Simplifying Cause Analysis: A Structured Approach Chester D Rowe Kristen Noakes-Fry, ABCI, Editor ISBN: 978-1-944480-46-2 (Perfect Bound) ISBN: 978-1-944480-47-9 (ePub) ISBN: 978-1-944480-48-6 (PDF eBook) info@rothstein.com www.rothstein.com Keep informed about Rothstein Publishing: www.facebook.com/RothsteinPublishing www.linkedin.com/company/rothsteinpublishing www.twitter.com/rothsteinpub Upon registration, paid purchasers of this book are entitled to a free download of the licensed Interactive Cause Analysis Tool See instructions on back page COPYRIGHT ©2018, Rothstein Associates Inc All Rights Reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise, without express, prior permission of the Publisher No responsibility is assumed by the Publisher or Authors for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein Local laws, standards, regulations, and building codes should always be consulted first before considering any advice offered in this book ISBN: 978-1-944480-46-2 (Perfect Bound) ISBN: 978-1-944480-47-9 (ePub) ISBN: 978-1-944480-48-6 (eBook - PDF) Library of Congress Cataloging Number 2017951738 Brookfield, Connecticut USA 203.740.7400 info@rothstein.com www.rothstein.com Upon registration, paid purchasers of this book are entitled to a free download of the licensed Interactive Cause Analysis Tool See instructions on back page Dedication This book is dedicated to: • • My father, Kenneth H Rowe He gave me more than life He ignited my quest for learning and taught me I could anything I set my mind to My mother, Ruth G Rowe She gave me, my brothers, and my sister everything we needed, even to her detriment Acknowledgments Steven Davis of Fulton, NY, was my business partner for many years, and he helped develop the Cause Road Map concept Steve and I used and taught this concept together for many years Steve was co-author of my previous book, The Excellence Engine Tool Kit David Collamore of Hampton, NH, was my second business partner and is one of my cousins Dave was the best sounding board for my ideas I ever had Table of Contents DEDICATION ACKNOWLEDGMENTS INTRODUCTION References CHAPTER 1: GETTING STARTED 1.1 Two Tools to Begin the Investigation 1.1.1 Investigation Effort and Rigor Assessment Tool 1.1.2 Checklist Tool CHAPTER 2: THE CAUSE ROAD MAP TAXONOMY 2.1 Conceptual Basis for the Cause Road Map 2.1.1 Find the Cause Model Compared to Swiss Cheese Model 2.2 Introducing the Cause Road Map 2.2.1 Major Causal Factor Groups (Map 1) of Cause Road Map 2.3 Cause Road Map Defined as a Taxonomy 2.4 Cause Road Map as a Data Trending Source References CHAPTER 3: HUMAN PERFORMANCE RELATED MAPS 3.1 Human Performance Related Maps 3.1.1 Cause Road Map − Map (Human Errors) 3.1.2 Cause Road Map – Map (Error Drivers) 3.1.3 Cause Road Map − Map (Flawed Defenses) 3.1.4 Cause Road Map – Map (Failed Oversight/Flawed Assessments) 3.1.5 Cause Road Map – Map (Latent Errors/Flawed Decisions) References CHAPTER 4: MACHINE/MATERIAL/HARDWARE FAILURE MAPS 4.1 Machine/Material/Hardware Failure Related Maps 4.1.1 Machine/Material/Hardware Failure Related Map A 4.1.2 Machine/Material/Hardware Failure Related Map B References CHAPTER 5: USING THE CAUSE ROAD MAP 5.1 Using the Cause Road Map 5.1.1 Step 5.1.2 Step – Human Error 5.1.3 Step – Error Drivers 5.1.4 Step – Flawed Organizational or Programmatic Defenses 5.1.5 Step – Flawed Assessment Capability 5.1.6 Step – Latent Management Practice Weaknesses 5.1.7 Step – Repeat for another observation 5.1.8 Step – Safety Culture 5.2 Displaying the Results 5.2.1 Human Performance Evaluation Briefing Report 5.2.2 Hardware/Material/Design Failure Evaluation Briefing Report 5.2.3 Human Performance Evaluation driven from previous Failure Evaluation 5.3 Capturing the Details References CHAPTER 6: HUMAN PERFORMANCE BASICS 6.1 Theoretical frame 6.1.1 Skill-Based 6.1.2 Rule-Based 6.1.3 Knowledge-Based 6.1.4 Slips, Mistakes, and Violations 6.2 Tools & Interventions Supporting this Theoretical Framework 6.2.1 Skill-Rule-Knowledge (Balance Beam) Tool 6.2.1.1 Corrective Actions Checklist for Skill-Based