitles ore ad-
dressed under node 64, Planning, Scheduling, or Tracking of Work Activities
LTA (AdminisbativeIManagement Systems, SPACs LTA).

Typical Recommendations
Previde supervisors with an adequZlte number of employees lo effec
tively and safely complete the tasks assigned for me shih
Distribute duties equally among similarly skilledltrained personne!
Consider the amounl of time and concentration lO perform each task.
Assign individuals fewer responsibilities for tasks thal require more time
and concentration

Examples
As a result of inadequate planning by a firsl-Iine supervisor, a control room
was staffed by one trained operalor and five trainees. Because tne trained
operalor was continuously sfopped by Ine lrainees to answer questions. ne
missed an important step in nis own procedure. This caused a significanl
penad of downtime in Ihe facility.
Four mechanics and three eleetricians were assigned lo install a new compres-
sor. There was only enough work to keep two of the mechanics and ene
electrician busy. The remaining four workers jusi sal around and watched lhe
olhers wark.

IMMEDIAU SUPEIMSION
 ApPEI\'DIX A - Roor USE MAP NOOE DESCRIPnONS liII'ii

1........,. Typicallssues
.."
s"~.,...'"
Did immediale supervision faillo seled capable workers lo perform the job?
Did workers assigned lo Ihe task have inadequate credentials? Were sufficienl
numbers of lrained or experienced workers assigned to the task?
Note: This node addresses [he assignment o/ existing or qualified workers to
job tasks. fur examp/e, the se/edion o/ a laborer from a preapprolJed pool 01
indiuiduals would be couered by this node. Ir doe.s NOT address the hiring or
preseleaion processes. Emp/oyee hiring is oddressed by Employee Screeningl
Hiring LTA (AdministraliveIManagement Systems, SPACs LTA).

Typical Recommendations
Before assigning any employee to a task. verify thallhe employee has
lhe credentials to successfully complete lhe task
Ensure lhat the individual assigned lo a task malches the expertence
level required to effectively and safely perlorm the task
Provide supervisors with the means to quickly determine if workers are
quaJifed for a task

Example
Three lechnicians were assigned lO a shift. Normally. at least one senior
technician was assigned as lhe Jead technician on each shift to plan and help
coordinale lhe work. On Ihe back shift, an older bul inexperienced lechnician
was assigned as lead lechnician even though he was nol qualified.

IMMEDIATE SUPEIlVlSION
liIID Roen USE A"W.YSIS HAN()fI()()K

Typicallssue
Did immedi~le supervision fail lo provide adequate support, cover-
age. oversighl, or supervision during job performance?

Note: The inlJestigator mUSl judge whol feuel 01 superuision was

necessary bosed on !he importance o/ he JOb in relation ro safery
ond produetion. Ir is nol possible or practIco! ro prouide superuision
on euery jobo

Typical Recommendations
Fer nemoutine jobs or jobs tha! require specific safery precau-
liaos, encourage supervisors to Qversee the job and provide
job support as necessary
EnCOUTllge supervisors lO provide more supeJVision lo less
experienced workers

Example
A first-Iine supervisor was in hls office performing lIudits of como
pleted procedures. He roJd !he operator in ,he control room to
contaet him if probJems arose. The operalor, a newly qualified
perseo on the job, did nol want the supervisor lO think mat he dd
nOl know what he was doing. so he ktook his best guess~ when he
ha<! questions. By the time the supervisor carne lO me control room
lo check on the operator's progress, a significant amount of product
had already been lost to the wasle stream
 ApPENDIX A - ROOT CAUSE MAP NODE DESCRIPnONS ...
Typical Issues
Did immediale supervision provide inadequale SUpport, coverage, or over-
sighl during performance of lhe job? Was an inadequale level of supervision
provided al lhe job sile? Was conlact wilh workers loo infrequenl? Oid direct
supervision's involvemenl in lhe lask inlerfere wilh lhe supervisory overview
Sup.rvlslon
Ounng Worlt role?

Typical Recommendations
For nonrouline job lasks or for lasks lhal require specifc safety precau-
lions, encourage supervisors lo remain al lhe job site lo provide cover-
age for the entire job, or al least frequently visil lhe job site to provide
direction as necessary
Encourage supervisors to give lheir supervisory role priorily over lheir
job task supporl role
Ensure lhat supervisors understand lheir responsibililies lo provide
more supervision lo less experienced workers

Example
A mechanic was lold by his immediate supervisor to "fx lhe leak" in a tank
containing a hazardous chemical. The supervisor gave him no instructions on
how to perform the task and did nol provide any oversighl of lhe work
aclivilies. Because of lhe mechanic's lack of underslanding aboul lhe hazards
associaled wilh lhis job, he alJowed lhe chemical lo come inlo conlact wilh
his skin. This caused severe burns.
During lhe installalion of a new computer system, the immediale supervisor
of lhe responsible crew became so interesled in inslalling lhe central control
unil lhal he picked up a screwdriver and became involved in lhe work. As a
resull, he ignored lhose members of lhe crew who were inslalling lhe auxiliary
unit. Some important checks were missed on lhe auxiliary unil; lherefore, il
failed upon slartup.

IMMEDIATE SUPERVlSION
ml;I Rocn CAuSE AAAlYSIS HAND800K

Typical Issues
Do supervisan corred improper performance when they observe il ar know
aboul il? Do they let improper performance slip Mjusl this once~?

Typical Recommendations
Correct the behavior when improper performance is observed ar is
known by supervision. lf supervision knows a task is being performed
incorreet/y and does nol corree! JI, workers will continue lo perform the
task incorrectly
Enforee existing rules and requirements lf he rule i5 importanl enough
lo exist. il should be enforced. If lfs nol importan! enough lo enforce,
eliminate me requirement

Examples
A supervisor noticed an operalor in the process aTea who was nol wearing a
har hat ar safety goggles. The supervisor was jusI passing through me area
, and did nol say anything lO the operator.
Operalors were supposed lo perform planl rounds alleast once per shift and
generale wark requests far any equipment that was inoperable or needed
repairs. Often !he operalors skipped !he rounds when it was cold or raining
even though !he rounds were still required. Supervisors knew what was
oeeurring and did nothing to correet the situation.

