Root Cause Analysis

Human Error; Human Error Prevention; Human Performance; Human Performance Improvement; Problem Reporting;
Root Cause Analysis; Corrective Action; Process Improvement Tools; Quality and Environmental Management Systems

Root Cause Analysis BW (Ben) Marguglio; President; BW (Ben) Marguglio, LLC
Why This Seminar?	This seminar is unique, particularly because Marguglio recognizes that root cause analyses techniques are: . Substantially similar in the ways by which the data are collected to begin with; . Differ only in the ways by which the collected data are organized and formatted; . Substantially similar in the ways by which the collected data are analyzed. Marguglio's approach makes for greater consistency in the application of root cause analysis techniques and for greater effectiveness in the root cause analysis results. Also, Marguglio focuses on human error causal factors.
Audience	Persons who are responsible for identifying and reporting off-normal conditions, evaluating the conditions and their effects, identifying causal factors, recommending various types of corrective actions, tracking the implementation of corrective actions, and managing the overall system.
Learning Outcomes	Upon completion of this seminar, one will be able to: • Understand and use problem identification, problem reporting, data codification, data grouping, data analysis, extent of condition, causal factor analysis, and corrective action terminology; • Perform root cause analysis using any of the techniques listed in the Outline, below; • Design and implement a problem reporting, root cause analysis, and corrective action system; • Manage or assess such a system.
Outline	1. Problem reporting, root cause analysis, and corrective action system objectives 2. System model 3. System participant responsibilities - different types of participants 4. System capabilities 5. Problem data collection criteria 6. Standard data tables / Data to be collected, and why 7. Problem report format - electronic or paper 8. Problem statement - elements of information 9. Fact versus conclusion 10. Analysis for extent of problem 11. Operating experience 12. Risk-based initial screening of problem reports / Criteria for requiring root cause analysis 13. Risk, urgency and significance 14. Root, contributing and direct causes 15. Types of corrective actions a. Part corrective action b. Preventive or process corrective action c. Compensatory corrective action d. Ameliorative corrective action 16. Analysis for extent of preventive corrective action 17. Administration of root cause analysis - e.g., ownership, team constituency, charter 18. Interviewing techniques 19. Other data collection techniques 20. Root cause analysis techniques a. Change analysis b. Failure mode & effects analysis c. Hazard-barrier-effects analysis d. Fishbone diagram / Cause & effects analysis e. Time line analysis f. Event & fault tree analyses / Probabilistic risk or safety analysis g. Management & oversight risk tree (MORT) analysis 21. Hardware performance root causes 22. Human performance root causes 23. Human performance cause taxonomy v 24. Corrective action commitment - elements of information 25. Preventive corrective action verification 26. Preventive corrective action effectiveness measurement / Performance indicators 27. Report & corrective action status tracking 28. Reports to management 29. Winning management support
Handouts	• Typical procedures for Problem Reporting, Root Cause Analysis, & Corrective Action • Copy of the visual aids • Copy of exercise materials • Supplemental reading materials • Certificate of Completion, with Continuing Education Units
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