A step-by-step approach to your successful cause investigation. 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 combines an instruction book with a downloadable Interactive Cause Analysis Tool – for the results you have been looking for. The book is intended for professionals like you. You have some familiarity with cause analysis projects, but you’re looking for a simple and efficient cause investigation methodology – a more effective and insightful way of asking “why?” Follows the Cause Road Map. The author provides a comprehensive taxonomy for every cause investigation. Supporting his instructions with diagrams, charts, and real-world examples from companies like yours, he takes you step-by-step through planning, completing, and documenting your investigation: Chapter 1 helps you determine the level of effort that your investigation will require, 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 offer 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 that will allow you 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,” guiding you to analyze and model the event, determine corrective action, and document the investigations and findings. Free Interactive Cause Analysis Tool. To fully implement Rowe’s Cause Road Map, you will need other tools to organize, analyze, and present the final results of your investigation. The author includes his downloadable Interactive Cause Analysis Tool – an easy-to-use tool in familiar spreadsheet format – free with your verified purchase of the book. The Interactive Cause Analysis Tool functions include: Help managing your cause investigation efforts. Providing supporting documentation for your report. Aiding in presenting the results. Structuring and sequencing of corrective action recommendations. Help assessing your organization’s Safety Culture. Free Interactive Cause Analysis Tool. To fully implement Rowe’s Cause Road Map, you will need other tools to organize, analyze, and present the final results of your investigation. The author includes his downloadable Interactive Cause Analysis Tool – an easy-to-use tool in familiar spreadsheet format – free with your verified purchase of the book. The Interactive Cause Analysis Tool functions include: Help managing your cause investigation efforts. Providing supporting documentation for your report. Aiding in presenting the results. Structuring and sequencing of corrective action recommendations. Help assessing your organization’s Safety Culture. “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.” – Chester D. Rowe.
Author(s): Chester D Rowe, Kristen Noakes-Fry
Publisher: Rothstein Associates
Year: 2019
Language: English
Pages: 236
Tags: Cause Analysis
Cover......Page 1
Title page......Page 2
Copyright......Page 3
Acknowledgments......Page 4
Table of Contents......Page 5
Introduction......Page 12
References......Page 15
1.1 Two Tools to Begin the Investigation......Page 16
1.1.1 Investigation Effort and Rigor Assessment Tool......Page 17
1.1.2 Checklist Tool......Page 22
2.1 Conceptual Basis for the Cause Road Map......Page 27
2.1.1 Find the Cause Model Compared to Swiss Cheese Model......Page 28
2.2.1 Major Causal Factor Groups (Map 1) of Cause Road Map......Page 32
2.4 Cause Road Map as a Data Trending Source......Page 34
References......Page 36
3.1 Human Performance Related Maps......Page 37
3.1.1 Cause Road Map − Map 2 (Human Errors)......Page 38
3.1.2 Cause Road Map – Map 3 (Error Drivers)......Page 42
3.1.3 Cause Road Map − Map 4 (Flawed Defenses)......Page 49
3.1.4 Cause Road Map – Map 5 (Failed Oversight/Flawed Assessments)......Page 54
3.1.5 Cause Road Map – Map 6 (Latent Errors/Flawed Decisions)......Page 56
References......Page 64
4.1 Machine/Material/Hardware Failure Related Maps......Page 65
4.1.1 Machine/Material/Hardware Failure Related Map A......Page 67
4.1.2 Machine/Material/Hardware Failure Related Map B......Page 72
References......Page 77
5.1 Using the Cause Road Map......Page 78
5.1.1 Step 1......Page 80
5.1.2 Step 2 – Human Error......Page 81
