APPENDIX C

Root Cause Failure Analysis Program

Root Cause Failure Analysis

Root cause failure analysis (RCFA) methodology is incorporated into the standard operating

procedures in the McElmo Creek Unit field area. It provides a structured format in analyzing

an event and helps to determine necessary measures to prevent future occurrences. The

RCFA program includes the following components:

Step I - Notification

Field supervisor determines that an investigation is warranted and appoints personnel to

conduct a root cause failure analysis for each Flaring Incident, except for those Flaring

Incidents caused by scheduled maintenance or a CO2breakthrough.

Step 2 - Plan Investigation

Once the decision is made to investigate a Flaring Incident, the investigator develops an

investigation strategy. To do this an investigator can use the information initially available to

develop a preliminary Snap Chart (see attachment). This will help the investigator

understand what happened, identify areas where more information is needed, and identify

conflicting information.

For each of the causal factors (problems) on the Snap Chart, the investigator can rapidly

consider the questions that need to be answered to identify root causes using the Root

Cause Tree.

With insight gained from using these two techniques, the investigator or the investigation

team can plan the initial investigation strategy by:

• Identifying the key plant parameters and event times that need to be checked to verify

the incident’s sequence of events and technical accuracy.

• Identifying key pieces of evidence (broken parts, logbooks, chart recorders, computer

printouts, etc.) that need to be collected and preserved.

• Requesting copies of the applicable procedures that should have been used during the

incident.

• Selecting an initial group of individuals for interviews to fill in gaps in the information or to

resolve conflicting information.

Step 3 - Collect Information

Collecting information (interviewing people and analyzing physical evidence) is an ongoing

process throughout the investigation and crucial to understanding the incident and why it

occurred. The investigator(s) are instructed to consult the TapRoot User Guides for each

technique.
Step 4 - Determine Sequence of Events

An investigator or team collects several people’s perceptions of what happened during an

incident and the problems that were associated with the activities and equipment during an

incident. The investigator has to blend these various perceptions into the story of what

happened. The best technique for doing this is the Snap Chart.

A Snap Chart is an excellent graphic tool. In developing the Snap Chart, the investigator

organizes the information being collected on a graphical chart to better understand it. This

organization of the information often causes the re-evaluation of assumptions or facts that

conflict with other information. This organization also helps the investigator identify gaps in

logic of what happened.

When you have team investigations or if you are interviewing several people at one time,

drawing a Snap Chart together helps facilitate gathering everyone’s information and

increases the effectiveness of meetings or group interviews. During individual interviews, the

investigator may find it helpful to sketch a Snap Chart with the interviewee to verify their

verbal communication. The investigator should keep a master Snap Chart updated as

“facts” are verified.

Step 5 - Identify Incident’s Causal Factors

Once the sequence of the incident is thoroughly understood, the investigator needs to

identify all the factors that, if eliminated, would have prevented the incident from occurring or

would have significantly mitigated its consequences. These factors are called causal factors.

Often investigators can identify the causal factors by simply inspecting the Snap Chart and

asking, if I could remove or correct the problems identified on this chart, which ones would

prevent this incident from occurring or make it less severe?” A more formal technique is

called Barrier Analysis and is used as an optional approach to identifying the causal factors

(which in barrier analysis would be called broken barriers). In the next step, the investigator

analyzes each causal factor for its root cause(s) using the Root Cause Tree.

Step 6 - Identify Root Causes

Once the causal factors are identified, the next step is to identify the root causes. This is

done using the Root Cause Tree. The Root Cause Tree Users Manual provides questions

that help the investigator pinpoint the incident’s root causes.

The Human Performance Troubleshooting Guide on the Root Cause Tree helps an

investigator decide which human performance related causes need further investigation. It

also ensures that experienced investigators consider all potential causes of human

performance difficulties (rather than just concentrating on the ones that they understand the

best).

