Phase I - Data Collection

supposed to have prevented this occurrence? (Was it lacking or did it fail?) Investigate the reasons why

this situation was permitted to exist.

This line of reasoning will explain why the occurrence was not prevented and what corrective

actions will be most effective. This reasoning should be kept in mind during the entire root cause process.

Effective corrective action programs include the following:

Management emphasis on the identification and correction of problems that can affect

human and equipment performance, including assigning qualified personnel to effectively

evaluate equipment/human performance problems, implementing corrective actions, and

following up to verify corrective actions are effective

Development of administrative procedures that describe the process, identify resources,

and assign responsibility

Development of a working environment that requires accountability for correction of

impediments to error-free task performance and reliable equipment performance

Development of a working environment that encourages voluntary reporting of

deficiencies, errors, or omissions

Training programs for individuals in root-cause analysis

Training of personnel and managers to recognize and report occurrences, including early

identification of significant and generic problems

Development of programs to ensure prompt investigation following an occurrence or

identification of declining trends in performance to determine root causes and corrective

actions

Adoption of a classification and trending mechanism that identifies those factors that

continue to cause problems with generic implications.

It is important to begin the data collection phase of the root cause process immediately following

occurrence identification to ensure that data are not lost. (Without compromising safety or recovery, data

should be collected even during an occurrence.) 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 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 fluids, partially completed work

orders and procedures. This should be done despite operational pressures to restore equipment to service.

Occurrence participants and other knowledgeable individuals should be identified.

Once all the data associated with this occurrence have been collected, the data should be verified

to ensure accuracy. The investigation may be enhanced if some physical evidence is retained. Establishing

a quarantine area, or the tagging and segregation of pieces and material, should be performed for failed

equipment or components.