3/22/20181RootCauseAnalysisTool(RCAT):AnOldToolwithaCriticalNewTwistforBetterPreventionANDSafetyCultureCathyA.Hansell,SMS,CSM,CCSR,MS,JDwww.breakthroughresults.org;chansell@breakthroughresults.orgCopyright@2010BreakthroughResults,LLC.AllRightsReservedRCAT:OldToolwithaNewTwistAgenda:•Assumptions•RootCauseAnalysisTool(RCAT)•Definitions•Process•Consideringthe“Influencers”:WhatPeopleKnow,SeeandFeel•RootCauseChart•TipsandTraps•PracticalApplication3/22/20182Assumptions•Anunderlyingrootcauseandothercontributorycauses•Peoplereacttotheircurrentworkdesign,peopleandsystems•Firstseektheunderlyingwork,safetymanagementsystemandculturaldefects,notplacingblame.•AtooleasytouseandeffectiveforfuturepreventionRCAT:OldToolwithaNewTwistIncidentInvestigationProcessMapRootCauseIncidentInvestigationandCorrectiveActionProcessKeyProcessInputKeyProcessOutputAmericanStandardIncidentInvestigationProcedureLocalIncidentinvestigationprocedureLocalRegulatoryrequirementsSiteemployeelistinglistingwithincidentinvestigationteammembersManagementdecisionIncidentinvestigationprocedurememberstrained,readytodeployprocedureIdentifiedteammembersBrokenProcessUnsafeActsFatality,Injury,Firstaid,NearmissUnsafeConditionsEnvironmentalSpillQuestions:Who?What?When?Where?ProblemStatement(conciseeventdescription)IncidentinvestigationprocedureIncidentinvestigationstartProblemStatement6hoursInterviewsObservation-Documenteddirectevidence(scene,witnesses)Photo's-Indirectevidence(writtensources)Direct/Indirectevidence5WhyFishbonewith6M'sExcelltabImmediatecauselisting24hoursAnsweron"Howtheaccidenthappened"Fishbonewithimmediatecauses5WhyRootcauseandcontributorycauselistingExcelltabPotentialsystemcauselisting48hoursRootcauseandcontributorycauselisting72hoursCorrectiveactionplanwithresponsiblepersonandtargetdatePreventiveactionplanwithresponsiblepersonandtargetdateRootcauselistingReportandactionsapprovedbymanagementActionplanActionplan-actionstepsCorrectedworkenvironmentSafetyAlertContinuousimprovementCorrectedworkenvironmentIncidentinvestigationreportDevelopLocalIncidentinvestigationProcedureIncidentnotificationINCIDENTPrepareteammembersthroughtrainingandexerciseSelectpossibleincidentinvestigationTeammembersIdentifySystemRootcauseforeachimmediatecauseAppointteamleaderandactivateteamCollectevidenceOrganizeevidenceforimmediatecauseidentificationDevelopproposalforcorrectiveactionthateliminateidentifiedrootcausesSharekeylearningsPreparereportformanagementapprovalImplementcorrectiveactionsandcheckeffectivenessRCATRCAT:OldToolwithaNewTwist3/22/20183•Problem–Obstacletosafety.The“effect”ofanincident•RootCause–Basic,underlyingreasonforanundesirableconditionorproblemwhich,ifeliminatedorcorrected,wouldhavepreventedtheproblemfromexistingoroccurring.Systemic,process,long‐term•Causes:•Immediate–“seen”;short‐term•Contributory‐worsenseffect,severityandfrequencyofproblem;short‐term•Solution‐Permanenteliminationoftheproblemandrootcause.•Implementation–Actionplan:documentation;introduction;training,trackingandauditing.DefinitionsRCAT:OldToolwithaNewTwistFishbone(Ishikawa)Diagram(sixM’s:Man,Materials,Method,Machine,Measurement/Metrics,MotherNature\Environment)Five“WHY”TechniqueorFault‐Tree…addotherinfluencersUtilizetheRootCausecharttoidentifypersonalandjobfactorsandspecificunderlyingrootcauseLinkcausestotheMaturi...
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