Root Cause Identification

DOE-HDBK-1078-94

6.2.4 Root Cause Identification. Identification of the root cause should lead to

determination of the appropriate corrective action. Utilize training and facility

personnel in the identification of root causes and the determination of

appropriate solutions. In general, root causes are identified by first identifying

specific symptoms of the problem. Then alternative causes are generated and

investigated until they are confirmed or eliminated.

Identification of root causes may be aided by the use of evaluation standards

produced during the design phase. When facility events or feedback from

employees or their supervisors indicate that workers have difficulty with

specific tasks, administering applicable evaluation standards to a group of

workers may disclose the nature of the problem and its cause.

If a performance discrepancy or potential problem is discovered and analysis confirms

that training can contribute to a solution, action should be initiated to correct the

existing or potential problem. Training modifications initiated because of existing

deficiencies in personnel performance and those resulting from changing needs should

be processed in a similar manner. Improvements and changes to training should be

initiated and tracked systematically. Analysis results should be retained to document

evaluation activities and indicators should continue to be monitored.

Because of the amount of work and cost involved, any decision to modify training

should be carefully considered. Each facility should establish a procedure for deciding

whether or not training should be changed, how it should be changed, and to whom the

new or modified training should be provided.

Improvements or revisions involving any phase of the training process (analysis, design,

development, implementation, or evaluation) should be completed in a timely manner.

Since some performance deficiencies can be eliminated by better implementation of an

existing program, with no changes in the program itself, this should be considered.

The following considerations should be emphasized when performing and evaluating

activities during the evaluation phase.

Responsibility for monitoring indicators, analyzing data, and approving

revisions is clearly defined;

The training department is alerted to facility operating, maintenance, and

industrial safety experiences;