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
businessa ability to recover from and prevent incidents with
financial and health/safety implications.
The book outlines ABS Consultingas SOURCETM (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:
a[ 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.
a[ Data gathering: How to collect data related to people,
processes, procedures, documents (hard copy & electronic),
position, and physical data associated with an incident.
a[ Data analysis: How to analyze incidents to determine causal
factors using tools such as causal factor charts, timelines, and
cause and effect trees.
a[ 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.
a[ Reporting and trending: How to archive findings and
recommendations to allow review and trending of incident patterns
after some period of SOURCETM use.
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