Causal Factor/Issue: ^

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START HERE with each causal factor/issue and select or eliminate each category to find root causes.

HUMAN
PERFORMANCE) Pages 6-26
DIFFICULTY .
Note: Consider
Equifactor™ Analysis

DESIGN EQUIPMENT/ PREVENTIVE / REPEAT

TOLERABLE
PARTS PREDICTIVE FAILURE
FAILURE
DEFECTIVE
J: MAINTENANCE

DESIGN SPECS DESIGN REVIEW PROCUREMENT (MANAGEMENT SYSTEM]

PM Nl
X MANUFACTURING Corrective
Specs Design Not Problem Not Independent Action
Nl To Specs Anticipated Review Nl HANDLING No PM PM for
Equip Nl — corrective action Nl
for Equip
• equipment - management of STORAGE corrective action
environment change (moc) Nl not yet implemented
not considered - hazard analysis Nl QUALITY CONTROL •— trending Nl

Human Performance Nl = NEEDS IMPROVEMENT

May also substitute LTA (Less Than Adequate)
Troubleshooting Basic Cause Categories
or PIO (Potential Improvement Opportunity)
(on back) to investigate
Guide
(15 Questions) Pages 27-38 Basic Cause Categories
Directions: (on back) to investigate
Answer all questions Was a person exces­
Yes i-tf HUMAN ENGINEERING] Pages 38-40
and then refer to the sively fatigued, impaired,
indicated Basic Cause upset, bored, distracted
WORK DIRECTION) Did verbal communications
Categories on the back or overwhelmed? Yes
or shift change play a role ^COMMUNICATIONS)
of this sheet to inves­

HC
in this problem?
]
tigate the causes of
WORK DIRECTION
the problem. Should the person have Yes Yes
had and used a written
procedure but did not?
PROCEDURES Did failure to agree about
the who/what/when/where
ri
TRAINING
J
^COMMUNICATIONS)
K HUMAN ENGINEERING of performing the job play
a role in this problem?
Yes -C{ WORK DIRECTION )
Was a mistake made
( PROCEDURES )
while using a procedure? Was communication
needed across organiza- Yes
I COMMUNICATIONS
tional boundaries or with 1

other facilities?
Were alarms or displays to Yes
recognize or to respond to -c( HUMAN ENGINEERING]
a condition unavailable or
misunderstood?
Basic Cause Categories
Yes (on back) to investigate
TRAINING
Were displays, alarms, controls,
Pages 40-44
tools, or equipment identified or PROCEDURES I
operated improperly? YeSpt|MANAGEMENT SYSTEM)
HUMAN ENGINEERING Was a task performed in a
hurry or a shortcut used?
WORK DIRECTION]
Did the person need more skill/ Yes
knowledge to perform the job or to
respond to conditions or to under­
TRAINING
J Had management been
WORK DIRECTION) Yes
stand system response? warned of this problem or ^MANAGEMENT SYSTEM)
had it happened before?

Was work performed in an Yes

Yes (MANAGEMENT SYSTEM)

<
adverse environment (such as Were policies, admin,
hot, humid, dark, cramped, or
HUMAN ENGINEERING controls, or procedures
WORK DIRECTION
hazardous)? not used, missing, or in
need of improvement?
PROCEDURES

Did work involve repetitive TRAINING

motion, uncomfortable Yes Should an independent Yes
Revised 4/6/07
positions, vibration, or •/HUMAN ENGINEERING quality control check ^(QUALITY CONTROL)
Copyright © 2007 by
heavy lifting? have caught the problem?
System Improvements, Inc.
WORK DIRECTION
Knoxville, Tennessee, USA
All Rights Reserved
Duplication Prohibited Continue on back by analyzing the indicated Basic Cause Categories
 TapRooT© Root Cause Tree® Basic Cause Categories

L PROCEDURES ) Pages 45-61

c_c
TRAINING
1 C
Pages 62-70
QUALITY CONTROL
3
Pages 71-77

Not Used / Wrong Followed Incorrectly No Training Understanding No QC Nl

Not Followed Nl Inspection
format confusing — task not
typo learning inspection
— no procedure > 1 action / step analyzed inspection
objective instructions
sequence wrong excess references not
— procedure — decided Nl Nl
facts wrong mult unit references required
not available or not to lesson inspection
inconvenient limits Nl train no hold techniques
situation not plan Nl
for use details Nl point Nl
covered — no learning
instruction
— procedure wrong revision data/computations objective hold
Nl foreign
difficult to use used wrong or incomplete point
•— missed practice/ material
•— procedure use second checker graphics Nl required not exclusion
repetition
not required needed no checkoff training performed during
Nl
but should be work Nl
checkoff misused — testing Nl
misused second check — continuing
ambiguous instructions training Nl
equip identification Nl

COMMUNICATIONS
J Pages 78-87

Standards,
c MANAGEMENT SYSTEM

I
Oversight /
J
Pages 88-106

No Comm. or Misunderstood SPAC Corrective

Turnover Policies, or Not Used Employee Action
Not Timely Nl Verbal Comm.
Admin Controls Relations
(SPAC) Nl comm. of - infrequent - corrective
• comm. no standard — standard
terminology SPAC Nl audits & action Nl
system Nl turnover
process not used — no SPAC evaluations
recently - corrective
• late (a & e)
— standard — not strict changed action
communi­ turnover
terminology Nl enough a & e lack not yet
cation process enforcement depth implemented
not used — repeat back — confusing Nl - a & e not
not used or incomplete independent L trending Nl
turnover no way to
process — long message — technical implement employee
Nl error communications Nl
noisy accountability
environment I— drawings/ Nl employee feedback Nl

c
prints Nl

HUMAN ENGINEERING
J Pages 107-131
WORK DIRECTION

] 1
Pages 132-149

Human - Machine Work Complex Non-Fault Preparation Selection Supervision

Interface Environment System Tolerant System of Worker During Work

labels Nl housekeeping knowledge- errors not no preparation — not — no

arrangement/ Nl based decision detectable supervision
work package/ qualified
placement hot/cold required
errors not permit Nl - fatigued
displays Nl wet/slick - crew
monitoring too recoverable pre-job briefing — upset teamwork Nl
controls Nl lights Nl many items Nl
monitoring — substance
— noisy walk-thru Nl
alertness Nl abuse
plant/unit — obstruction scheduling Nl team selection Nl
differences — cramped quarters
lock out/
excessive — equipment guard Nl
tag out Nl
lifting — high radiation/contamination
fall protection Nl
tools/instruments Nl
Revised 4/6/07
Nl = NEEDS IMPROVEMENT Copyright © 2007 by System Improvements, Inc.
May also substitute LTA (Less Than Adequate) or PIO (Potential Improvement Opportunity) All Rights Reserved - Duplication Prohibited