IMMEOLATE SUPUtvlSION
 ApPENDIX A - ROOT CAUSE MAP NODE DfSCRIPTlONS ami
Typical Issues
Was there a lack of coordination between workers? Was a plan developed to
assign responsibilities to different team members? Were lhere overlaps or gaps
in lhe work lhat was assigned to different groups or team members? Was
there a lack of communication between work groups?
SupelViSlon
During Work

Typical Recommendations
On tasks lhat require coordination of work, ensure lhat tasks are as-
signed to team members and that an adequate means of communica-
tion is provided between workers
For work that requires coordination of multiple work groups (Le.,
operations, maintenance, and chemistsl, ensure lhat there are c1ear
methods and means for exchanging information between work groups
Coordinate tasks between different work groups. Develop a work plan
prior to beginning the work

Example
Work was being performed on two different portions of a pipeline. The work
performed at one booster station affected the work being performed at the
receiving station. Because the work of lhe two groups was not coordinated, a
small release of material occurred from the pipeline.

IMMEDIATE SUPERVISION
~ ROOT CAUSE ANAlYSIS HANDBOOK

Note: "Communicorions" is defined os the cet 01 exchonging jn/arma/ion. This node addresses many modes
01 communication (e.g. /oce-tofoce, lelephone, rodio. short wriuen messages, lag en/res). Ir does nol
address rhe more formal melhods o/ communication nvo/uing wrirten procedures, specificotions. etc.

Typical Issues
Was the problem caused by a {aHure lo communicale? Dd a method or system exist for communicaling
between the groups or individuals? Wa:. an error caused by misunderstood communication between person-
nel? Was there incorrecto ncomplete, OT otherwise inadequate communication between workers during a
shift or between workers during a shift change? Was Ihere a problem communicating with contractors or
customers?

Typical Recommendations
Provide a backup means af communication when the primary syslern is inoperable
Establish standard terminology tor equipment and operations
Use the repeatback method of communication
Conduct shih change meetings to alert oncoming shihs of special job lasks. safety issues. or problems
thal occurred during the previous shift

COMMUNICATlONS
 ApPENDIX A - Roor CAUSE MAP Noor Dr.scRIPnONs E:I
Examples
An operalor opened the wrong valve. resulting in a process upset. He misunde~lood the verbal instrUctions
from a coworker. No repeatback or oiher verification method was used.
A lank rransfer was in progress during shift c.hange. During shift change, lhe shift going off duty dki not tell
lhe one coming on duty thi!lllhe nansfer v.'aS in progress. The tank overfl~.

... COMMUNJCATlONS
lE Rom CAusf. ANAlYSIS HAND800K

Typical Issues
Was the problem caused by a failure to cornmunicale? Oid a melhod OT system exist for communicating
between the groups eT individuals? Oid the communicalion take place loo late? Od obstac1es hinder ar
delay communication?
Note: Eoch indiuidual inuollJed in Ihe occurrence should be questioned regording messoges he or she fee/s
should houe been receiued OT trol1smitted. Determine whot mecns o{ commun!corion were used (Le" lhe
techniques). Persons on 01/ sides 01 a communicQrion link should be questioned regarding known Or sus-
pected problems.

Typical Recommendations
Provide a backup means of communication when the primary system is inoperable
Establish formal means of communication when required
Canducl meetmgs between shjft workers and management

Example
An operalor failed to c10se a valve when needed, resulting in a process upset. He should have received an
instruction from control room personnello c10se he valve. The instruclion was nol given lo the operator in
time because the two-way radios did nol work in the arca in which the operalor was located.

COMMUNlCATlONS
 ApPENDIX A - Roor C~USE MAl> NODE DESCRIPT/ONS .mm
Typical Issues
Oid a method or system exist for communicating the necessary message or
information? Was the communication syslem oul of service or olherwise
unavailable at the time of the incidem?

Typical Recommendations
Ensure thal sorne rnethod of cornrnunication is in working order al all
times
When the primary melhod of communication is unavailable, provide
some lemporary means of communicalion (e.g., two-way radios)

Example
An aulomatic valve was stuck open. The control room operator attempted lo
contad Ihe building operator using the public address system lo instrucl him
lo manually clase the valve. The public address syslem was nol functioning
properly, and Ihe building operator could not be contacted, resulting in
overflow of a vessel.

COMMUNlCATlON5
mm Roer USE ANAlYSIS HAND800k

Typical Issues
Old lack of communication bet\veen work groups (production. tecnnical.
maintenance, warehouse. etc.) contribute to Ihe inciden!? Did methods exist
fOI communicating between work groups?

'e C'-"o"o<.I_O o'

'01 ~I'. Typical Recommendation
Establish an administralive procedure thal requires a work permil {ar
sign-in/sign-Qulj lO be issued and authorized by the ccntralliog work
group befare anolher work group may perform job lasks in the control-
liog work group's area

Example
A lank overflowed because maintenance had taken lhe [iquid level insITu-
mentation oul of servlce lar calibralion A misunderstanding with production
occurred over which equipmenr was OUI of service. Blieving tha! il was
another instrument tna! was being calibrated, production slarted a transfer
into the tank, resultmg in an overflow.

CoMMUNlCAT10NS
,
ApPENDlX A - Roo1 USE MA.p NaDe DEscRIPnONS mi

Typical Issues
Oid lack o communicalion between management and the shifts contribute lo
he incident? Had managemenl effectively eommunicated polides lo he
employees? Were employees' eoncerns communicated lO management?

