Environmental Engineering Reference
In-Depth Information
.
a.
Situation appraisal . to. identify. concerns,. set. priorities,. and. plan. the.
next.steps.
.
b..
Problem analysis .to.precisely.describe.the.problem,.identify.and.evalu-
ate.the.causes,.and.conirm.the.true.cause.(this.step.is.similar.to.change.
analysis).
.
c.
Decision analysis . to. clarify. purpose,. evaluate. alternatives,. assess. the.
risks.of.each.option,.and.make.a.inal.decision.
.
d..
Potential problem analysis .to.identify.safety.degradation.that.might.be.
introduced.by.the.corrective.action,.identify.the.likely.causes.of.those.
problems,.take.preventive.action,.and.plan.contingent.action.(this.inal.
step.provides.assurance.that.the.safety.of.no.other.system.is.degraded.
by.changes.introduced.by.proposed.corrective.actions).
.
These.four.steps.cover.all.phases.of.the.occurrence.investigation.process..
Thus,. Kepner-Tregoe. can. be. used. for. more. than. causal. factor. analysis..
Separate.worksheets.(provided.by.Kepner-Tregoe).provide.a.speciic.focus.
on.each.of.the.four.basic.steps.and.consist.of.step-by-step.procedures.to.aid.
in.the.analyses..This.systematic.approach.prevents.overlooking.any.aspect.
of.concern..As.formal.Kepner-Tregoe.training.is.needed.for.those.using.this.
method,.a.further.description.is.not.included.in.this.topic.
The. use. of. different. methods. to. conduct. root. cause. analysis. has. been. widely.
accepted..Certain.methods.are.used.for.different.circumstances.(see.Figure 8.1.and.
Table 8.1).
Root. cause. categories. have. been. selected. with. the. intention. of. addressing. all.
problems.that.could.arise.in.conducting.industrial.operations..Elements.necessary.to.
perform.any.task.are.equipment.and.material,.procedures.(instructions),.and.person-
nel..Design.and.training.determine.the.quality.and.effectiveness.of.the.equipment.
and.personnel..These.ive.elements.must.be.managed;.therefore,.management.is.also.
a.necessary.element..External.phenomena,.beyond.operational.control,.serves.as.a.
seventh.cause.element..Whenever.there.is.an.accident.or.incident,.one.of.the.seven.
program.elements.was.inadequate.to.prevent.the.occurrence..(Note.that.a.direct,.con-
tributing,.or.root.cause.can.occur.anywhere.in.the.cause.factor.chain;.that.is,.a.root.
cause.can.be.an.operator.error,.while.a.management.problem.can.be.a.direct.cause,.
depending.on.the.nature.of.the.occurrence.).These.seven.root.causal.categories.are.
further.subdivided.into.a.total.of.thirty-two.subcategories.as.is.illustrated.and.used.
in.Causal.Factor.Analysis.(see.Table 8.2)..The.direct.cause,.contributing.causes,.and.
root.cause.are.all.derived.from.these.subcategories..The.major.cause.categories.are
•.
Equipment/Material.Problem
•.
Procedure.Problem
•.
Personnel.Error
•.
Design.Problem
•.
Training.Deiciency
•.
Management.Problem
•.
External.Phenomenon
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