Excerpt from the FOREWORD

Organizations across industries experience incidents ranging from near misses to major loss events. You should understand the causes of these incidents because many regulations require it, and industry initiatives encourage it. But more importantly, the root cause analysis process helps your organization learn from past performance and develop strategies to improve safety, reliability, quality, financial performance, and the overall work environment for your personnel.

ABS Consulting’s SOURCE™ (Seeking Out the Underlying Root Causes of Events) methodology, presented in this handbook, is flexible enough to analyze incidents with safety, health, environmental, quality, reliability, production, security, and financial impacts in almost any industry.

The SOURCE™ methodology provides an effective and efficient approach for investigating incidents of any magnitude. The application of the SOURCE™ techniques by ABS Consulting personnel and our clients ensures that these methodologies are field-proven, not just theories. The objectives of the SOURCE™ approach are to provide an investigation approach and tools that:

• Guides incident investigators in identifying the causes (causal factors, intermediate causes, and root causes) of incidents.
• Provides organizations with a structured approach for developing recommendations to address the causes of incidents.
• Applies to a wide variety of types of incidents (including fires/explosions, manufacturing errors, equipment malfunctions, and customer complaints) with consequences ranging from minor to major.
• Applies to a wide variety of types of operations, including manufacturing, chemical processing, logistics/transportation, mining, governmental operations, forensics, consumer services, and many others.
• Is sufficiently flexible to allow customization to each client’s management system, health, safety, and environment programs, or related initiatives.
• Facilitates analysis of losses, whether they are related to safety, the environment, security, reliability, quality, or business losses.
• Supports compliance with root cause analysis and incident investigation-related industry guidelines and regulations.

The SOURCE™ Methodology

The SOURCE™ RCA methodology addresses the (1) incident investigation and (2) corrective and preventive action program requirements found in many regulations, industry standards, and guidance documents.

Scope of the Handbook

The focus of this handbook is on the application of structured analysis techniques, including the use of ABS Consulting’s Root Cause Map™, to the root cause analysis (RCA) process. The Handbook is structured around three classes, or levels of investigations: Class 1 (simple), Class 2 (intermediate), to Class 3 (very complex). The sections in this handbook generally apply to all three levels or classes of analyses. For example, the data gathering techniques covered in the handbook apply to all three levels (classes) of investigations. However, some details applicable to Class 3 incidents (i.e., rare, catastrophic incidents) are beyond the scope of this handbook.

This handbook provides detailed guidance for performing RCA activities, including:

• Initiating the investigation: How to determine whether an investigation should be performed, how to classify and categorize the incident, and how to determine the appropriate depth of analysis.
• Data gathering: How to collect data related to people, processes, procedures, documents (both hard copy and electronic), position, and physical data associated with an incident.
• Data analysis: How to analyze incidents to determine causal factors using tools such as timelines and cause-and-effect trees. Guidance is also provided on identifying root causes using ABS Consulting’s Root Cause Map™.
• Developing recommendations: How to identify what changes (i.e., recommendations) may be needed to enhance management systems and reduce risk to a tolerable level.
• Documenting the analysis: How to develop a report that will efficiently and effectively communicate the results of the analysis to others.
• Reporting and trending: How to document findings and recommendations to allow review and trending of incident patterns after some period of SOURCE™ use.

Contents of the Handbook

Each of the 13 sections of this handbook focuses on one aspect of the incident investigation process. The handbook sections are as follows:

Section 1:   Basics of Incident Investigation presents a basic overview of the SOURCE™ investigation process. It describes the reasons why an organization should perform investigations and includes basic definitions of terms used in the handbook.

Section 2:   Initiating Investigations describes the steps an organization must perform before the investigation begins, such as setting up processes for incident classification and team selection.

Section 3:   Gathering and Preserving Data provides guidance for gathering and preserving the different types of data that are needed for an investigation.

Section 4:   Analyzing Data discusses two different methods (timelines and cause and effect trees) for analyzing the data that has been collected.

Section 5:   Identifying Root Causes describes the use of ABS Consulting’s Root Cause Map™ to assist in identifying the underlying causes of incidents.

Section 6:   Developing Recommendations explains the different types of recommendations that should be developed to ensure that the highest return is obtained from the analysis.

Section 7:   Completing the Investigation describes the activities that should be performed to complete an investigation.

Section 8:   Selecting Incidents for Analysis provides guidance on determining which incidents need to be analyzed.

Section 9:   Data and Results Trending explains the method for setting up and monitoring a trending system. Trending is used to identify chronic incidents that trigger analyses.

Section 10: Program Development describes the process of setting up the overall incident investigation program.

Section 11: Legal Aspects of Investigations is specifically aimed at legal professionals involved in guiding investigations.

Section 12: Supervising and Reviewing Investigations is specifically aimed at individuals that provide guidance to personnel performing investigations.

Section 13: Preparing Investigation Team Members for an Investigation is intended to provide an overview of the investigation process for personnel that will participate, but not lead, an investigation.

Additional information that can help the reader use the SOURCE™ approach is provided in the appendices:

Appendix A:  Glossary provides definitions of and notes on terms used in this handbook.

Appendix B:  Timeline Details provides in-depth information about the use, development, and construction of timelines. Example timelines are also included. This appendix supplements information provided in Section 4, “Analyzing Data.”

Appendix C:  Cause and Effect Tree Details provides in-depth information about the use, development, and construction of cause and effect trees. Example cause and effect trees are also included. This appendix supplements information provided in Section 4, “Analyzing Data.”

Appendix D:  ABS Consulting’s Root Cause Analysis Handbook Resources describes the content of ABS Consulting’s web resources, including the Root Cause Map. The Root Cause Map guidance presents detailed descriptions of the individual nodes (or items) on the map. The Root Cause Map™ itself is included as part of the SOURCE™ Investigator’s Toolkit in Appendix E.

Appendix E:  SOURCE™ Investigator’s Toolkit provides summary guidance and resources (such as checklists and forms) that can be used to document incident investigation activities.