Environmental Engineering Reference
In-Depth Information
PhAse I: dAtA collectIon
It.is.important.to.begin.the.data.collection.phase.of.root.cause.analysis.immediately.
following. the. occurrence. identiication. to. ensure. that. data. are. not. lost.. (Without.
compromising. safety. or. recovery,. data. should. be. collected. even. during. an. occur-
rence.). The. information. that. should. be. collected. consists. of. conditions. before,.
.during,.and.after.the.occurrence;.personnel.involvement. (including.actions. taken);.
environmental. factors;. and. other. information. having. relevance. to. the. occurrence,.
condition,.or.problem..For.serious.cases,.photographing.the.area.of.the.occurrence.
from. several. views. may. be. useful. in. analyzing. information. developed. during. the.
investigation.. Every. effort. should. be. made. to. preserve. physical. evidence. such. as.
failed.components,.ruptured.gaskets,.burned.leads,.blown.fuses,.spilled.luids,.and.
partially.completed.work.orders.and.procedures..This.should.be.done.despite.opera-
tional.pressures.to.restore.equipment.to.service..Occurrence.participants.and.other.
knowledgeable.individuals.should.be.identiied.
Once. all. the. data. associated. with. this. occurrence. have. been. collected,. the. data.
should. be. veriied. to. ensure. accuracy.. The. investigation. may. be. enhanced. if. some.
physical.evidence.is.retained..Establishing.a.quarantine.area.or.the.tagging.and.segre-
gation.of.pieces.and.material.should.be.performed.for.failed.equipment.or.components.
The.basic.need.is.to.determine.the.direct,.contributing,.and.root.causes.so.that.
effective.corrective.actions.can.be.taken.that.will.prevent.recurrence..Some.areas.to.
consider.when.determining.what.information.is.needed.include
•.
Activities.related.to.the.occurrence
•.
Initial.or.recurring.problems
•.
Hardware. (equipment). or. software. (programmatic-type. issues). associated.
with.the.occurrence
•.
Recent.administrative.program.or.equipment.changes
•.
Physical.environment.or.circumstances
Some.methods.of.gathering.information.include
•.
Conducting. interviews. and. collecting. statements—interviews. must. be.
fact-inding.and.not.fault-inding..Preparing.questions.before.the.interview.
is.essential.to.ensure.that.all.necessary.information.is.obtained.
•.
Interviews. should. be. conducted,. preferably. in. person,. with. those. people.
who. are. most. familiar. with. the. problem.. Individual. statements. could. be.
obtained.if.time.or.the.number.of.personnel.involved.makes.interviewing.
impractical..Interviews.can.be.documented.using.any.format.desired.by.the.
interviewer..Consider.conducting.a.“walk-through”.as.part.of.this.interview.
if.time.permits.
Although.preparing.for.the.interview.is.important,.it.should.not.delay.prompt.con-
tact.with.participants.and.witnesses..The.irst.interview.may.consist.solely.of.hearing.
their. narrative.. A. second,. more-detailed. interview. can. be. arranged,. if. needed.. The.
interviewer.should.always.consider.the.interviewee's.objectivity.and.frame.of.reference.