Errors 6.2.1.2 Corrective Actions Checklist for Rule-Based Errors 6.2.1.3 Corrective Actions Checklist for Knowledge-Based Errors 6.2.2 Substitution Test Tool References CHAPTER 7: EFFECTIVE INTERVIEWING 7.1 Planning the Interview 7.2 Opening the Interview 7.3 Conducting the Interview 7.3.1 Open-ended Questions 7.3.2 Closed-ended Questions 7.3.3 Follow-up Questions or Questioning to the Void 7.3.4 Other Tips to a Successful Interview 7.4 Closing the Interview 7.5 Recording References CHAPTER 8: ANALYSIS TOOLS AND TECHNIQUES 8.1 Tool Types and Use Matrix 8.2 Comparative Event Line 8.3 Failure Modes and Effects Analysis 8.4 Barrier Analysis 8.4.1 Classifying Barrier Functions 8.4.2 Typical Barrier Analysis Checklist Questions 8.4.3 Barrier Analysis Display Format 8.4.4 Advantages and Weaknesses of Barrier Analysis Tool 8.5 Change Analysis 8.5.1 The Five Steps in Change Analysis 8.5.2 A Cause Analysis Example 8.5.3 Advantages and Weaknesses of Change Analysis Tool 8.6 Task Analysis 8.6.1 Two Types of Task Analysis 8.6.2 Steps in Task Analysis 8.6.3 Task Analysis Example 8.6.4 Advantages and Weaknesses of Task Analysis Tool 8.7 Common Cause Analysis 8.7.1 Using Common Cause Analysis: Nuclear Power Station Example 8.7.1.1 Approach to the Seven Events 8.7.1.2 Suggested Common Cause Analysis Method 8.8 The Why’s/Why Staircase References CHAPTER 9: EVENT MODELING AND ANALYSIS TOOLS 9.1 Causal Factor Trees 9.1.1 Advantages and Disadvantages of Causal Factor Tree 9.2 Events and Causal Factors (E&CF) charts 9.2.1 Defining Problems 9.2.2 Considerations 9.2.3 How to Develop the E&CF Chart 9.2.4 Formatting 9.2.5 The Dump Truck Accident E&CF Chart 9.2.6 E&CF Charting Advantages and Disadvantages References CHAPTER 10: EVENT MODELING AND ANALYSIS TOOLS 10.1 Investigation Tools Integration Protocol 10.2 Commonalities Matrix CHAPTER 11: EXTENT OF CONDITION AND EXTENT OF CAUSE 11.1 Examining the Broader Implications of an Event 11.1.1 Three-Step Approach to Implications 11.2 Step 1: Define Same and Similar Conditions 11.2.1 Extent of Condition Assessment 11.2.2 Extent of Cause Assessment 11.3 Step 2: Determine the Potential Consequences and Risks 11.4 Step 3: Actions Matrix CHAPTER 12: CORRECTIVE ACTIONS 12.1 Eight Basic Elements of Corrective Actions 12.2 Effective Corrective Action Structure Elements 12.3 Ten Criteria for Effective Corrective Actions 12.4 SMART Corrective Actions 12.5 Specific Corrective Actions 12.6 Relative Effectiveness of Types of Corrective Actions 12.7 Measurable Corrective Actions 12.8 Assigned and Accepted Corrective Actions 12.9 Realistic Corrective Actions 12.10 Timely Corrective Actions 12.11 Comprehensive Effectiveness Review Plan 12.11.1 Assigning Effectiveness Reviews Recommended Reading CHAPTER 13: DOCUMENTATION AND REPORTING 13.1 Points to Remember when Reporting Investigation Results 13.2 Use of Graphics and Pictures in Reports 13.3 Report Specifics 13.3.1 Executive Summary 13.3.2 Problem Statement • • • • • Corrective Action Program Manager Corrective Action Program Coordinator/Engineer Equipment Performance Monitoring/Plant Engineer Management Consultant and Root Cause Training Instructor Co-founder and Vice Chairman of the Central PA Section of the American Nuclear Society (ANS) Prior to his commercial nuclear experience, Chet served in the US Navy aboard three submarines, completing qualification as an Engineering Watch Supervisor (EWS) – equivalent to a Reactor Operator at a commercial nuclear plant He achieved the rank of First Class Petty Officer (EM1-SS) in under four years, received several Navy commendations, and was recommended for a billet aboard the NR-1 deep submergence research submarine and a limited duty officer (LDO) commission (both of which he declined in favor of returning to civilian life and college) Credits Kristen Noakes-Fry, ABCI, is Executive Editor at Rothstein Publishing, since 2011 Previously, she was a Research Director, Information Security and Risk Group, for Gartner, Inc.; Associate Editor at Datapro (McGraw-Hill), where she was responsible for Datapro Reports on