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ROOT CAUSE ANALYSIS HANDBOOK:
A GUIDE TO EFFECTIVE INCIDENT INVESTIGATION
by Risk & Reliability Division, ABS Group, Inc., JBF Associates

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ROOT CAUSE ANALYSIS:
IMPROVING PERFORMANCE FOR BOTTOM-LINE RESULTS (Second Edition)
Kenneth Latino & Robert J Latino

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Special Offer - - - Save $10.00!
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ROOT CAUSE ANALYSIS:
IMPROVING PERFORMANCE FOR BOTTOM-LINE RESULTS (Second Edition)
Kenneth Latino & Robert J Latino

* Introduces Enterprise Reliability Management System technology to identify the
most costly events in an organization
* Updates the PROACT software chapter to reflect the newest version
* Includes new client case histories illustrating the application and success of the
PROACT process
* Updates RCA implementation strategies
* Emphasizes and updates data collection strategies
* Expands the understanding of Physical, Human, and Latent Root Causes and their
relationship to the mechanics of failures

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“Undesirable outcomes, chronic failure, incidents, and accidents… The cost of such events to
corporations is high, generally adding up to tens and hundreds of millions of dollars in
"accepted" losses. Why accept these losses? What if you could understand why these
errors occur and eliminate chronic events from occurring altogether?

“Root Cause Analysis: Improving Performance for Bottom-Line Results, Second Edition
shows how to identify, understand, and prevent chronic problems that hinder the attainment of
organizational goals using Root Cause Analysis (RCA). In addition, the PROACT software,
voted "Product of the Year" by Plant Engineering Magazine, and the steps outlined in this
text teach you how to automate the RCA process. Used effectively, the information in Root
Cause Analysis will improve the reliability of your plant assets and save your company
precious time and money.”

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"Informative, well-illustrated and well-organized text…worthwhile reading for any plant
engineer seeking to understand why errors occur and how to eliminate them, and have a
direct positive impact on his company's bottom line."
- Jeanine Katzel, Plant Engineering Magazine

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"RCA should be used as a tool to help correct ongoing problems that are sucking dollars from
your organization…This book should be a standard part of any RCA practitioner's 'toolbox'."
- Bret Ridgway, Maintenance Resources

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"…if you read this book…you will be able to "Talk the Talk", and with the help of the
methodology explained, "Walk the Walk" down the path of improved equipment reliability and
increased profits."
- John W. Vanauken, Inland Steel ISPAT

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"...Packed with a wide variety of subjects and detailed information for engineering
problem-solving...comprehensible and comprehensive...illuminating."
- Duy H. Hua, Kansas State University

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CONTENTS

Introduction to Root Cause Analysis
Failure Classification
Problems vs. Opportunities
Chronic vs. Sporadic Events
Creating the Environment to Succeed
The Role of the Champion
The Role of the Driver
The Role of the Analyst
Modified Failure Modes and Effects Analysis
The Manual Approach
Enterprise Reliability Management System (ERMS)
The Automated Approach
Preserving Event Data
The Error-Change Phenomenon
Data Collection Strategies for Chronic Events
Data Collection Strategies for Sporadic Events
Ordering the Analysis Team
The Ideal RCA Facilitator
The Ideal RCA Team Members
Their Roles
Analyzing the Data
Defining the TOP BOX
Developing Hypotheses
Validating Hypotheses
Identifying Physical, Human and Latent Root Causes
Communicating Recommendations & Findings
Developing, Prioritizing and Selling Recommendations
The Final Report
The Final Presentation
Tracking For Bottom-Line Results
Developing Tracking Metrics
Exploiting Successes
Creating the "Critical Mass"
Automating Root Cause Analysis
Introducing PROACT V2.0 Software
The Role of RCA in a CMMS Environment
Root Cause Analysis Case Histories
ISPAT Inland, Inc.
Eastman Chemical Company (Kingsport, TN)
LYONDELL-CITGO Refining
Eastman Chemical Company (Worldwide Customer Focus)
Alabama Power Company
Weyerhaeuser Company

Bibliography
Index

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ABOUT THE AUTHORS

“ROBERT J. LATINO is Vice President of Strategic Development for Reliability Center, Inc.
(RCI). RCI is a Reliability Engineering firm specializing in improving equipment, process, and
human reliability since 1972. Mr. Latino received his bachelor's degree in business
administration and management from Virginia Commonwealth University. He has a special
interest in the theory of human error as applied to root cause analysis (RCA). Mr. Latino has
been a practitioner of RCA in the field with his clientele as well as an educator for 17 years.
Mr. Latino is an author of RCI's Root Cause Analysis Methods© course and coauthor of
Problem Solving Methods (PSM)© for Field Personnel. Mr. Latino has been published in
numerous trade magazines on the topic of RCA and is also a frequent speaker on the topic at
trade conferences.

