Root Cause Analysis Guidance Document

• Root Cause Analysis Guidance Document
• Abstract
• Contents
• Root Cause Analysis Guidance Document
• Definitions
• Overview of Occurence Investigation
• Phase I - Data Collection
• Phase I - Data Collection cont'd
• Phase II - Assessment
• Figure 1. Causal Factor Categories Associated in a Logical Chain
• Assessment and Reporting Guidance
• Root Cause Methods
• Figure 2. Summary of Root Cause Methods (Flow Chart)
• Table 1. Summary of Root Cause Methods
• Figure 3. Causal Factor Relationships
• Change Analysis
• Human Performance Evaluation
• Phase III - Corrective Actions
• Phase V - Follow-Up
• References
• Appendix A - Cause Codes
• Appendix B - Causal Factor Worksheets
• Equipment/Material Worksheet
• Procedure Worksheet
• Personnel Error Worksheet
• Design Problem Worksheet
• Training Deficiency Worksheet
• Management Problem Worksheet
• External Phenomena Worksheet
• Worksheet Summary
• Appendix C - Causal Factor Analysis Examples
• Appendix C - Causal Factor Analysis Examples
• Appendix C - Causal Factor Analysis Examples cont'd
• Figure C-1. Events and Causal Factors Chart
• Equipment/Material Worksheet
• Procedure Worksheet
• Personnel Error Worksheet
• Design Problem Worksheet
• Training Deficiency Worksheet
• Management Problem Worksheet
• External Phenomena Worksheet
• Worksheet Summary
• Appendix D - Events and Casual Factor Analysis
• Cause and Effect Chart
• Figure D-1. Conceptual Process of Cause and Effect Charting
• Figure D-2. Example of Cause and Effect Charting
• Figure D-2. Continued
• Appendix E -Change Analysis
• Appendix E -Change Analysis cont'd
• Appendix E -Change Analysis cont'd
• Appendix E -Change Analysis cont'd
• Figure E-1. Six Steps Involved in Change Analysis
• Change Analysis Work Sheet
• Appendix F - Barrier Analysis
• Appendix F - Barrier Analysis cont'd
• Figure F-1. Examples of Barrier Analysis
• Appendix G - Management Oversight and Risk Tree (MORT) Analysis
• Appendix G - Management Oversight and Risk Tree (MORT) Analysis cont'd
• Figure G-1. Mini-MORT Analysis Chart
• Figure G-2. MORT-based Root Cause Analysis Form
• Appendix H - Human Performance Evaluation
• Concluding Material
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Root Cause Analysis Guidance Document

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