Root Cause Analysis Handbook

Each of the 13 sections of this handbook focuses on one aspect of the incident investigation process. The handbook sections are as follows:

Section 1: Basics of Incident Investigation presents a basic overview of the SOURCE⢠investigation process. It describes why an organization should conduct investigations and includes basic definitions of terms used in the handbook.

Section 2: Initiating Investigations describes the steps an organization must perform before the investigation begins, such as setting up processes for incident classification and team selection.

Section 3: Gathering and Preserving Data provides guidance for gathering and preserving the different types of data that are needed for an investigation.

Section 4: Analyzing Data discusses two different methods (timelines and cause and effect trees) for analyzing the data that has been collected.

Section 5: Identifying Root Causes describes the use of ABS Consulting's Root Cause Map⢠to assist in identifying the underlying causes of incidents.

Section 6: Developing Recommendations explains the different types of recommendations that should be developed to ensure that the highest return is obtained from the analysis.

Section 7: Completing the Investigation describes the activities that should be performed to complete an investigation.

Section 8: Selecting Incidents for Analysis provides guidance on determining which incidents need to be analyzed.

Section 9: Data and Results Trending explains the method for setting up and monitoring a trending system. Trending is used to identify chronic incidents that trigger analyses.

Section 10: Program Development describes the process of setting up the overall incident investigation program.

Section 11: Legal Aspects of Investigations is specifically aimed at legal professionals involved in guiding investigations.

Section 12: Supervising and Reviewing Investigations is specifically aimed at individuals who provide guidance to personnel performing investigations.

Section 13: Preparing Investigation Team Members for an Investigation is intended to provide an overview of the investigation process for personnel who will participate, but not lead, an investigation.

Additional information that can help the reader use the SOURCE⢠approach is provided in the appendices:

Appendix A: Glossary provides definitions of and notes on terms used in this handbook.

Appendix B: Timeline Details provides in-depth information about the use, development, and construction of timelines. Example timelines are also included. This appendix supplements information provided in Section 4, "Analyzing Data."

Appendix C: Cause and Effect Tree Details provides in-depth information about the use, development, and construction of cause and effect trees. Example cause and effect trees are also included. This appendix supplements information provided in Section 4, "Analyzing Data."

Appendix D: SOURCE⢠Investigator's Toolkit provides summary guidance and resources (such as checklists and forms) that can be used to document incident investigation activities.

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