Environmental Engineering Reference
In-Depth Information
Occurrence
Serious
or Complex
Yes
No
Use all applicable
analytical models
Use scaled down methods
or informal analysis
For
Use
Obscure Cause
Organizational Behavior Breakdown
Change Analysis
(Use concept for all cases)
Complex Barrier and Controls
(Procedure or Administrative Problems)
Barrier Analysis
(Built into MORT)
Multi-faceted Problems
with Long Causal
Factor Chains
Events and Causal Factor Charting
and/or MORT
Human Performance Evaluation
and/or MORT
People Problems
ˆorough Analysis of both
Causes and Corrective Actions
Kepner-Tregoe Problem Solving
and Decision Making
FIgure 8.1
Summary.of.root.cause.analysis.methods.lowchart..(
Source:
.Courtesy.of.the.
United.States.Department.of.Energy.)
PhAse III: correctIve ActIons
Implementing.effective.corrective.actions.for.each.cause.reduces.the.probability.that.
a.problem.will.recur.and.improves.reliability.and.safety..Root.cause.analysis.enables.
improvement.of.reliability.and.safety.by.selecting.and.implementing.effective.cor-
rective.actions..First,.identify.the.corrective.action.for.each.cause,.and.then.apply.the.
following.criteria.to.the.corrective.actions.to.ensure.they.are.viable..If.the.corrective.
actions.are.not.viable,.reevaluate.the.solutions.
.
1.. Will.the.corrective.action.prevent.recurrence?
.
2.. Is.the.corrective.action.feasible?
.
3.. Does.the.corrective.action.allow.meeting.the.primary.objectives.or.mission?
.
4.. Does. the. corrective. action. introduce. new. risks?. Are. the. assumed. risks.
clearly. stated?. (The. safety. of. other. systems. must. not. be. degraded. by. the.
proposed.corrective.action.)
.
5.. Were.the.immediate.actions.taken.appropriate.and.effective?
