���ǯ=:e���\Q}[�u��P��k����ѿ���\� �Tl�ϘT.�1�;�r������/���e��y3��Mq|����eW���JǴg5���/lg���\�w����.�pZ. 136 0 obj <>/Filter/FlateDecode/ID[<420B19CC9AFDF643BA104D5BF58A8DDA><36535497FD6916418DEF79F498DAEA17>]/Index[107 52]/Info 106 0 R/Length 130/Prev 283975/Root 108 0 R/Size 159/Type/XRef/W[1 3 1]>>stream
7. . .
{��@���U)�����Y趗�l���3א�.����-�v�7=�'��$R��x7GU���n��z�'��f�'�����s�\UA�q���r��F�ۉ�M_E����]g��2���>7̄/3f���L:h���D����� ]�:�l�1�\?��ׅP�F&H���*^�f䨕ˠCu��&:T�n�ղ��k�L��XU%uBmi�CP 2���I�|Ғl*'u�3� endstream endobj startxref or . Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself. . h�b```����@��(������A$pĔ)��m����U��V�Y��@� �Ꝼ�.��a��fz~�~ʚ��[�NK�X(�o:v���%>�w�̇������s�y��]�ⷓK���&�|�X�=OP�Nr̿��㎎A���& �5�b` 2L:@i �� R�@6nG)���@Z�����`�gz&�!��qCcC�����lj. . It is not “rocket science” – anyone can do it. You probably do it 0 or . h�bbd```b``�"���� ��XD��I�$f����j��d,X��� f{�l��;��L��-� �&�E��C�c�,|f9� . Access the RCA Overview Page1.
*� We can usually trace surface causes to inadequate safety policies, programs, plans, processes, or procedures. endstream endobj startxref 610 0 obj <>stream 335 0 obj <>stream At this level we're analyzing the root causes contributing to the accident. h�b```a``:����p�� eX��cSg�� 3 2^*[Ϸ8�N]W��������������U\lRǀ�4ˀE,���*�w�$�9�667����_��v���t�틥�%,O� :TL�v�a>�y�e�1�l�@����4���Ϛ w2?��T�J� �? Overview: Root cause analysis is a structured team process that assists in identifying underlying factors or causes of an adverse event or near-miss. ������Ҋ�"��t'� �p��]"lhMrDh���}9� 9�Nr����-�x�E�S? endstream endobj 292 0 obj <>/Metadata 15 0 R/Outlines 87 0 R/Pages 289 0 R/StructTreeRoot 88 0 R/Type/Catalog/ViewerPreferences<>>> endobj 293 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/Properties<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 294 0 obj <>stream . Root Cause Analysis Workflow4. Root Cause Analysis (RCA): A technique used to identify the conditions that initiate the occurrence of an undesired activity or state.
0 h�b```f``:������� Ȁ �,@Q�l+��YNo��-z)t��T9�����X\;::�dcFGT=P!ӺE@Z�%@:�:XJ&30p;r��J�Vaf��~�Pɑž�m*� !��v���@��f`�Z 2�ۀ���� v�p!X�u��L�j!�� o*%� 0 .175 . US Government Accountability Office (GAO) The process of problem solving used to identify the underlying or initiating source of a nonconformance. . immediate, causes of an incident. "i�yiw|���f@�4�J5� �r�^�wS�|˂�T��_A1���&j�K)'=���L��a>U)�Ugc���hn�#=͕�I�]A�C������u�,�S-�,.�t���.�p_�/�p�G�;�B � ��� r(@���x��E�(�NU��#���K�]�WzY�ON���p��c�����LgO����է���q�GZ��3N^q!袙7}9S�w���j�[est�%c�9й�Ѵ>3z�����ù�IuһD��i5�̄k�GF����!��S��Q6��;������Ͻ8/4k�%V3�iSe�"��[M��% ��p 107 0 obj <> endobj 6. . %%EOF cause analysis. 291 0 obj <> endobj %PDF-1.5 %���� . Root Cause Analysis – Escape Points. Workflow4.
Identify the root causes A thorough analysis of contributing factors leads to identification of the underlying process and system issues (root causes) of the event. Overview of the Root Cause Analysis \(RCA\) Module1. endstream endobj startxref This level of investigation is also called "special cause" analysis because the analyst can point to a specific thing or behavior. 568 0 obj <> endobj weaknesses.
`ۙ@"��}��n����8 ��O� ��� h�bbd```b``��+@$��v ���,��j��"z`�=���V`��`�.�T ��@$w�dT��� 2��d�h"�'���H�`�&�,� . �uȬ�F2py��`��ɶ��8$�� |��vP]6��n�Dj�l4��z4����\�8K�ӿ���jq\��M�3�D���A{�~��|(�pV�tŐ��߸�����4��8��z�4�9n�Y�'[���2��֎��G8]�|�&2)�\@?�g2�nǘ_^U=�WL���t�P0���WTM�lpv�� �� Systems analysis. Define When a Root Cause Analysis Should be Performed 10 Access a Root Cause Analysis 10 Create a Root Cause Analysis 12 Copy a Root Cause Analysis 13 ii Root Cause Analysis. h�bbd``b`���`�b���& �{H��' �2��T��&�X����$8�A�( !R���N���y �� �{@37�,g`�:���{� �*f hެ�mo�6����}i1�G�]@�q�6k�dq�n�����X�,��&����$[v,�N��I�����l�qf����� �g�ř��� A root cause analysis allows an employer to discover the .
It is used so we can correct or eliminate the cause, and prevent the problem from recurring. �@RIy�T�j������f!ĩ�L�$�Z����o�����x7���|�TZһ ���L5�V���|Uh Rr�ߴ�gK2�zxjC�Y����Ɩ��>@�^�s 1.Focus on quantity: The theory is that the greater the number of ideas generated, the greater the chance of producing a radical and effective solution. endstream endobj 108 0 obj <. . v CHAPTER 8: Root Cause Analysis Case Studies from the Field . How to Conduct a Root Cause Analysis. %PDF-1.5 %���� "����)��R& ɘ�b3X�H�~�l>�,����"�@��%&F��`��4!�30\�` �ll %%EOF
5. Overview1. . 316 0 obj <>/Filter/FlateDecode/ID[<4C34323A3FDD4CEB9F42C60FE317F3C1><989D873E80B5AA428598E9F2AD493A45>]/Index[291 45]/Info 290 0 R/Length 109/Prev 193448/Root 292 0 R/Size 336/Type/XRef/W[1 2 1]>>stream 158 0 obj <>stream TÜV SÜD There are four basic rules in brainstorming. Understanding the contributing factors or causes of a system failure can help develop actions that sustain the correction. underlying. Root Cause Analysis (RCA) is a method that is used to address a problem or non-conformance, in order to get to the “root cause” of the problem. %PDF-1.5 %���� . generalized. %%EOF . Design and implement changes to eliminate the root causes The team determines how best to change processes and systems to reduce the likelihood of another similar event. RCA Workflow3. 593 0 obj <>/Filter/FlateDecode/ID[<7B71D2A10FA87848B32807BF3A2943A0><328A2FF17ABBA747A00CFF911D073D4C>]/Index[568 43]/Info 567 0 R/Length 119/Prev 252989/Root 569 0 R/Size 611/Type/XRef/W[1 3 1]>>stream systemic, rather than the .