Typical Recommendations
Condud shift meetings thal involve members o management duriog
various shifts
Provide a management/shift logbook for each produdion un! so that
various issues concerning production, safety, maintenance, elc" can be
communicated as needed between managemeni and aH shifts (and
between shifts)
Provide a suggeslion box in the facility
Encourage aJl employees lo submit wark requests/suggestions regarding
maintenance, safety ssues. etc.. to management. Post the work TeQuests
weekly lo acknowledge thatlhe requesl was received. and include the
status of the request

Examples
A valve failed. resulting in a process upset. Shift employees had noticed
problems wilh the va!ve and had expressed concern to lhe first-line supervi-
sors, but Ihe prob1em had nol been recognized by management and cor-
rected.

A policy was recently changed tha! required personne1 to enier their work
hours into a new computer system. However. (he delails of the policy were
noi communicated to personne! on ihe weekend shift.

COMMUNICATlONS
amiI ROOT CAUSE ANo\lYSIS HAND8001(

Typical Issues
Were there problems communicang v..ith contraclors? Were they made
aware of changes in policies and procedures?

Typical Recommendalions
Provide methods ror communicauon between your eompany and
contraetors
Ensure tha! contraetors have a designated conlaCl in your organization
Provide policy and procedure updates to conrractors

Example
A contraetor was assigned the task of digging a dllch lo install an under
ground lank. An engineer used flags lo mark areas tha! should be avoided so
as not to disturb underground utmties The contri:'.lctor thought the fIags
marked he $pOI to dig As a result. a natural gas !ine feeding the planl was
struck and broken.

CQM."lUNlCATIONS
 Apl'ENDIX A - Raen USE MAl' NaDE DESCRIPTlONS EJ
Typical Issues
Were lhere problems communicating wilh customers? Are cuslomers able lo
communicale Iheir needs lo the company? Does Ihe eompany respond to
requests from cuslomers? Are phone calls retumed and leners acknowledged?

Typical Recommendations
Track customer calls and letters to ensure timely processing
Provide convenienl means fOr customers lO contad Ihe company

Examples
A customer called with a question on instaliation o your producto The cus-
tomer was told that an installation technician would return the can in an hour.
The cuslomer called again lhe next day after having nol been called bac\<.
A cuslomer called in 10 order a batch o slaintess sleel bolts. The order was
nOI recorded correctly. and lhe cuslomer received a batch of threaded rods
inslead.

COMMUNlCATlONS
mm Rom CAUSE ANAlYSIS HA!\lD800K

Typical Issues
Was an error caused by misunderstood communications between personnel? Was there an error in verbal
communication? Dd someone misunderstand a hand signa!? Was a sigo misunderstood? Were oral instruc-
lians given when written instruClions should have been provided?

Typical Recommendations
Establish standard terminology for equipment and operations
Use the repeat-back method of communication
Provide wrirten instruclions when necessary
Minimize inlerference from noise

Example
An operalor l~ted in a noisy par! of che plan! was given an instruction by "walkie-talkie" lo apeo Valve
B-2. He lhoughllhe verbal instruction was lo apeo Valve 0-2. No repeat-back aT other type of verification
was used. He opened D-2, resulting in a process upset.

COMMUNICATIONS
 Al'l'fNDIX A - Roor CAuse MA.I' NODe DilCIlII'TlONS m:D
Typical Issues
Was standard or accepted terminology used? Could the communicalion be
interpreted more Ihan one way? Oid ene piece af equipment have tI.vo or
more commonly used names? Could the terminology have applied lo more
han one item?
"o.l
.... U"~..
CO."".'Clhll'

Typical Recommendations
Establish standard terminology for equipment. process operations. and
maintenance operations. Encourage alJ employees to stop using non-
standard terminology
Avoid ambiguou5 lerms and phrases in proceduTes, WOrK inslructions.
logbooks, etc.

Example
An operator was lold lo verify that a solution was dear before adding il to a
process. The operater Ihought Ihat "dear" meant "not cloudy. ~ What was
actually meanl was "no color" since color was an indicalion af contaminants
in the solution. The solution was clear (translucentJ, but had a slightly pink
lint. As a result, an oul-ofspecification solution was used.

COMMUNlCATrONS
mil ROOT use ANAlYSIS HANOIlOOK

Typical Issue
Was a commumcation error caused by failure lO repea! a message back lo the
sender far he purpose of verifying {ha! the message was heard and under-
stood correctly?

Typical Recommendalions
Encourage employees and personnel al alllevels lo use the repeat-hack
communicatlOn method lO ensure thorough understanding of relaled
job tasks
If employees/workers forge! lo use the n:~peatback method, instruet
supervisors and wark team leaders to request [hat he employee repeat
back

Example
An operatar was given an instrudion by ~walkie-Ialkier lo apen a valve. The
instruction was lO apen Valve 62. The operalor understood D-2. No repeat-
back ar other type o verification was used.

COMMUNICATlONS
 ApH.NOIX A - Roor CAUSE MM' NOOE DCSCRIPTION5 El
Typical Issues
Was a message or instruction misunderstood because it was too long? Should
the message have been written instead of spoken? Coukllhe message have
been shortened or broken up?

Typical Recornrnendations
Keep oral instructions short and rehearsed (especially if communicating
in nolsy areas)
lf several lengthy detalls must be conveyed, eonsider providing them as
written instruetions rather Ihan oral (i.e., generale a written procedure)

Example
An operatar was verbally instructed to apen Valves A7. 8-4, B-5. C-6. D.6,
D-7. D-8, and F-l He failed ta apen D-6. resulting in a process upset. No
written instruetions were given.

