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Root Cause Analysis and Incident Investigation

ABS Consulting assists with investigations of safety, reliability, quality, production or environmental losses with proven, structured analysis techniques. The techniques apply to both acute (one-time) and chronic (repeated) events. ABS Consulting helps get beyond the immediate causes of the event (the causal factors) and identify the root causes of the event(s). This allows effective recommendations to be identified that are targeted at preventing recurrence. ABS Consulting develops a report that will withstand the scrutiny of regulators, internal reviews, the public and the media.

ABS Consulting uses a set of widely accepted and proven techniques (causal factor charting, fault tree analysis and change analysis) to gather and analyze information to identify the causal factors that contributed to the event. Then, the root causes are determined using ABS Consulting's Root Cause Map and Root Cause Analysis Handbook. Once the causal factors and root causes are identified, development of recommendations is generally a straightforward process.

Objectives of an investigation:

• Understanding what caused the incident
• Preventing an incident from occuring again
• Preventing similar incident occurrences
• Improving the operation of the facility and the organization
• Satisfying stockholders such as regulators, the public and internal reviewers

How can ABS Consulting help?

Conducting an investigation under adverse conditions is always a difficult task. ABS Consulting can ease this burden by providing assistance with leading and organizing the investigation, which includes:

• Gathering and organizing the needed data
• Analyzing the data to determine causal factors
• Identifying root causes of the event
• Developing effective recommendations
• Writing required reports

What is an incident?

An incident is an actual loss event or a near miss that should be investigated so that effective actions can be taken to prevent the same or similar losses from happening again. Incidents may have a negative impact on health, safety, reliability or company reputation.

What are causal factors?

Causal factors are human errors or equipment problems that directly led to the loss event or allowed the consequences of the event to be more severe. Elimination of the causal factors will prevent recurrence of the losses or reduce the consequences of the event. Many "investigations" and "root cause analyses" simply identify these causal factors and make recommendations to correct them. This may prevent the same event from recurring, but if the root causes are not addressed, similar events are likely to happen in the future. The root causes of these causal factors must also be identified and corrected.

What are root causes?

Root causes are the management system weaknesses that allowed the causal factor to occur. Management systems are the processes a company has in place to control the work process and to encourage personnel to take the appropriate actions and discourage them from taking inappropriate actions. Examples of typical management systems include:

• Equipment Design Process
• Procedures
• Supervision
• Standards and Policies
• Training
• Communication Practices
• Maintenance Practices

Once deficiencies in management systems are addressed, employees and equipment are set up to succeed. ABS Consulting's analysis methods are designed to systematically help seek out these management system weaknesses.

Why ABS Consulting?

1. The investigators have performed hundreds of investigations.
2. Recognized throughout industry as leaders in this field.
3. The ABS Consulting investigation process requires no licensing fees or other such costs. Commonly available and well-known, customized analytical tools are used to be more effective and efficient.
4. A hot line staffed 24 hours a day for immediate, DIRECT access to a lead investigator day or night.
5. The investigators are also instructors. Instructors can train clients' employees to perform incident investigations and coach them in person or by phone or e-mail once they begin to use their skills. ABS Consulting offers several public courses each year and provides onsite training for employees using their site-specific procedures and scenarios.
6. ABS Consulting's clients are so satisfied with the training that they use ABS Consulting to investigate their incidents and perform real-time coaching of their previously trained employees during the actual investigation.
7. ABS Consulting developed easy-to-use software (RootCause Leader) that implements the techniques. The software helps users perform any root cause analysis and to track and trend the data generated from the analysis.
8. ABS Consulting also developed a FREE Excel worksheet to document a causal factor diagram and fault trees--no new software to learn or buy!

For more information, contact:

Lee N. Vanden Heuvel
Manager, Incident Investigation and Root Cause Analysis Services
1-865-671-5848 | lnv@absconsulting.com

William Bradshaw
Senior Engineer
1-865-671-5829 | wmbradshaw@absconsulting.com

David Whittle
Manager, Process Safety Solutions
1-865-671-5819 | dwhittle@absconsulting.com