
Cause Analysis Manual
Description
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A failure or accident brings your business to a sudden halt. How did it happen? What's at the root of the problem? What keeps it from happening again? Good detective work is needed -- but how do you go about it? In this new book, industry pioneer Fred Forck's seven-step cause analysis methodology guides you to the root of the incident, enabling you to act effectively to avoid loss of time, money, productivity, and quality.
From 30+ years of experience as a performance improvement consultant, self-assessment team leader, and trainer, Fred Forck, CPT, understands what you need to get the job done. He leads you through a clear step-by-step process of root cause evaluation, quality improvement, and corrective action. Using these straightforward tools, you can avoid errors, increase reliability, enhance performance, and improve bottom-line results -- while creating a resilient culture that avoids repeat failures. The key phases of this successful cause analysis include:
- Scoping the Problem
- Investigating the Factors
- Reconstructing the Story
- Establishing Contributing Factors
- Validating Underlying Factors
- Planning Corrective Actions
- Reporting Learnings
At each stage, Cause Analysis Manual: Incident Investigation Method and Techniques gives you a wealth of real-world examples, models, thought-provoking discussion questions, and ready-to-use checklists and forms.
The author provides:
- references for further reading
- hundreds of illustrative figures, tables, and diagrams
- a full glossary of terms and acronyms
- professional index
You know that identifying causes and preventing business-disrupting events isn't always easy. By following Fred Forck's proven steps you will be able to identify contributing factors, align organizational behaviors, take corrective action, and improve business performance!
Are you a professor or leader of seminars or workshops? On confirmed course adoption of Cause Analysis Manual: Incident Investigation Method and Techniques, you will have access to a comprehensive, professional Instructor's Manual.
More details
Persons
Fred Forck, CPT, is a highly experienced incident investigator and self-assessment team leader who completed a 25-year career at the Callaway Nuclear Power Plant in Fulton, MO, in May 2007. He offers a rich array of root cause evaluation, quality assurance, quality improvement, facilitation, and teaching skills - including proven abilities to determine and correct the organizational weaknesses linking multiple adverse business incidents.
In 1982 Fred joined Quality Assurance (QA) at Callaway Nuclear Power Plant while the station was still under construction. As QA training supervisor, Fred developed the initial auditor and lead auditor training for the Callaway plant. He supervised the QA operations support group. As a certified lead auditor, Fred led inspections of vendors, chemistry, health physics, training, environmental monitoring, and corrective action. He also led the first self-assessment of industrial safety at the Callaway plant. At Callaway and at Palo Verde Nuclear Generating Stations, Fred developed the root cause analysis (RCA) training programs and compiled root cause manuals for both stations (the latter for Palo Verde's regulatory recovery). At Callaway, Fred participated on over 90 root cause investigations generally as the lead investigator or the mentor. Besides participating in five common cause analyses, Fred developed and delivered the station's common cause analysis training. In 1999, Fred participated on a Nuclear Energy Institute (NEI) team that benchmarked best corrective action processes in the nuclear industry. Fred's final position at Callaway was root cause analysis coordinator. He has recent qualifications as a root cause analyst at Palo Verde, Ft. Calhoun, Tennessee Valley Authority (TVA), and Entergy nuclear stations. He was the lead RCA investigator for Fort Calhoun station's Nuclear Regulatory Commission (NRC) 95002 inspection and qualified as a root cause subject matter expert at TVA's Browns Ferry nuclear plant to support the NRC's 95003 inspection. After Duke Energy completed its merger with Progress Energy in 2012, Fred consolidated the corrective action and cause analysis programs of both utilities into a single set of procedures. His most recent work has been with Entergy Nuclear as an investigator to support the Arkansas Nuclear One (ANO) 95003 regulatory recovery and the River Bend Nuclear Generating Station 95001 regulatory recovery.
In 2007, Fred was designated as a Certified Performance Technologist (CPT) in accordance with the International Society of Performance Improvement (ISPI) standards. ¿is certification is a reflection of Fred's work for over 35 years improving workplace performance by focusing on organizational assessment, incident investigation, continuous improvement, and safety culture.