COMMUNlCATlONS
liEliI Roer CAusE ANAlYSIS HAND800K

) t.~.
1'

<
I

'.-"'.'.-"
'" "'"
~
~<-
"' '''u
_.
~.
'" ,.~- .. ,,'.
.. ,.,,"" ...
~"'" ~,-
~ "-......,.",
~
-~.',

c,.,~
fOl....
~'.n\'
...,.
a,~
: ,"
...,-.,,,,-
!t.... ' s.-,

e,-- ,- oo'.
e,,. ". s '"'
'''~~r'

t,--,'O"-
." t,,',-.,
l"

Typical Issue
Was !he communication erran! or inaccurale?

Typical Recommendation
Consulllhe procedure. training. supervision. human faclors engineering. and/or personal performance
branches oi the map

Example
A supervisor !old an operator lO apen Valve 101 instead of Valve 201.

COMMUN1CAT10NS
 ApPfNOIX A- Roor CAUSf MAl' NOOf DfSCRI,noNS mi

Typical Issue
Was lhere incorrect, incomplete. or olherwise inadequate communication between workers during a shift or
be[Ween shifts during a shift change?

Typical Recommendalions
Provide a means of communication for employees working on the same shift (e.g., two-way radios)
Conduct shift change meelings to aJert oncoming shifts of speciaJ job !asks. safety issue5. or problems
that occurred during Ihe previous shift
Provide guidance on the conlenl of shift turnovers

Example
A tank transfer was in progress during shift change. Ouring shift change. Ihe shift going off duly did nollell
the one coming on that the transfer was in progress. The tank overflowed.

COMMUNICATlONS
amiI Roor V.USE ANAlYSIS HANDaooK

Typical Issues
Was there incorrect, ncomplete, ar olherwise inadequate communication
between workers during a shift? Could a more effective method of communi-
cauon have becn used?
Note: Planning ond coordination o/ jobs between indiuidua/s and work
groups should be coded under Teamwork LTA (lmmediate Supcrvision,
Supervision During Work).

Typical Recommendations
Encourage employees to alert others on their shift of changes in job
task,s ha! may affee! orhers (Iel! others when you plan ID take a break
tell others when you move from one job lacallon lo another. te.)
Encourage employees lo keep each other informed about changes in
equipment status ha! may affecl olher areas of the planl

Example
A tank transfer was in progress when Operator A wen! on break He men-
tioned lo Operator B tha! Ihe Iransfer was going on. bul Operator B did no!
reaJize Ihal he needed lO SIOp Ihe transfer. As a result, !he tank overnowed.

COMMUNICATlONS
 ApPENOIX A - Roo, CAUSE MAP NOVE DESCRIPnO,'l/S l'iE!D
Typical Issue
Was there incorred, incomplete. or olherwise inadequate communication
between workers during a shift change?

Typical Recommendations
Conduct shift change: meelings to alert lhe oncoming shifts of special
job tasks. safery issues. or problems thal occurred during the previous
shift
Use logbooks lO communicate between shifts
Provide guidance on the contenl of shift turnovers

Example
A lank transfer was in progress during shift change. During the lurnover, the
shift going off dury did nollell the one coming on !hat the transfer was in
progress. The lank overflowed.

COMMUNlCATlONS
~ ROOT USl AAAlYSIS H ....NOBOQK

. tt ~"." " _ ,. '" ~ ,,~ rt

Typical Issues
Note; The six oslerrsked Leuel D nodes (OIJo/s. neor roor causes} are neluded ro prouide Ihe investigaror
wilh on underslanding 01 fne types o/ problems hal mighl be coregorited as Personal Performance lssues.
Howeuer, the muestlga/or should nol ndude hese Leve/ D nocies in he inuesligation reporto Also, there.
should be managemenl sysLems in place lo derect and corred most (i! nol 01/) personal performance issues
~ a loss euent occurs. Therefore. the failure or absence o/ 'he management systems shou/d be coded as
well
Did rhe worker's physical or mental welJbeing. anirude. mental capacity. anenlion span. rest. substance
abuse. etc.. adversely affee! lhe performance of he task? Was Ihe problem he resulr ol the individual nol
betng capable of performing lhe lask or no! wanting lO do his or her job? Was a personal performance
problem promptly delecled? Was correCIVe aClion promptiy laken?

Typical Recommendations
Ensure lhal lhere is a process in place lO delecl personal performance problems
Provide a means for personnello self-report problems

Examples
An operalor failed lO clase a valve afler completion of a transfer. The operalOr was nol paying ancntion 10
the level of Ihe lank inlo which lhe malerial was being rransferred. The operalor had a history of nOI paying
attention lO hlS work. He had been involved In several olher incidenls during which he had 112ft his job sile or
was nol performing his job reqUlremen!s. Olher operalors performed Ihese SCIme job requiremenls wilh no
problems.
An individual came lO I.'.'ork drunk. The operator was slumbling while walking lO his workstalion. However.
no one did anYlhing lO SIOp him from going lO work.

P[l~SONAl PUlfORMANU
 ApPCNDIX A - RooT C"usc MA.p NaDc DUCRJPTlONS ~

~ 1~.,(1' .....-. u.,<.~,

( . "u""

. o. ", N>.<o .. " . . '''~. ~ ,.~ ..., .","

Typical Issues
Did personal performance issues contribute to the event? Should the personal performance issues have been
detecte<:! prior to the event?
Note: Consider duol coding under Supervl5ion LTA (lmmediate Supervision, Supervision During Work).

Typical Recommendations
Provide supelVisors with training on the detection of personal problems
Give supervisors the authority to remove workers from hazardous assignmenls when personal prob-
lems are detected
Encourage coworkers to help identify personal performance problems

Examples
A worker came lo work drunk. He was having trouble walking and talking. While going lO get a parl from
Ihe warehouse. he fell down some sleps and injured himself and another worker.
Six months ago, a maintenance technician was hired who could not read. His supervisor had nol deteeted
Ihe problem. even though this techmcian had trouble with all of his nonroUline tasks (those Iha! required
'him lO use a procedurel.