“Kenneth C. Latino has a bachelor's of science degree in computerized information systems.
He began his career developing and maintaining maintenance software applications for the
continuous process industries. After working with clients to help them become more proactive
in their maintenance activities, he began instructing industrial plants on reliability methods
and technologies to help improve the reliability of their facilities.
Over the past few years, a majority of his time has been spent developing reliability
approaches with a heavy emphasis on root cause analysis (RCA). He has trained thousands
of engineers and technical representatives on how to implement a successful RCA strategy
at their respective facilities. He has coauthored two RCA training seminars for engineers and
hourly people respectively.

“Mr. Latino is also the software designer of the RCA program entitled PROACT°. PROACT°
was a Gold Medal Award winner in Plant Engineering's 1998 and 2000 Product of the Year
competitions for its first two versions on the market. He is currently working with client
companies of Meridium, Inc. to integrate all of their reliability data and initiatives into an
automated enterprise reliability management system.”

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ROOT CAUSE ANALYSIS HANDBOOK:
A GUIDE TO EFFECTIVE INCIDENT INVESTIGATION
2005 Edition
By ABS Consulting - Lee N. Vanden Heuvel, Donald K. Lorenzo, Randal L. Montgomery,
Walter E. Hanson, and James R. Rooney

Includes a 17 inch by 22 inch pull-out Root Cause Map

This is a new printing of the 2000 edition of this book

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Published by Rothstein Associates Inc.
ISBN #1-931332-30-4
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ROOT CAUSE ANALYSIS HANDBOOK: A GUIDE TO EFFECTIVE INCIDENT
INVESTIGATION presents a proven system designed for investigating, categorizing, and
ultimately eliminating, root causes of incidents with safety, health, environmental, quality,
reliability, and production-process impacts.

Defined as a tool to help investigators describe what happened, to determine how it
happened, and to understand why it happened, the Root Cause Analysis System enables
businesses to generate specific, concrete recommendations for preventing incident
recurrences.

Using the factual data of the incident, the system also allows quality, safety, and risk and
reliability managers an opportunity to implement more reliable and more cost-effective
policies that result in major, long-term opportunities for improvement.

Such process improvements increase a business' ability to recover from and prevent
disasters with both financial and health-and-safety implications.

Special features include a 17 inch by 22 inch pull-out Root Cause Map, a powerful tool for
identifying and coding root causes.

The book helps readers to understand why root causes are important, to identify and define
inherent problems, to collect data for problem solving, to analyze data for root causes, and to
generate practical recommendations.

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ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOK

The focus of this handbook is on the application of the Root Cause Map to the root cause
analysis process. The Root Cause Map is used in one of the later steps of the root cause
analysis process to identify the underlying management systems that caused the event to
occur or made the consequences of the event more severe. The first five chapters of this
handbook are an overview of the root cause analysis process. These provide the context for
use of the Root Cause Map. Chapter 6 provides references.

Chapter 1, "Introduction to Root Cause Analysis," presents a basic overview of the SOURCE
(Seeking Out the Underlying Root Causes of Events) root cause analysis process. Chapter 2,
"Collecting and Preserving Data for Analysis," outlines the types of data and data sources
that are available. Chapters 3, 4, and 5 describe the three major steps in the root cause
analysis process.

Chapter 3, "Data Analysis Using Causal Factor Charting," provides a step-by-step description
of causal factor charting techniques. Chapter 4, "Root Cause Identification," explains the
organization and use of the Root Cause Map. Chapter 5, "Recommendation Generation and
Implementation," provides guidance on developing and implementing corrective actions. The
references section, Chapter 6, provides additional information for those interested in learning
more about specific items contained in the handbook.

