
Simplifying Cause Analysis
Description
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When the challenge is to get to the heart of a problem, you need a simple and efficient cause investigation methodology. And what would make a real difference would be an interactive map to lead you to the answer every time. Chester Rowe's Simplifying Cause Analysis: A Structured Approach is your instruction book combined with the included downloadable Interactive Cause Analysis Tool you have been looking for.
The author intends this book for professionals like you, who have some familiarity with cause analysis projects and are looking for a simple and efficient cause investigation methodology -is a more effective and insightful way of asking "why?"
Introducing his multi-function event investigation tool, Chester Rowe says, "There are already many scientific tools to help us understand the physical causes for machine failures; the challenge now is to find a way of investigating human performance failure modes...humans are often a major source of slips, lapses, and mistakes."
Supporting his instructions with diagrams, charts, and real-world examples from companies like yours, the author takes you step-by-step through planning, completing, and documenting your investigation:
- Chapter 1 gives you a process to determine the level of effort that your investigation should encompass, assess the level of effort needed, and determine the rigor needed. Your investigation needs to be as risk-informed as possible.
- Chapters 2 through 5 presents a new and innovative structure -rigorous yet intuitively easy to remember - to identify the underlying causes for the event (Cause Road Maps) and conduct the investigation.
- Chapter 6 introduces conceptual human performance models and tells you how to begin focusing on the human behaviors involved.
- Chapters 7 and 8 present you with methods, tools, and techniques for carefully interviewing personnel.
- Chapters 9 through 13 "put the pieces together," showing you how to analyze and model the event, determine corrective action, and document the investigations and findings.
Chester Rowe developed the Cause Road Map over many years to provide a comprehensive taxonomy for every cause investigation. However, fully implementing the Cause Road Map requires the use of other tools to organize, analyze, and present the final results of your investigation. To get you started, Rowe includes his downloadable Interactive Cause Analysis Tool - an easy-to-use tool in familiar spreadsheet format - free with your verified purchase of the book.
More details
Persons
Chester D. Rowe's self-reliance and problem-solving abilities emerged early when, at age 14, he was given some parts for a ham radio receiver. To complete this project, he taught himself calculus and electronics. By the time his father died, when he was 16, Chet had designed the circuits for and then built this receiver using parts from discarded TVs. His father's death pushed Chet into early adulthood and responsibilities to help his raise his siblings.
After overcoming 16 years of financial and other obstacles, Chet earned a BS in Nuclear Engineering and an AS in Physics/General Studies. In addition, Chet has completed training equivalent to a degree in Electrical Engineering. Chet recently retired after over 40 years in the commercial nuclear industry. Chet is the creator of the Cause Road Map© Taxonomy and trained in Kepner-Tregoe, TapRoot®, PII, MORT, and other cause investigation and problem-solving techniques. As a result, he has been involved in more cause investigations than he can remember.
Content
- Cover
- Title Page
- Copyright
- Dedication
- Acknowledgments
- Table of Contents
- 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 2 (Human Errors)
- 3.1.2 Cause Road Map - Map 3 (Error Drivers)
- 3.1.3 Cause Road Map - Map 4 (Flawed Defenses)
- 3.1.4 Cause Road Map - Map 5 (Failed Oversight/Flawed Assessments)
- 3.1.5 Cause Road Map - Map 6 (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 1
- 5.1.2 Step 2 - Human Error
- 5.1.3 Step 3 - Error Drivers
- 5.1.4 Step 4 - Flawed Organizational or Programmatic Defenses
- 5.1.5 Step 5 - Flawed Assessment Capability
- 5.1.6 Step 6 - Latent Management Practice Weaknesses
- 5.1.7 Step 7 - Repeat for another observation
- 5.1.8 Step 8 - 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 5 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
- 13.3.3 Investigation Scope
- 13.3.4 Event Discussion
- 13.3.5 Compensatory and Immediate Actions
- 13.3.6 Extent of Condition/Cause
- 13.3.7 Event Significance
- 13.3.8 Review of Operating Experience
- 13.3.9 Presenting Results
- 13.3.9.1 Before the Presentation
- 13.3.9.2 Presentation Scenarios
- 13.3.10 Use of Charts and Graphics
- 13.3.11 Commonalities Matrix
- 13.3.12 Human Performance Précis
- References
- Chapter 14: Final Thoughts
- About the Author
- Credits
- How to Get Your Free Download
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