Root cause problem solving methodologies have been around for many years. Very few organizations have recognized the potential of using such methodologies the proactive analysis of processes and work systems and the analysis of the human performance part of potential equipment failures. This presentation will describe:

  • The basic elements of root cause methodology, including its various tools and components.

  • How the methodology can be used to proactively anticipate human performance errors in interactions with complex processes such as we find in PSM.

  • A simple case study.

In a case study, since a permit to work is a component of Process Safety Management, proactive root cause analysis was performed by mapping the permit to work process, identifying what key components should be reviewed, and auditing those key components.

Most audits go from issue to recommendation. This produces corrective actions but does not produce preventive actions. Once the audit revealed the significant issues, a forum was held with permit issuers and receivers to determine the "good reasons why" the significant issues existed within the work system. Using this information, a comprehensive root cause analysis was performed.

The analysis resulted in a wide ranging list of recommendations that touched almost every part of the permit to work system. The recommendations were reviewed by operating, training and safety personnel and found to be substantive and directly addressed common failures in the permit to work system.

Proactive root cause analysis is a powerful tool and can be used to analyze human performance errors both before and after an incident has occurred. Use of root cause analysis in a proactive manner can significantly reduce major incidents that result from the human error element of process failures.

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