Environmental Engineering Reference
In-Depth Information
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1.
Identify the problem.
.Remember.that.actuation.of.a.protective.system.con-
stitutes.the.occurrence.but.is.not.the.real.problem;.the.unwanted,.unplanned.
condition. or. action. that. resulted. in. actuation. is. the. problem. to. be. solved..
An example.of.this.would.be.when.dust.in.the.air.actuates.a.false.ire.alarm..
In this.case,.the.occurrence.is.the.actuation.of.an.engineered.safety.feature..
The.smoke.detector.and.alarm.functioned.as.intended;.the.problem.to.be.
solved.is.the.dust.in.the.air,.not.the.false.ire.alarm.
.
. Another. example. is. when. an. operator. follows. a. defective. procedure.
and.causes.an.occurrence..The.real.problem.is.the.defective.procedure;.the.
operator. has. not. committed. an. error.. However,. if. the. operator. had. been.
correctly.trained.to.perform.the.task.and,.therefore,.could.reasonably.have.
been.expected.to.detect.the.defect.in.the.procedure,.then.a.personnel.prob-
lem.may.also.exist.
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2..
Determine the signiicance of the problem.
.Were.the.consequences.severe?.
Could.they.be.next.time?.How.likely.is.recurrence?.Is.the.occurrence.symp-
tomatic.of.poor.attitude,.a.safety.culture.problem,.or.other.widespread.pro-
gram. deiciency?. Base. the. level. of. effort. of. the. subsequent. steps. of. your.
assessment.on.the.estimation.of.the.level.of.signiicance.
.
3.
Identify the causes.
.Identify.the.causes.(conditions.or.actions).immediately.
preceding.and.surrounding.the.problem.(i.e.,.the.reason.the.problem.occurred).
.
4.
Identify the reasons why the causes in the preceding step existed.
.By.working.
back.to.the.root.cause,.the.fundamental.reason.that,.if.corrected,.will.prevent.
recurrence.of.this.and.similar.occurrences.throughout.the.facility.and.other.
facilities.under.control.of.the.organization..This.root.cause.is.the.stopping.
point.in.the.assessment.of.causal.factors..It.is.the.place.where,.with.appro-
priate.corrective.action,.the.problem.will.be.eliminated.and.will.not.recur.
r
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EtHoDs
The.most.common.root.cause.analysis.methods.are
.
1..
Events and Causal Factor Analysis
.identiies.the.time.sequence.of.a.series.
of.tasks.or.actions.and.the.surrounding.conditions.leading.to.an.occurrence.
as.well.as.determines.the.causal.factors..(See.Chapter.9.)
.
2..
Change Analysis
.is.used.when.the.problem.is.obscure..It.is.a.systematic.pro-
cess.that.is.generally.used.for.a.single.occurrence.and.focuses.on.elements.
that. were. planned. and. unplanned. changes. in. the. system. and. determines.
their.signiicance.as.causal.factors.in.an.accident..(See.Chapter.10.)
.
3..
Barrier Analysis
.is.a.systematic.process.that.can.be.used.to.identify.physi-
cal,. administrative,. and. procedural. barriers. or. controls. that. should. have.
protected. persons,. property,. and. the. environment. from. unwanted. energy.
and.prevented.the.occurrence..(See.Chapter.11.)
.
4..
Management Oversight and Risk Tree (MORT) Analysis
. is. used. to. iden-
tify. inadequacies. in. barriers. and. controls,. speciic. barrier. and. support.
functions,.and.management.functions..It.identiies.speciic.factors.relating.
to.an.occurrence.and.identiies.the.management.factors.that.permitted.these.