Appendix A, "Root Cause Map Node Descriptions," describes each segment of the Root
Cause Map and presents detailed descriptions of the individual nodes on the map. Appendix
B is the Root Cause Map itself.”

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EXCERPT FROM THE INTRODUCTION TO THE 2005 EDITION

This edition of the Root Cause Analysis Handbook is a reprinting of the version originally
published in 1999. In the six years since the original book was published, organizations have
come under increasing pressure to produce more with less and to produce higher quality
outcomes (products and services). Organizations are constantly striving to meet these
demands through the implementation of a variety of different strategies, such as:

- Lean strategies (sharing of work between operations and maintenance)
- Reliability improvements (reliability-centered maintenance, predictive maintenance,
and improved use of maintenance resources)
- Quality initiatives (ISO certification, setting up critical variables to monitor and adjust,
quality circles and teams, and six-sigma)
- Improved data collection and analysis (both internal and external to the business
unit)
- Workplace culture improvements (behavior-based safety and risk management)
- Staff reductions, both in central corporate support and resources at production
facilities.

However, certain issues remain constant: societal and management demands for continuous
improvement in safety, reliability, environmental stewardship, and quality. Incidents that
impact these areas are not acceptable and, worldwide, organizations are being required to
improve their operations and culture to address these issues. While some industries have
made significant progress, governmental entities and the public often demand more.

It is easy to say that it cannot be done. We are already so much better than we were in the
past. But some organizations (including some of your competitors) continue to improve. To
remain competitive, your organization must maximize the efficiency with which it spends
resources. Your organization must recognize the changing climate and accept the challenge
of achieving better results with fewer resources.

If you find yourself in this position, root cause analysis (RCA) and ABS Consulting's
SOURCE (Seeking Out the Underlying Root Causes of Events) technique for performing
RCAs (which is described in this handbook) can benefit your organization. The handbook
describes a simple, step-by-step method for performing RCAs.

RCA is a structured method for determining whether all these new programs and initiatives
are really helping your organization and how these programs (and their interactions and
interrelationships) can be improved by learning from experience. RCA methods can be
applied to a wide spectrum of problems, including those with safety, reliability, environmental,
quality, productivity, and security consequences. And, not only can these methods be
applied to acute, one-time incidents, they can also be used to understand the underlying or
chronic problems within the organization.

We try hard to make implementation of any new program go well. But our first efforts often
leave room for improvement. RCA provides a structured approach for identifying and targeting
those improvements, and it allows us to see how our organization is functioning.

Why not continue to do it the old way? Why use a structured approach? Accidents, errors,
problems, near misses, and deficiencies all provide an opportunity to learn about our
organization's performance at many levels.

Most organizations don't get beyond the human error or equipment failure level without a
structured program. They are able to correct one problem, at least temporarily. But they fail
to dig deeper to generate permanent solutions. RCA processes help organizations identify
and justify leveraged changes to improve their organization's performance. By investing
resources in an RCA, the organization solves problems once, not repeatedly.

Lee N. Vanden Heuvel
Manager, Incident Investigation and Root Cause Analysis
Services
Operational Risk and Performance Consulting Division
ABS Consulting, June 2005

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TABLE OF CONTENTS

Organization of the Root Cause Analysis Handbook
Acronyms and Nomenclature
Limitations of Liability
Acknowledgments
Chapter 1 Introduction to Root Cause Analysis
Chapter 2 Collecting and Preserving Data for Analysis
Chapter 3 Data Analysis Using Causal Factor Charting
Chapter 4 Root Cause Identification
Chapter 5 Recommendation Generation and Implementation
Chapter 6 References
Appendix A Root Cause Map Indexes Node Descriptions
Appendix B Root Cause Map

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ABOUT THE AUTHORS

ABOUT THE AUTHORS

MR. LEE N. VANDEN HEUVEL is the Manager of Incident Investigation/Root Cause Analysis
Services and the Manager of Training Services for ABS Consulting. He has more than 20
years of experience in plant operations and analysis.