Content
- Cover
- Title
- Copyright
- Table of Contents
- Acknowledgments
- Preface
- Foreword by Ben Whitmer
- Foreword by John D. Schnack
- Foreword by Mark Reidmeyer
- Introduction: Getting Started with Cause Analysis
- 0.1 Defining Cause Analysis
- 0.1.1 Purpose
- 0.1.2 Method
- 0.2 Successful and Unsuccessful Results
- 0.2.1 Success (Positive Results)
- 0.2.2 Failure (Negative Results)
- 0.3 Human Behavior
- 0.3.1 Behavior Model 1
- 0.3.2 Behavior Model 2
- 0.3.3 Behavior Model 3
- 0.3.4 Behavior Model 4
- 0.4 Accountability
- 0.4.1 Personal and Organizational Accountability
- 0.5 Investigator Attitude (Mindset)
- 0.6 Investigation Steps
- 0.6.1 Job Task Analysis
- 0.6.2 The Seven-Step Methodology
- Step 1: Scope the Problem
- 1.1 Problem Statement
- 1.1.1 Problem Statement Examples
- 1.2 Problem Description
- 1.2.1 Problem Description Examples
- 1.3 Difference Mapping
- 1.3.1 Difference Mapping Examples
- 1.4 Extent of Condition Review
- 1.4.1 Extent of Condition Review Examples
- Step 2: Investigate the Factors
- 2.1 Evidence Preservation
- 2.1.1 Preserve and Control Evidence
- 2.1.2 Collect Physical Evidence
- 2.1.3 Collect Documentary Evidence
- 2.1.4 Collect Human Evidence
- 2.2 Witness Recollection Statement
- 2.3 Interviewing
- 2.3.1 Lines of Inquiry: Question Generators
- 2.3.2 Question Generator: Individual Mindset
- 2.3.3 Question Generator: Personal and Organizational Accountability
- 2.3.4 Question Generator: Management Control Elements
- 2.4 Pareto Analysis
- 2.4.1 Pareto Chart Template
- 2.4.2 Pareto Analysis Examples
- Step 3: Reconstruct the Story
- 3.1 Fault Tree Analysis
- 3.1.1 Fault Tree Example
- 3.2 Task Analysis
- 3.2.1 Task Analysis Example
- 3.3 Critical Activity Charting(Critical Incident Technique)
- 3.3.1 Critical Activity Chart Example
- 3.4 Actions and Factors Charting
- 3.4.1 Actions and Factors Chart Example
- 3.4.2 Notes
- Step 4: Establish Contributing Factors
- 4.1 Contributing Factor Test
- 4.2 "Five" WHYs
- 4.2.1 "Five" WHYs Example
- 4.2.2 Exxon-Valdez Oil Spill Example
- 4.2.3 Tokai-Mura Criticality Incident Example
- 4.2.4 Reactor Trip Example
- 4.3 Cause and Effect Trees
- 4.3.1 Cause and Effect Tree Examples
- 4.4 Difference Analysis (a.k.a. Change Analysis)
- 4.4.1 Broken Back Example
- 4.4.2 Falling Objects Example
- 4.4.3 Breaker Trip Example
- 4.5 Defense Analysis (a.k.a. Barrier Analysis)
- 4.5.1 Breaker Fire Example
- 4.6 Structure Tree Diagrams
- 4.6.1 Fishbone (Ishikawa) Diagram
- 4.6.1.1 Forearm Fracture Example
- 4.6.1.2 Poor Safety Culture Example
- 4.6.2 Defense-in-Depth Analysis
- 4.6.3 MORT Analysis
- 4.6.3.1 MORT Maintenance Example
- 4.6.4 Production/Protection Strategy Analysis
- 4.6.5 Safety Culture Analysis
- Step 5: Validate Underlying Factors
- 5.1 Support/Refute Methodology
- 5.1.1 Truck Will Not Start Example
- 5.1.2 Crane Incident Example
- 5.2 WHY Factor Staircase
- 5.2.1 Lost Time Away Injury Example
- 5.2.2 Criticality Incident Example
- 5.2.3 Broken Back Example
- 5.3 Root Cause Test
- 5.4 Cause Evaluation Matrix
- 5.4.1 Dump Truck Example
- 5.5 Extent of Cause Review
- 5.5.1 Example 1: Flood Protection Strategy Inadequate
- 5.5.2 Example 2: Leak Due To Stress Corrosion Cracking
- 5.5.3 Example 3: Rental Car Flat Tire
- 5.5.4 Example 4: Waste Not Labeled as Required
- Step 6: Plan Corrective Actions
- 6.1 Action Plan
- 6.1.1 Change Management
- 6.1.2 S.M.A.R.T.E.R
- 6.1.2.1 Safety Precedence Sequence (Hierarchy of Corrective Action Effectiveness)
- 6.1.3 Barriers and Aids Analysis (Pros and Cons)
- 6.1.4 Solution Selection Tree
- 6.1.5 Solution Selection Matrix
- 6.1.6 Contingency Plan
- 6.1.7 Lessons To Be Learned Communication Plan
- 6.1.8 Institutionalization/Active Coaching Plan
- 6.2 Effectiveness Review
- 6.2.1 Performance Indicator Development
- Step 7: Report Learnings
- 7.1 Preparing to Create Your Report
- 7.2 Report Template
- 7.2.1 Sample Incident Analysis Report Template
- 7.3 Grade Cards/Scoresheets
- 7.3.1 Root Cause Analysis - Sample Organizational Learning Scoresheet
- Appendix A: Creating Working Definitions
- Appendix B: Common Factor Analysis
- Glossary
- Index
- Credits
- About the Author
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