PERSONAL PERFOR.'o\ANCE
r:iIII::I Roen USf AAAlYS'S H"NDBOOk

."......
,- .",... .
. ."
..'h"

',, _ _",.'."'.".'w ,,"

Typical Issues
Note: Code as Personal Performance only The six ostrisked Level D nodes (oua/s. neaT root causes) are
induded /O prouide lhe investiga/or wirh en underslonding of he types of problems hal mi9hl be categorized
as Personal Performance issues. Howeuer, he investigarar should nof nelude these Level D nodes in the
InlJestigotlon repon. A/so. rhere should be monagemenl systems in place 10 deteet and correet mos/ (i! nol al/)
personal performance issues be,JQm o loss euenr occurs Theref()re. he ailure or ahsence of lhe monogemenr
systems should be coded as well.
Was the problem a result of less than adequate vision (e.g.. poor visual acuily. color blindness. tunnel vi-
sicn)? Was the problem a resuh of sorne defeet in hearing (e.g.. hearing loss, lone deafnessl? Was Ihe prob-
lem a result of sorne sensory defect (e.g.. poor sense of toueh or smell)?

Typical Recommendalions
Ensure lhat job requirernenls are complete. including required physicaL'perceptual capabilities
Provide reasonable accomodations for coworkers with sensory'pereepruallimits
Nale: A reuiew of lhe human faaors engineering for rhe process is o/so appropriare lO rJccommcxJate a wider
spearum of sensory capabililies Far example: Can me disp/ays be re.designed so rhal Iights rhm indicare
Me/asedO< condilions 01 /Jo/ves are a/woys in Ihe some re/orive locolian on fhe panel? Con more charr record-
ers be rnstolled wh fewer points per charr'

Example
An operatar read the wrong lemperature on a chan thal recarded temperalures for several tanks The ehart
was color ceded. The operalor was partially color blind and confused lhe readlngs. He reearded a tempera-
ture that was In range when he aetualtemperalure was out of range.

Note: Consider codmg under Employee Screening'Hlring LTA (AdmlnistrativeiManagement Syslems.

SPACs LTA} becouse here sllould be manogelllenr conrrols to ensure employees possess fhe required job
capabilitles.

PEKSONAl PERfORMANCE
 ApPENDIX A - Roor USE MAl' NaoE DESCJlIPnONS mil

D, lO "" lO,...

Typical Issues
Note: Code as Personal Performance on/y. The siK asterisked Level D nodes (oua/s, near root causes) ore
included to prouide the inuestigaror with an understanding 01 the types 01 prob/ems !hai might be categori2ed
as Personal Performance i.ssues. Howeuer, the inuestigalor shou/d no! indude mese Leue/ D nodes in the
inuestigarion reporto Also, there should be monagement systems In place lo detect ond corred most (if nol al/}
personal performance issues ~ a /oss event occurs. Therefore, lhe fai/ure or absence 01 !he manogemenl
sy.stems should be coded as well.
Was the problem caused by inadequate inlel1eetual capacity? Does the persan frequently make wrong
decisions? In general. does me persan have difficulty processing information? Do other workers have diffi.
eulty performing mese tasks or is it isolated lO Ihis one worker?

Typical Recommendation
Review employee screening and hiring processes lo ensure thal Ihe individuals who are hired have the
required reasoning capabilities

Examples
An operator made a mistake in a calculation and added too mueh material lo the mixer. The operator had
frequently made errors with calculatons and appeared lo have problems with numbers. Other operalors did
not have difficulty performing these tasks.
An operatar missed several sleps in a procedure. The operatar was unable lo dearly understand the prace-
dures because they were written at a sixth-grade level and he could only read al a secondgrade leve!.
Note: Consider eoding under Employee ScreeningIHiring LTA (Administrative/Management Syslems. SPACs
LTA) as weJl, since there should be mcnagement controls lo ensure that emp/oyees possess the appropriate
reoding ond mcthemalicol ski/ls. .

PfRSONAl PfRFQRMANCf
I'DI ROOT CAUSf AMlrSI5 HA"OeooK

~~ /

~~ ....
<....;c"..
"''''''~''''''~'
<".,

.~. ' l ' " '. . . . . . ., " , . " .. ,., ......., ~,."

Typical Issues
Note: Code as Personal Performance cn/y. The six asrerisked Leve! D nades (DIJO/S, neor rool causes) are
included lO prouide rhe invesligOlor wirh on unders:onding 01 rhe I~'pes o/ problems Ihol mighr be caregorized
as Personal Performance issues. Howeuer. rhe investigator shou/d 'lOI oc/ude ,hese Level D nades in Ihe
mvestigarlon repon Also, here should be manogement s~'Slems in place fa detea ond correa most (il nol 01/)
personal performance issues ~ o 10$5 euen! occurs. Therefore. rhe failure or obsence ol/he manogemem
systems should be coded as wel/.
Can lhe causal factor be amibuled lO trouble with inadequate coordination or ;nadeQuate strength? Was the
problem a result of inadequate Slle or Slalure of Ihe indiVidual involved? Oid olher physicallimilarions (e.g..
shaking. poor reaction time) eonrribute la lhe problem?

Typical Recommendations .
Ensure lhal job requirements are complele, inc1uding required phl.'sicaLperceptual capabililies
Provide reasonable aecomodalions for workers WIlh physlcallimltalions
Nole: A review of (he human faclors englneerng for (he process is o/so oppropriole. Is I( reasonab/e for on
"overage" individuo/lO perJorm (his lask? Con Ihe individua/ be prouided wilh a 1001 lo os.siss in rhe losk?
Con he osk be redesigned lO reduce he physica/ requirements?