In some cases, the root causes of an incident are impossible to identify. When the Root

Cause tree is used to analyze these difficult cases, the failure to identify the root cause is

clear because the investigation stops before the lowest level on the Root Cause Tree is

reached.

A particular incidents specific root causes identified using the Root Cause Tree are used in

the next two steps to identify programmatic causes and to develop/evaluate corrective

actions.
Step 7 - Identify Generic (Programmatic) Causes

The specific causes for a particular incident may stem from more pervasive problems -

generic or programmatic causes. For example, if a particular incident is caused by a valve

not having a label plate, other incidents may occur because of similar valve labeling

problems with different valves. Therefore, the investigator needs to look at each specific

cause for a particular incident and decide if a more program-wide weakness exists that

needs broader corrective action.

Generic causes can be identified by investigating the pervasive nature of the problem. The

pervasive nature of the problem can be determined by the investigator’s experience,

performing a special programmatic evaluation, or by reviewing previous incident statistics.

Correcting generic problems can have a much broader impact on safety, environmental

performance, and reliability since they address whole classes of problems rather than just the specific causes of an incident.

Step 8 - Develop Corrective Action

The specific and generic causes that are identified in steps 6 and 7 provide a list of problems

that require corrective action implemented in a timely manner. No matter what corrective

action is proposed, there is always a chance to somehow circumvent the intent of the

corrective action. Therefore, proposing corrective actions for each cause identified (that is,

multiple corrective actions) provides a defense-in-depth to preventing the incident from

recurring. In some cases, correcting a particular root cause may be too difficult. In these

cases, the investigator should ensure that there are sufficient other corrective actions

proposed to reduce the likelihood of the incident’s recurrence.

If the root cause level was reached in the incident investigation, the corrective actions are

usually fairly straightforward to identify. If the investigator Gould not reach the root cause

level, he/she will still need to develop ideas for corrective actions. If the incident has been

identified as a repeat of a similar past incident, the investigator should ask if the corrective

actions proposed are different from the corrective actions previously tried and why the

previous corrective actions failed.

Investigators should work with line management as much as possible when developing

corrective actions. They should have thoughtful consideration to ensure the corrective

actions recommended are SMART:

S - Specific

M - Measurable

A - Accountable

R - Reasonable

T-Timely

The investigator should develop a Corrective Actions Matrix Table to use in conjunction with

the Snap Chart for effective management presentations. The Corrective Actions Matrix

should have headings as shown below:

! Causal Factors Root Causes & Corrective Responsible Due Date For

Generic Causes Actions Department & Corrective

Person to Actions . Implement Completion

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Step 9 - Report

All of the information and analysis performed up to this point allows the investigator to write a

clear, complete incident report describing what happened, why it happened, and what needs

to be corrected to prevent the incident (or similar incident), and make effective management

presentations. Reports and presentations are extremely important because the case made

therein often determines whether the recommended corrective action is expeditiously

implemented or is given a low priority and delayed indefinitely.

An important part of incident reporting communication is the Snap Chart. A Snap Chart can

be particularly helpful in providing an organized display of what happened and why it

happened. When used with the Corrective Actions Matrix described in step 8, these two

tools make a powerful presentation of much information in a short time to provide

management with knowledge needed to make the best decisions about using resources to

improve performance.
ATTACHMENT
Develop SnapCharT®

Get Started

- Determme what you are investigating

Define sequence of events

- Identify missing or needed

information

- Investigate further to find missing

information

Define causal factors

Root Cause Analysis

Analyze each Causal Factor’s Root

Causes

- Analyze one Causal Factor at a

time

- begin at the top of the Tree and work

through the questions to determine

what Basic Cause Categories apply

- Examine all of the Basic Cause

Categories that apply to determine

what root causes apply

Use the TapRoor® Root Cause Tree®

Dictionary for definitions to all of the

questions and root causes on the Root

Cause Tree®

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OCopynght 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.