dow restricted - for internal use only root cause analysis presented by abc texas gulf coast chapter

DOW RESTRICTED - For internal use only

ROOT CAUSE ANALYSIS

PRESENTED BY

ABC

TEXAS GULF COAST CHAPTER


TRAINING AGENDA

1. Introduction to RCA2. RCA Problem Solving

A. Problem Solving Flow ChartB. Cause and Effect Chain

C. Primary Effect DefinitionD. Root Cause DefinitionE. Cause and Effect Chart ProcessF. Root Cause Analysis ExampleG. Cause/Effect Flow Chart ExampleH. Summary Report Example

3. Skills Exercises


Course Objective

To provide the knowledge and skills necessary to participate

in effective Root Cause Analysis.


LEARNING OBJECTIVES

1. State the definition of Root Cause2. State the purpose of Root Cause Analysis3. State the three elements of problem analysis4. Explain the cause and effect principle5. Be able to identify the three basic root cause

categories and know their basis6. State the four root cause criteria7. Given and example, be able to recognize a root cause

summary statement8. Given a sample scenario demonstrate competence in

the use of the Cause and Effect charting technique


ROOT CAUSE ANALYSIS

• A tool that helps find a way to prevent problem recurrence

• Main intent of process is not to place blame

• Starts out as a reactive process and after it is full understood, it’s use becomes more proactive


WHY USE THE ROOT CAUSE ANALYSIS PROCESS?

• Provides and orderly approach to problem solving

• Avoids opinion and forces the use of facts• Helps find a root cause or admit a root

cause is not clear• Leads to true solution that will prevent

recurrence of the problem• Documents your thinking in the form of a

cause and effect diagram.


ROOT CAUSE ANALYSIS


DEFINE THE PROBLEM

Gather Information

When did it happen?

What is the problem?

Gather Information

Where did it happen?

What is the significance?

Write the Problem

Perform Analysis


Perform Analysis

Prepare Cause and Effect Chart

Define the Problem

Identify Root Cause(s)

Write Cause and Effect Summary

Identify Associated Solutions

Verify Solution


VERIFY SOLUTION

Does the Solution prevent recurrence?

Perform Analysis

Is the solution within your control?

Does the solution meet your goals?

Does the solution cause other problems?


CAUSE AND EFFECT CHAIN

All events are a result of a chain of causes and effects; starting with

the primary effect, and ending with the root cause or causes


CAUSE AND EFFECT PROCESS

DIRECTCAUSE

SUBSEQUENTEFFECT

ROOT CAUSE

CONTRIBUTING CAUSE

PRIMARYEFFECT


PRIMARY EFFECT

The effect or problem you are trying to prevent from recurring is the primary effect. It is singular with one or more

root causes.


ROOT CAUSE

The cause that if removed or prevented from happening will prevent the primary effect

from occurring.


ROOT CAUSE CATEGORIES

• Personnel performance problems

• Procedure problems

• Hardware problems


ROOT CAUSE CRITERIA

The Root Cause has a solution that:

Prevents recurrence

Is within your control

Allows you to meet your goals and objectives

Does not cause other issues. No “side effects”


CAUSE AND EFFECT CHART PROCESS

Step 1. Write down the primary effect

Step 2. Ask why this happened

Step 3. After you have found the answer write it down as the cause

Step 4. Ask how it is that you know this to be the cause, and write down at least two ways you know it to be true

Step 5. Repeat steps 2, 3, and 4 until the root causes are found.


ROOT CAUSE ANALYSIS EXAMPLE

Incident Report 4/1/1994

Description of Occurrence:On March 21, 1991 at PF-41, hazardous material was released which contaminated

several workers and the immediate area.

Immediate Actions Taken and Results:Several workers went to Industrial Medicine, and received first aid. The effects were not

serious, but the employees were shaken up by the unexpected event.

Investigation:A system improvement project for the TBA plant was being undertaken. The project consisted

of installing a pump and a new piping system. The block machinists and pipefitters were utilized

for all the required work. After all the work was completed, operations was asked to test the

system. An operator started the pump while a machinist and pipefitter stood by observing the

start-up of the system. After a few minutes, a leak occurred at one of the flanged connections

by the pump and sprayed the operator, machinist and pipefitter. The operator immediately

shutdown the pump and called the board operator for assistance. All three worked went to

the safety showers and stayed there until the ambulance arrived.


SIMPLIFIED CAUSE AND EFFECT CHARTPersonnel /area

contamination with hazardous material

Flange seal failure

O-Ring Blowout

O-Ring misalignment with flange

Wrong O-ring installed

Maintenance Procedures not adequate

Root Cause


CAUSE AND EFFECT CHART

A A

Recorded at 100psig

O-ring separated & sticking out of flange

Observed by Mechanics

Observation

Reportable EventStandard Operating Practice

Personnel /area contamination with hazardous material

Hazardous Material in System

Flange Seal

Failure

O-Ring Blew Out

O-Ring Misaligned with Flange

System Pressure

Runs High

AWrong O-Ring

Installed

Maintenance Procedures less than adequateROOT CAUSE


SUMMARY STATEMENT

• A good summary has this format– Problem Definition with Primary Effect– Caused by, or Why, ect..– Root Cause Stated– Root Cause Categories


Root Cause Analysis Report

• Things to include in RCA Report:– Goal– Report Writer– Report Date– Significance– Cause and Effect Summary Statement– Root Cause– Root Cause Category– Corrective Action and Those Responsible

Example Report in Packet


ROOT CAUSE ANALYSISGoal: Prevention, Not Blame

1. Define the Problem: What?When?Where?Significance?

2. Perform Analysis: Create C&E ChartIdentify Root Cause(s)Identify Associated

Solutions

3. Verify Solutions Prevents RecurrenceWithin Your

ContolMeets Goals

and ObjectivesDoes Not Create

New Problems


PRACTICE


ROOT CAUSE ANALYSISCAUSE AND EFFECT CHART-SIMPLE

Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise it is not necessary to include the evidence portion

Use the Checklist in your book to keep you on track.


ROOT CAUSE ANALYSISCause and Effect Chart w/ Evidence

Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise you will need to include the evidence portion



ROOT CAUSE ANALYSISCause and Effect Chart w/ Evidence and RCA Report

Read the incident report and use the post-it notes to prepare a cause and effect chart. For this exercise you will need to include the evidence portion and complete a Root Cause Analysis Report


dow restricted - for internal use only root cause analysis presented by abc texas gulf coast chapter

Documents

solution cause

root cause analysis

root cause definition

definition of root cause

root cause criteria

root cause analysis

root cause analysis

internal use