Environmental Engineering Reference
In-Depth Information
8
RootCauseAnalysis
IntroductIon
A.root.cause.analysis.is.not.a.search.for.the.obvious.but.an.in-depth.look.at.the.basic.
or.underlying.causes.of.occupational.accidents.or.incidents..The.following.should.be.
considered.when.performing.analyses:
•. Chart.events.in.chronological.order,.developing.an.events.and.causal.factors.
chart.as.initial.facts.become.available.
•. Stress.aspects.of.the.accident.that.may.be.causal.factors.
•. Establish.accurate,.complete,.and.substantive.information.that.can.be.used.
to.support.the.analysis.and.determine.the.causal.factors.of.the.accident.
•. Stress.aspects.of.the.accident.that.may.be.the.foundation.for.judgments.of.
needs.and.future.preventive.measures.
•. Resolve. matters. of. speculation. and. disputed. facts. through. investigative.
team.discussions.
•. Document. methodologies. used. in. analysis:. Use. several. techniques. to.
explore.various.components.of.an.accident.
•. Qualify.facts.and.subsequent.analysis.that.cannot.be.determined.with.rela-
tive.certainty.
•. Conduct. preliminary. analyses:. Use. results. to. guide. additional. collection.
of.evidence.
•.
Analyze.relationships.of.event.causes.
•.
Clearly.identify.all.causal.factors.
•.
Examine.management.systems.as.potential.causal.factors.
•.
Consider.the.use.of.analytic.software.to.assist.in.evidence.analysis.
A.root.cause.analysis.is.only.the.beginning.and.a.fraction.of.the.analysis.process.and.
should.not.be.considered.the.sole.approach.to.an.analysis.of.an.accident.
The.basic.reason.for.investigating.and.reporting.the.causes.of.occurrences.is.to.
enable. the. identiication. of. corrective. actions. adequate. to. prevent. recurrence. and.
thereby. protect. the. health. and. safety. of. the. public;. the. workers;. the. equipment,.
machinery,. and. facility;. and. the. environment.. Every. root. cause. investigation. and.
reporting. process. should. include. ive. phases.. While. there. may. be. some. overlap.
between.phases,.every.effort.should.be.made.to.keep.them.separate.and.distinct..The.
phases.of.a.root.cause.analysis.are
•.
Phase.I:.Data.collection
•.
Phase.II:.Assessment
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