5.1.3 Step 3 – Error Drivers......Page 82
5.1.4 Step 4 – Flawed Organizational or Programmatic Defenses......Page 83
5.1.5 Step 5 – Flawed Assessment Capability......Page 84
5.1.6 Step 6 – Latent Management Practice Weaknesses......Page 85
5.1.7 Step 7 – Repeat for another observation......Page 86
5.1.8 Step 8 – Safety Culture......Page 87
5.2.1 Human Performance Evaluation Briefing Report......Page 88
5.2.2 Hardware/Material/Design Failure Evaluation Briefing Report......Page 89
5.2.3 Human Performance Evaluation driven from previous Failure Evaluation......Page 91
5.3 Capturing the Details......Page 92
References......Page 99
6.1 Theoretical frame......Page 100
6.1.2 Rule-Based......Page 101
6.1.4 Slips, Mistakes, and Violations......Page 102
6.2.1 Skill-Rule-Knowledge (Balance Beam) Tool......Page 103
6.2.1.1 Corrective Actions Checklist for Skill-Based Errors......Page 109
6.2.1.3 Corrective Actions Checklist for Knowledge-Based Errors......Page 110
6.2.2 Substitution Test Tool......Page 111
References......Page 113
Chapter 7: Effective Interviewing......Page 114
7.1 Planning the Interview......Page 115
7.3.1 Open-ended Questions......Page 118
7.3.3 Follow-up Questions or Questioning to the Void......Page 119
7.3.4 Other Tips to a Successful Interview......Page 120
7.5 Recording......Page 121
References......Page 123
8.1 Tool Types and Use Matrix......Page 124
8.2 Comparative Event Line......Page 126
8.3 Failure Modes and Effects Analysis......Page 129
8.4 Barrier Analysis......Page 132
8.4.1 Classifying Barrier Functions......Page 133
8.4.3 Barrier Analysis Display Format......Page 134
8.4.4 Advantages and Weaknesses of Barrier Analysis Tool......Page 136
8.5.1 The Five Steps in Change Analysis......Page 137
8.5.2 A Cause Analysis Example......Page 139
8.6 Task Analysis......Page 143
8.6.2 Steps in Task Analysis......Page 144
8.6.3 Task Analysis Example......Page 145
8.6.4 Advantages and Weaknesses of Task Analysis Tool......Page 146
8.7.1.1 Approach to the Seven Events......Page 147
8.7.1.2 Suggested Common Cause Analysis Method......Page 148
8.8 The 5 Why’s/Why Staircase......Page 153
References......Page 156
9.1 Causal Factor Trees......Page 157
9.1.1 Advantages and Disadvantages of Causal Factor Tree......Page 159
9.2 Events and Causal Factors (E&CF) charts......Page 160
9.2.2 Considerations......Page 161
9.2.4 Formatting......Page 162
9.2.5 The Dump Truck Accident E&CF Chart......Page 165
9.2.6 E&CF Charting Advantages and Disadvantages......Page 167
References......Page 168
10.1 Investigation Tools Integration Protocol......Page 169
10.2 Commonalities Matrix......Page 171
11.1 Examining the Broader Implications of an Event......Page 177
11.2 Step 1: Define Same and Similar Conditions......Page 179
11.2.2 Extent of Cause Assessment......Page 180
11.3 Step 2: Determine the Potential Consequences and Risks......Page 181
12.1 Eight Basic Elements of Corrective Actions......Page 189
12.2 Effective Corrective Action Structure Elements......Page 190
12.3 Ten Criteria for Effective Corrective Actions......Page 191
12.4 SMART Corrective Actions......Page 193
12.6 Relative Effectiveness of Types of Corrective Actions......Page 194
12.7 Measurable Corrective Actions......Page 195
12.8 Assigned and Accepted Corrective Actions......Page 196
12.9 Realistic Corrective Actions......Page 197
12.10 Timely Corrective Actions......Page 198
12.11.1 Assigning Effectiveness Reviews......Page 200
Recommended Reading......Page 205
13.1 Points to Remember when Reporting Investigation Results......Page 206
13.2 Use of Graphics and Pictures in Reports......Page 207
13.3.1 Executive Summary......Page 208
13.3.2 Problem Statement......Page 209
13.3.3 Investigation Scope......Page 210
13.3.7 Event Significance......Page 211
13.3.8 Review of Operating Experience......Page 212
13.3.10 Use of Charts and Graphics......Page 213
13.3.12 Human Performance Précis......Page 214
References......Page 217
Chapter 14: Final Thoughts......Page 218
About the Author......Page 221
Credits......Page 223