Example
A lank overnov..ed because lhe operalor could nOI close the valve. The valve was large and difficuh ro close.
The operalor did nol have lhe strenglh to close Ihe valve. By Ihe lime he obtained help in c10sing il. lhe lank
had overflowed.

Note: Corlsider coding under Employee Screening Hiring LTA (AdminislJative Managemenl Syslems.
SPACs LTAl because Ihere should be managemenl con/rols fo ensure employees possess {he required job
capabililies.

PfRSO""Al PUfORMANCf
 ApPCNDIX A - Roor usc MM NODc DcscRIPnONS EJ

DOl ""~ ........" ...... "" .. og'l6II"'.~

Typical Issues
Note: Code as Personal Performance on/y. The six asrerisked Leuel D nocies (oua/s. near roor causes) are
induded fa prouide Ihe inuesligalor wilh en undersronding of he types of problems Ihol mighr be cafegorized
as Personal Pt:!rformance issues. Howeuer, lhe investigOlor shou/d nol nelude these Level D nocies in Ihe
inuestigation reporto Also. there should be monogement sySlems in place lo detect ond corred mos! (if not 01/)
personal performance issues ~ a 10$5 event occurs. Therelore, the lailure or absence 01 rhe managemem
systems should be coded as we/l.
Was the problem a result of a peor attitude on Ihe part of an individual? Did the individual involved show
signs of emolional illness? Was Ihe problem caused by lack of attenlion? Does the individual involved in this
M

occurrence frequently "daydream ? Is the persan distracled easily? Is the person's abiliry to maintain vigi
lance fNquently below minimum acceptable standards? Do other workers have difficulty performing these
tasks or is il isolated to this one worker?
Typical charaeteristics inelude:
- engages in horseplay
is not at work location
does nol perform expected work
exhibits maliciousness
exhibits inability to operate under stress
exhibilS insuborclinaiion
exhibils inability lo work well or communicate with other people
ignores safety rules

Examples
An operator failed lo dose a valve while fiJling a tank. resulting in an overflow from lhe lank and a process
upset. The operator often was away from his assigned work location for personal reasons. such as making
personal pnone caUso
An operator failed to stop a transfer. resulting in a tank overnow. The operator had a history of being dis-
tracted easily and losing track of the next slep in the process.
Note: Consider coding under Employee Screening..Hiring LTA (AdminisrrativeJManagement Systems,
SPACs LTA) because here should be management COnlro/s to ensure emp/oyees possess he required job
capabi/ilies. Also consider coding under Supervision LTA lImmediate Supervision. Supervision During Work)
because superuision should deteet. mis prob/em.
~ Rom USE ANAlYSIS HAND800K

".'-_'"
".". "

.~ .." ",~,. ..... ",,,. .....,..

~ '~.' .. ..
, ,"

Typical Issues
Note: Code as Personal Performance on/y. rile six aste,isked Level D nodes (DIJO/S. neor rOOI causes) are
inc1uded 10 prouide Ihe inuestigolOT LVilh en underslonding ollhe Iypes 01 problems thm mighr be calegorized
as Personal Performance issues. Howeuer. Ihe investigatar should no/ nelude rhese Level D nades in rhe
investiga/ion repon. A/so. tlleTe should be monagement sysrems in place fa detea ond COrTea m~ (j[ nol 011)
personal performance issues ~ a loss euent occurs. Therefore, Ihe /aj/ure or obsence oi rhe managemenl
syslems should be coded as well.

Note: This nade addresses problems ossociared wilh on indiuidual's Tese ond sleep prodlCes outside o/ fhe
workplace. Problems w;lh workers wllo ore forced ca work unreasonable omoums 01 ouerlme should be
coded using he lmmediale Supervision or AdminisO'ative'Management Systems segmenLs 01 the map.
Was Ihe worker involved in lhe Inciden! asleep while on duty? Was the person too tred lO perform the job?

Example
A mechanic was lound asleep while he was supposed to be calibraling equipmem. The mechanic had
anolher job away from Ihe site and roulineJy appeared lO be extTemely lired.

PERSONAL PERfORMANCE
 ApPENDIX A - ROOT CAUSE MAP NODE DESCRIPnONS mEI

.o.", ~ .. ".... ", p, ". ''',"

Typical Issues
Note: Code as Personal Performance on/y. Toe six asterisked Leve/ O nodes (ova/s, neor rool causes) are
included to prouide rhe inuestigator wito an understanding 01 lhe types 01 problems roat migo! be ca!egorized
as Personal Performance issues. Howeuer, rhe inuestigator should not indude these Leuel D nades in lhe
inuestigation reporto A/so, Ihere shouJd be management systems In place lO deted and corred mosl (if not 01/)
personal performance issues ~ o loss euenl oceurs. Therefore, the lailure or obsenee 01 Ihe managemenl
sysrems should be coded as well.
ls the individual experiencing personal problems that are affeeting his or her job performance? Is the indi-
vidualtaking medications that affeet his or her job performance?
Typical symploms include:
- chronic inattention
- acule inattention
- freQuenl daydreaming
- easiJy distracled
- poor vigilance
- iIlness
- impairmenl due to prescription drugs
- poor psychologicaJ heaJth
- abuse of drugslalcohol

Typical Recommendations
Establish an employee assistance program
[nform and encourage workers lo take advanlage nf employee assiSlance programs

Example
An operalor was prescribed a medication that caused drowsiness. During a lank transfer. he losl track of time
and the lank overflowed.
 _. I ...... .., .n. g
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 ABOUT THE AUTHORS

Mr. Lee N. Vanden Heuvel is he Manager of Incident Investigatian/Rool

Cause Analysis Service:s and Ihe Manager o Training Services for ABS
Consulting. He has more Ihan 20 years of experience in plan! operaiions
and analysis.

