Root Cause Analysis
Ben Marguglio

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.    Overall system objectives
2.    System model
3.    System participant responsibilities - different types of participants

4.    System capabilities

5.    Problem / condition data collection criteria

6.    Standard data tables / Data to be collected, and why   

7.    Problem / condition report format - electronic or paper

8.    Problem / condition statement - elements of information

9.    Fact versus conclusion

10.  Analysis for extent of problem / condition

11.  Operating experience

12.  Initial screening of problem / condition reports

13.  Risk, urgency and significance
14.  Root, contributing and direct causes

15.  Types of corrective actions

a. Part corrective action

b. Containment corrective action

c. Preventive or process corrective action

d. Compensatory corrective action

e. Ameliorative corrective action

16.  Analysis for extent of preventive corrective action     

17.  Administration of root cause analysis - e.g., 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

21.  Hardware performance root causes

22.  Human performance root causes

23.  Human performance cause taxonomy

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