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The Root Cause Analysis Handbook

A Simplified Approach to Identifying, Correcting, and Reporting Workplace Errors

Max Ammerman

A production line error is causing defective products to be manufactured.  What should you do?  A line worker is accidentally hurt.  How do you determined what caused it?  Could it have been prevented?

The answer can be found with root cause analysis, a process that guides you in finding the "root cause" of a single "significant event."

In "The Root Cause Analysis Handbook:  A Simplified Approach to Identifying Correcting, and Reporting Workplace Errors, author Max Ammerman presents a walk-through example that illustrated the methodology behind root cause analysis and how it can be implemented in your workplace.  Written in a user-friendly format, the author discusses in detail each of the nine steps that make up the process.  The steps are accompanied by hints and shortcuts to make your evaluation easier and faster, and has pitfalls you should avoid.

You'll learn how to evaluate the event, define and investigate the problem, identify the cause, implement corrective actions, and report your findings and recommendations.  Included at the end of each chapter is an example that will help you reinforce what you have learned.  The author emphasizes the necessity of developing a complete initial problem definition to ensure an effective analysis.

The Root Cause Analysis Handbook is especially useful to those who need to clearly document workplace problems.  Quality Managers, engineers, safety managers, and teams implementing ISO or QS initiatives will find it to be very valuable.

Max Ammerman worked for 20 years in the nuclear program of FP&L where he focused on quality and human performance issues, and specifically, reducing human errors in the workplace.  More recently, he has provided training and consultation for Great Britain's' nuclear program and the U.S. Postal Service.

INTRODUCTION

  Overview of Chapters

  Background

  Terms

  Subject Mater/Chapters of Handbook

Chapter 1:  DEFINE PROBLEM/COLLECT DATA

  Define the Problem

  Collect Data

Chapter 2:  TASK ANALYSIS

  Paper and Pencil Task Analysis

  Walk-Through Task Analysis

Chapter 3:  CHANGE ANALYSIS

Chapter 4:  CONTROL BARRIER ANALYSIS

  Two Methods for Control Barrier Analysis

Chapter 5:  EVENT AND CAUSAL FACTOR CHARTING

  Criteria for Event Description

  Cause and Effect Analysis

Chapter 6:  INTERVIEWS

  Techniques for Conducting Interviews

  Stage 1:  Prepare for the Interview

  Stage 2:  Open the Interview

  Stage 3:  Conduct the Interview

    Types of Interview Questions

    Techniques for Asking Questions and Responding to Answers

    The Communication Process

  Stage 4:  Close the Interview

Chapter 7:  DETERMINE ROOT CAUSE

  What Are the Types of Causes?

  Causal Factor Category List

  Determine the Causes of Event

Chapter 8:  DEVELOP CORRECTIVE ACTIONS

Chapter 9:  REPORT

  Preparing a Written Report

  Presenting to Management

Glossary

Appendix A:  Initial Data Gathering Forms:  Personnel Statement

Appendix B:  Causal Factor Category List

Appendix C:  Other Root Cause Analysis Tools and Techniques

Appendix D:  Blank PIC Forms and Worksheets

Appendix E:  Healthcare Example:  Incorrect Operating Room Setup