Root Cause Analysis: A Guide to Efficient and Effective Incident Investigation

The Root Cause Analysis Handbook presents a proven system for investigating, categorizing (and ultimately eliminating) the root causes of incidents with safety, health, environmental, quality, reliability, and production-process impacts. Understanding and applying the processes outlined in this book increases your business ability to recover from and prevent incidents with financial and health/safety implications.

The book outlines ABS Consulting's SOURCE(TM) (Seeking Out the Underlying Causes of Events) root cause analysis (RCA) system, enabling businesses to generate specific, concrete recommendations for preventing incident recurrences. The instructions for performing RCA activities include:

- Initiating an investigation: How to determine whether an incident has occurred, how to classify and categorize the incident, and how to decide whether or not to conduct an in-depth investigation.

- Data gathering: How to collect data related to people, processes, procedures, documents (hard copy & electronic), position, and physical data associated with an incident.

- Data analysis: How to analyze incidents to determine causal factors using tools such as causal factor charts, timelines, and cause and effect trees.

- Developing recommendations: How to document causal factors and root causes identified during the earlier analysis including how to identify what changes (recommendations) may be needed to enhance management systems and reduce risks. - Reporting and trending: How to archive findings and recommendations to allow review and trending of incident patterns after some period of SOURCE(TM) use.