Mr. Vanden Heuvel has assisted organizations in many different industries with the
development and implementation of incident investigation and root cause analysis (RCA)
programs. He also led and participated in investigations in many types of industries, including
chemical, refining, healthcare, manufacturing, machining, pharmaceuticals, waste disposal,
nuclear power, and food processing. He is a coauthor of Guidelines for the Investigation of
Chemical Process Incidents, Second Edition, published by the American Institute of
Chemical Engineers' Center for Chemical Process Safety.

Mr. Vanden Heuvel was previously the project manager and lead analyst for a large
quantitative risk assessment program at the Oak Ridge National Laboratory. He also worked
for 8 years at a nuclear power plant in operations, engineering support, and training. His
current responsibilities are in the areas of RCAs, incident investigations, human factors,
safety analyses, and economic/decision analyses. He is the prime developer of ABS
Consulting's incident investigation course and has taught RCA techniques to thousands of
students.

MR. DONALD K. LORENZO is the Director of Training Services for ABS Consulting. He has
more than 25 years of experience in hazard analysis and risk assessment. He was previously
a development engineer for Union Carbide Corporation. He is the author of A Manager's Guide
to Reducing Human Errors and A Manager's Guide to Quantitative Risk Assessment
(published by the Chemical Manufacturers Association, now known as the American
Chemistry Council) and a coauthor of Guidelines for Hazard Evaluation Procedures, Second
Edition with Worked Examples (published by the Center for Chemical Process Safety).

Mr. Lorenzo specializes in safety and environmental applications of ABS Consulting's
SOURCE technique. He is a registered Professional Engineer in the state of Tennessee and
a Certified Technical Trainer.

MR. RANDAL L. MONTGOMERY is the Manager of Business and System Performance
Solutions for ABS Consulting. His experience includes conducting reliability-centered
maintenance analyses and developing planned maintenance programs for industry and
government clients. In addition, he has developed process safety management (PSM) and
mechanical integrity (MI) programs and has written maintenance procedures for the
petroleum, chemical, and pulp and paper industries. He is a coauthor of Guidelines to
Effective Mechanical Integrity Programs, published by the Center for Chemical Process
Safety. Mr. Montgomery has performed numerous root cause analyses focusing on reliability
issues and machinery applications.

Mr. Montgomery previously worked at Henkel Corporation, where he served as MI coordinator,
implemented management systems to meet PSM regulations, and managed production and
maintenance groups.

MR. WALTER E. HANSON is a Project Manager and Risk/Reliability Engineer for ABS
Consulting. He has more than 15 years of experience in developing, implementing, and
managing loss prevention management systems, including mishap investigation, system
safety, policy and procedure, training systems, performance measurement, and human
factors. At ABS Consulting he works on various risk-management projects for the U.S. Coast
Guard (Coast Guard) and other transportation and maritime clients. Before joining ABS
Consulting, Mr. Hanson had 13 years of safety management responsibilities as a
commissioned officer of the Coast Guard. He completed nearly 25 years of commissioned
service and attained the rank of captain.

Mr. Hanson was a primary developer of ABS's Marine Root Cause Analysis Technique
(MaRCAT). He is the lead instructor for ABS Consulting's Maritime Root Cause Analysis
course.

MR. JAMES J. ROONEY is a Senior Risk/Reliability Engineer and the Manager of Webinar
Training Services for ABS Consulting. He has more than 25 years of experience in quality
engineering, reliability engineering, risk assessment, and process safety management. He is
a Fellow of the American Society for Quality (ASQ).

Mr. Rooney is an ASQ-certified HACCP auditor, Certified Quality Auditor, Certified Quality
Engineer, Certified Quality Improvement Associate, Certified Quality Manager, and Certified
Reliability Engineer. He is also a registered Professional Engineer in the state of Tennessee.

Mr. Rooney teaches courses on quality engineering, qualitative and quantitative
hazard/reliability analysis, management system development/auditing, and incident
investigation/root cause analysis. He specializes in quality and medical applications of the
SOURCE technique.

ABS GROUP INC., is an engineering firm that specializes in reliability, system safety,
environmental engineering, process safety management, risk management planning and
communication, and quantitative risk assessment. Its training divisions provide more than 200
courses each year in more than 35 topics. The company's principle engineers are
internationally recognized experts who have extensive experience in all areas of safety,
reliability, and risk assessment.

2005, 215 pages plus 17 inch by 22 inch pull-out Root Cause Map.

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