Lessons Learned

Root Cause Analysis

Integrated Safety Management TSP

Operational Readiness Review TSP

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Occurrences that may appear minor on the surface can often be harbingers of much deeper causal factors that management needs to identify and resolve in an expeditious manner.  Causal factors identify program control deficiencies and guide early and effective corrective actions. 

The primary reason for investigating and reporting the causes of occurrences is to identify corrective actions that adequately prevent or circumvent recurrence.  Such actions are made to protect the investment of the stockholders in physical facilities and minimize legal exposure to damage claims as well as to help protect the health and safety of the workers, the public, and the environment.

Root cause analysis is segregated into five phases.  Each phase is relatively independent, but some overlap may occur during the course of the analysis.  They are:

Phase 1 - Event Reporting and Characterization

Phase 2 – Data Collection 

Phase 3 – Assessment of the event

Phase 4 – Corrective Actions

Phase 5 – Documentation

Phase 6 – Follow-Up and Feedback to Lessons Learned

What is OAC’s Role?

There are two possible roles for the OAC staff.  The first is leadership and participation in root cause analysis efforts with the facility or management staff.  The second is to provide hands-on training in the process including working through the different methods that can be used and leading teams through initial root cause efforts.  

Management involvement is a necessity for root cause analysis to be effective.  Resources must be provided to ensure that all five phases of the process can be successfully accomplished.  

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