Information Security; and Associate Professor of English at Atlantic Cape College in New Jersey She holds an M.A from New York University and a B.A from Russell Sage College, and resides in St Petersburg, Florida Cover Design & Graphics: eBook Design & Processing: Lead Copy Editor: Sheila Kwiatek, Flower Grafix Donna Luther, Metadata Prime Nancy M Warner Philip Jan Rothstein, FBCI, is President of Rothstein Associates Inc., a management consultancy he founded in 1984 as a pioneer in the disciplines of Business Continuity and Disaster Recovery He is also the Executive Publisher of Rothstein Publishing Glyn Davies is Chief Marketing Officer of Rothstein Associates Inc He has held this position since 2013 Glyn has previously held executive level positions in Sales, Marketing and Editorial at several multinational publishing companies and currently resides in San Rafael, California Rothstein Publishing is your premier source of books and learning materials about Business Resilience, including Crisis Management, Business Continuity, Disaster Recovery, Emergency Management, Security, and Risk Management Our industry-leading authors provide current, actionable knowledge, solutions, and tools you can put in practice immediately Rothstein Publishing remains true to the decades-long commitment of Rothstein Associates, which is to prepare you and your organization to protect, preserve, and recover what is most important: your people, facilities, assets, and reputation How to Get Your FREE DOWNLOAD of Bonus Resource Materials for This Book You are entitled to a free download of the Interactive Cause Analysis Tool with your purchase of Simplifying Cause Analysis: A Structured Approach, by Chester Rowe This licensed software is an MS Excel Workbook that provides: An Event/Issue Summary and Problem Statement template combined with an Event/Issue Time Line worksheet from Chapter An automated Human Performance Evaluation Summary Report and the Hardware/Material/Design Failure Evaluation Summary Report from Chapters 3, & Separate worksheets and editable MS Word versions of most of the tools presented in Chapter and A tool to help develop, structure and sequence, but not track, corrective actions developed to guidance provided Chapter 12 The functionality to automatically draw lines between identified causal factors on the Cause Road This graphic can then be printed and used as a presentation like the Human Performance Précis graphic presented in this chapter A unique Generalized Culture Assessment tool To access these materials just login to our website as an existing user or register as a new user, and then register your book by following these simple instructions: IT’S EASY – LOGIN OR REGISTER ON OUR WEBSITE FIRST, login as an existing user or register as a new user at www.rothstein.com/register New users will receive an email link to confirm THEN REGISTER YOUR BOOK Logging in or registering takes you to our Product Registration page You’ll see a list of books Simply select your book by clicking the corresponding link to the left and just follow the instructions You will need to provide proof of purchase You will receive a confirming email within a few hours with additional information and download instructions Your registration will also confirm your eligibility for future updates if applicable 203.740.7400 or 1-888-ROTHSTEin fax 203.740.7401 Arapaho Road, Brookfield, Connecticut 06804-3104 USA info@rothstein.com www.rothstein.com ... Task Analysis 8.6.2 Steps in Task Analysis 8.6.3 Task Analysis Example 8.6.4 Advantages and Weaknesses of Task Analysis Tool 8.7 Common Cause Analysis 8.7.1 Using Common Cause Analysis: Nuclear... Weaknesses of Barrier Analysis Tool 8.5 Change Analysis 8.5.1 The Five Steps in Change Analysis 8.5.2 A Cause Analysis Example 8.5.3 Advantages and Weaknesses of Change Analysis Tool 8.6 Task Analysis. .. discover the apparent causes of an event is generally referred to as an Apparent Cause Evaluation (ACE) b Structured Analysis (or Structured Cause Analysis) : A structured investigation typically identifies