Mr. Vanden Heuvel has assisled organizations in many different indus-

tries wilh Ihe development and implemenlation of inciden! investigalion
and root cause analysis (RCA} progTams. He al50 led and participated
in invesligations in many types af industries, including chernica!, refin-
iog, healthcare. manufacturing, machining. pharmaceulicals. waste
disposal. nuclear power. and food processing. He is a coauthor of GuidelinesJor the lnvestigalion
01 Chemicol Process lndden~. Second Edifioo. published by the American lnstitule of Chemical
Engineers' Center for Chemical Process Safety.

Mr. Vanden Heuvel was previausly rhe praject manager and lead analyst for a large quantitative
risk assessment program at rhe Oak Ridge National Laboralory. He also worked for 8 years at a
nuclear power plant in aperations, engineering support, and training, His current responsibilities
are in the areas of RCAs. incidenl investigations, human factors. safety analyses. and
economic/decision analyses, He is the prime developer of ABS Consulting's incidenl investigarion
course and has laught RCA techniques lo Ihousanrls of students.

Mr. Donald K Lorenzo is he Director of Training Services for ABS

Consulling. He has more than 25 years of experience in hazard analy-
sis and risk assessmenl. He was previously a developmenl engineer for
Unan Carbide Corporation. He is the aulhor 01 A Managers Guide ro
Reducing Human Errors and A Manager's Guide to Quantitatiue Risk
Assessmenl (published by Ihe Chemical Manufacturers Association,
now known as the American Chemistry Council) and a coauthor of
Guidelines for Hazard Eua/ualon Procedures, Second Edition wirh
Worked Examples (published by the Center for Chemical Pracess
Safery),

Mr. Lorenzo specializes in safety and environmental applications of ABS Consulting's SOURCE.
He is a regislered Professional Engineer in Ihe stale of Tennessee and a Cerlfied Teclmicl Tramer.
Mr. Randal L. Montgomery is lhe Manager of Business aod System
Performance Solutions for ABS Consulting. His experience ineludes
conduclmg rehability-centered mainteoance analyses and developmg
planned mamtenance programs for IOdustry and government c1ienls In
addition. he has developed process safety management (PSM) and
mechanical integrity (MI) programs and has wntlen maintenance prece-
dures for Ihe petroleum. chemica!. and pulp and paper industries. He is
a coauthor of Guidelines to Effective Mechanical lnlegrity Pregrams.
publishe b!lo' Ihe Center for Chemical Process Safely. Mr. MOnlgomery
has performed numerous root cause analyses focusing on reliabililY
issues and machinery applicalions

Mr. Montgomery previously worked at Henkel Corporal ion. where he served as MI coordinator.
implemenled management systems lo mee! PSM regulations. an managed prouction and
mainlenance groups.

Mr. Waller E. Hanson i5 a Project Manager an RisklReliability Engineer

for AB5 Consulting He has more Ihan 15 years of experience in devel-
opiog, Implementing, ao managing 1055 prevenlion managemenl
syslems. including mishap invesligalion. syslem safely. policy and pro-
cedure, training syslems, performance measurement, and human
fac!ors. Al ABS Consulting he works on various risk-management proj-
eCls for Ihe USo Coasl Guard (Coasl Guard) and other transportarion
and mantime clients Befare joining ABS Consulting. Mr. Hanson had
13 years of safery managemenl responsibihties as a commissioned off-
cer of Ihe Coast Guard. He compleled nearly 25 !lo'ears of commissioned
service aod allained Ihe rank of capta in

Mr. Hanson was a primary developer of ABS's Marine Rool Cause Analysls Technique
(MaRCAT). He is Ihe lead instruclor lar AB5 Consuhing's Marilime ROOl Cause Analysis course
Mr. James J. Rooney is a Senior RisklReliability Engineer and he r - - - - - - - -
Manager of Webinar Training Services for ABS Consulting. He has
more than 25 years of experience in Quality engineering, reliability engi-
neering. risk assessmenl, and process safety management. He s a
FeJlow of the American Society for Quality (ASQ).

Mr. Rooney is an ASQ-certified HACCP auditor, Certified Quality

Auditor, Cerlified Quality Engineer, Certified QuaJity lmprovement
Associate. Certified Qualiey Manager, and Certified Reliability Engineer.
He is a[so a registered Professional Engineer in the stale of Tennessee.

Mr. Rooney teaches courses on quality engineering. qualitative and Quantitative hazardlreliability
ana[ysis, management system developmentlauditing. and incident invesligation/root cause ana[y
siso He specializes in Quality and medica[ applicalions of the SOURCE' technique.
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consulting effart.

THE COMPLETE GUIDE TO IT SERVICE LEVEL AGREEMENTS,

MATCHING SERVlCE QUAUTY TO BUSINESS NEEOS
3rd Edition. by Andrew Hiles
Covering aH aspects of Informarion Technology Servce Level Agreemenls (SLAs). this essential
manual is a slep-bystep guide lO designing. negotiating C1nd implementmg 5LAs mIo your argan-
ization It reviews Ihe disadvantages and advantages. gives clear guidance on what types are
approJj -iale. how jo sel up SLAs and to control lhem_ An invaluable aid lO IT managers. data
center managers. computer services. syslems and operations managers.

