Incident Investigation and
Root Cause Analysis Training
September 15, 2005
What Brought this Class Forward
• Quality of the Root Causes Identified
• Building Consistency in Findings
• Provide a Basic Tool
• Provide Quality Statistics
• Pre-planning for investigations.
• Performing an investigation.
• Developing a timeline.
• Identifying the direct cause(s).
• Identifying root cause(s).
• Corrective actions.
First Training Session
Goals of an Investigation
• Identify the cause(s).
• Develop and implement corrective actions.
• Prevent recurrence.
• Foster a safe workplace.
• Improve morale.
• Demonstrate leadership.
• Improve a work process.
Preparing for an Investigation
• Putting together an investigation kit.
• Practicing techniques.
• Setting up an investigation team.
• Develop a checklist.
• Develop basic questions.
• Identify standard interviewees.
• Gathering information.
Challenges to Investigating
• The culture – company, project, and client.
• Severity of the incident.
• Parties involved.
• Legal issues.
• Gathering information.
• Lack of training or experience in investigating
The Importance of Focusing on Just the FACTS
• Leads to a clear understanding of what happened.
• Keeps from persecuting the innocent.
• Identifies the right cause.
• Identifies the appropriate corrective actions.
Developing a Timeline
• Put down “key” moments.
• Determine when to start.
• Everything is important, at first.
• Include known information, facts, assumptions,
questions, and need for further research.
• Alone versus Team.
• Adding detail to key moments.
• Weeding out period.
Timeline of Actions
Identify the Direct Cause
• Agree on a definition.
• Do not limit yourself.
• Identify the links in the chain.
• Look for direct effects.
Digging for the Root Causes
Root Cause Definition
The most basic cause (or causes) that can reasonably be
identified that management has control to fix and, when
fixed, will prevent (or significantly reduce the likelihood or
consequences of) the problem's recurrence.
TapRooT®; System Improvements, Inc.
Root Cause Focus Areas
• Front Line Supervision
• Administrative Controls (Policies and Procedures)
Finding the Root Cause
• Keep asking why.
• Review systems/processes.
• Review management direction and involvement.
• Look at the training and the quality of the training.
• Crew make-up and assignment of a task.
• Qualification of personnel.
• Task review (hazard analysis).
• Existence, quality, and thoroughness of
Identified Typical Root Causes
• Lack of focus/awareness.
• Lack of attention.
• Did not follow policy/procedure.
• Use of incorrect tool.
• Not wearing proper PPE.
• Not tied off.
• Tripped on uneven surface.
• Employee in a hurry.
• Act of God/uncontrolled event.
Root Cause Examples
• Poorly written procedure.
• Lack of enforcement.
• Lack of accountability.
• Poorly qualified personnel.
• Lack of instruction.
• Poor administrative control.
• Pre-planning of task.
• Lack of training/poor quality training.
• Work schedule.
• Communication needs improvement.
Example of Finding Root Cause
Root Cause Flowchart
Policies/ Preparation Equipment
Training Management And Instructions
Supervision Work Area
Wrong Revision Not Provided No Policy No Preparation No Communication Hot Environment
Typo Did Not Attend Lack of Enforcement Pre-Job Brief Turnover Cold Environment
No Procedure Teaching Lacking Lack of Walk Thru Complex Instructions Display Poor
Not Available No Testing Accountability Lock-Out/Tag-Out Terminology Slippery Surface
Steps Wrong Continuing Training Employee Relations Employees Timely Instruction Cramped Position
Instruction Wrong Commitment Assigned Body Position
Ambiguous Instruction Policy Not Strict No Supervision
Three Standard Corrective Actions
Regression to the Mean
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Developing Corrective Actions
• Deal only with the root cause.
• Make it something that can be accomplished.
• Make it measurable.
• Assign to a specific person or group.
• Review periodically.
Loss Analysis Form (LAF)
Loss Analysis Form (LAF) Continued