Root Cause Analysis Guidance Document

This document is a guide for root cause analysis specified by DOE Order 5000.3A, "Occurrence

Reporting and Processing of Operations Information." Causal factors identify program control deficiencies

and guide early corrective actions. As such, root cause analysis is central to DOE Order 5000.3A.

The basic reason for investigating and reporting the causes of occurrences is to enable the

identification of corrective actions adequate to prevent recurrence and thereby protect the health and

safety of the public, the workers, and the environment.

Every root cause investigation and reporting process should include five phases. While there may

be some overlap between phases, every effort should be made to keep them separate and distinct.

Phase I. Data Collection. It is important to begin the data collection phase of root cause analysis

immediately following the 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 occurrence.

Phase II. Assessment. Any root cause analysis method may be used that includes the following

steps:

Identify the problem

Determine the significance of the problem

Identify the causes (conditions or actions) immediately preceding and surrounding the

problem

Identify the reasons why the causes in the preceding step existed, working back to the root

cause (the fundamental reason which, if corrected, will prevent recurrence of these and

similar occurrences throughout the facility). This root cause is the stopping point in the

assessment phase.

The most common root cause analysis methods are:

Events and Causal Factor Analysis. Events and Causal Factor Analysis identifies the time

sequence of a series of tasks and/or actions and the surrounding conditions leading to an

occurrence. The results are displayed in an Events and Causal Factor chart that gives a

picture of the relationships of the events and causal factors.

Change Analysis. Change Analysis is used when the problem is obscure. It is a systematic

process that is generally used for a single occurrence and focuses on elements that have

changed.