CREATING A CUSTOMER-fOCUSEO HELP DESK,

HOW TO WIN ANO KEEP YOUR CUSTOMERS
by Andrew Hiles & Dr. Yvonne Gunn
This volume and Ihe componion produc!. Help Desk Framework CD-ROM came ahout as a resuh
of lhe aulho~' ouon practlcal experience in Help Dsk operallon and managemenl and of hu n-
dreds 01 workshops the authors have conducled world-wide over Ihe last hfteen years. 11 is
ntended lo he a practical reference guide. bUI lhe suggeslions. chE'cklisls an templales al!
need lo be inlerpreled and amended in lhe I1ghl of lhe culture. lechnology. service maturilY and
conslrainls of each individual organizalion

SERVICE LEVEL AGREEMENTS,

A FRAMEWORK ON CD-ROM FOR SERVICE BUSINESSES
by Andrew Hiles
SERVICE LEVEL AGREEMEI'HS: A FRAME\VORK O:--J CD-ROM FOR SERVICE BUSINESSES
hrings logelher Ihe critical elements needed lO build a Service Level Agreemenl for sen'ice or sup-
ply businesses (non-Iechnology focused). wilh extensive lemplates. examples and lools

SERVICE LEVEL AGREEMENTS, WINNING A COMPETITIVE EDGE fOR

SUPPORT & SUPPLy SERVlCES
by Andrew Hiles
This book holds lhe key to crealing enduring. satisfying and profilable relalionships between cus-
lomer and supplier. lt shows how bOlh internal and external services and supply can be aligned
lo meel business visiono mission, 90als. cntical success faclors and key performance indicalors.
The lechniques described will help you balance service cost againsl quality. leading lo competilive
advamage and bUSiness success. They can be applled to any induslry. to any supply or SUppOTl
service. They have becn used by leading companies IOlernationaJly - and lhey work!
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BCM fRAMEWORK' CD-ROM

by Andrew Hiles
BCM Framework consists of a number of easiJy tailored modules Ihal are selecled from OUT database
of dienl work tram a combined lolal of over cne hunclred years of consuJlancy experience . modules
that are hand picked as the mes! relevan! to your own situation. culture, organization, equipment
platform and infrastructure. It contains documents, examples, checklists and templates covering each
of the DRlI I BCl's len disciplines, model projecl plans, questionnaires aod Business Recovery Aclien
P1ans for with Organization Schematics and role desoiptions, with sorne vital - and aften forgotten -
actions included. These are in M5 Worcl', M5 Exeel' and M5 Proje<;tS formals designed to be easily
tailored lo your organization's needs.

ENTERPRlSE R1SK ASSESSMENT ANO BUSINESS IMPACT ANALYSIS, BEST PRACTlCES

by Andrew Hiles
This book de-mystifies risk assessment. In a practical and pragmatic way, il covers many tedmiques
and methods of risk and impacl assessment with detailed, practical examples and checklists. It
explains, in plain Janguage. risk assessmenl methoclologies used by a wide variety of industries and
provides a comprehensive loolkit for risk assessment and business impacl analysis.

AUDITING BUSINESS CONTINUITY, GLOBAL BEST PRACTlCES

by Rolf von Roessing
"The work no! only provides a general outline of how lo conduct different typeS of audits bul also
reinforces their appJication by providing practical examples and advice to ilIustrate Ihe step-by-step
methodology. including contracts, reports and techniques. The practical application of the method-
ology enables the professional auditor and BCM practitioner lo identify and mustrate the use of good
BCM practice whilst demonstrating added value and business resilience." - Dr. David J. Smith. MBA
LL.B(Hons), Chairman of the Business Continuity Instilute, Educanon Comminee

BUSINESS CONTINUITY PLANNING,

A STEP-BY-STEP GUIDE WITH PLANNING fORMS ON CD-ROM
by Kenneth L. Fulmer, CDRP
This popular book for Ihose new lo business conlinuity gives a slep-by-step outline filled with precise
instructions. risk and business impact analysis guidelines and forms for crealing your basic business
continuity blueprint. h serves as a werkbook fer those organillog a plan and as a guidebook for lhose
responsible far implementation. Clear and complete, Business Conlinuity Planning will prove an
invaluable resource and Quide for managers. owners and planning coordinalors.
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DISASTER RECOVERY TESTING,

EXERC1SING YOUR CONllNGENCY PLAN
PhUip Jan Rothstein, Editor
From this book. he canlingency planner can understand more Ihan jusI how lO lest: why lo lest.
when lO lest (and nol lest) 21nd the necessary partidpants and resources. Further. this book addresses
sorne ohen-ignored. real-world consideralions: Ihe justificalion. politics aod budgeling affecling
recovery testing. By having multiple authors share their respective aTeas of expenise. il is hoped ha!
this book will provide the reader wilh a comprehensive resouree addressing Ihe significan! aspects of
recovery lesln9.

BUSINESS COmlNlJl1Y PRQGRAM SELF-ASSESSMENT CHECKUST WITH CDROM

by Edmond D. Jones
This book and companion CO-ROM contains l comprehensive sel of qusions assess the status of
an organization's business conlinuity programo The questions may be used by a nev.r or experienced
business conlinuity planner lO assess Ihe overall program lO determine Ihose areas needing wark. The
same checklisls can be used by internal ar external audit or by olhers having a responsibility fer evaJ
uating an erganization's business contmuity programo

BUSINESS THREAT AND RlSK ASSESSMENT CHECKUST WITH CD-ROM

by Edmond O. Jones
This manual contains checklists Ihal an individual or group may use lO evaluate Ihe lhreals and risks
which may lmpacl an organization's campus. faciJity or even specific departments wlthin the organi.
zation. Each of Ihe checkJists shown in this manual and a cover page hal may be used lO assemble
your own checkJists are contamed on the CO thal accompanies this manual.

BUSINESS COmlNlJl1Y ANO HIPAA, BUSINESS CONllNUI1Y MANAGEMENf IN THE

HEALTH CARE ENVIRONMENT
By James C. Bames
Ths book examines business conlinuty planning as adapted lO encompass the requirements of The
Heallh Care Portability and Accountability Acl of 1996. or HIPAA. We \Viii examine {he rypical busl'
ness continuity planning model aod highlighl how Ihe special requlrements of HIPAA have shifted Ihe
emphasis. The layout of Ihis book \Vas designed lO afford assislance. hiots. and templales lo the pero
san charged \Vilh the task of implementing business coniinully planning ioto a healthcare
organizanon.