1: Start Here

DEFINITION / TYPICAL ISSUES

Start here with each causal factor. Select the appropriate path(s) through the Root Cause Map™ to identify causes at each level of the map.

EXAMPLES

Example 1

  • Desired performance: Analyze a sample from each product tank prior to transferring it to a storage tank.
  • Actual performance: The operator did not take a sample prior to transferring material from a product tank to a storage tank. As a result, the material in the storage tank may no longer meet specifications.

Example 2

  • Desired performance: Do not have fan bearings fail in service.
  • Actual performance: The outboard fan bearing on a fan failed.

Example 3

  • Desired performance: Close the sample valve following maintenance.
  • Actual performance: The mechanic failed to close the sample valve following maintenance.

Example 4

  • Desired performance: The reactor feed pump should supply 18 to 22 gallons per minute of catalyst to the reactor.
  • Actual performance: The reactor feed pump supplied 27 gallons per minute of catalyst to the reactor.

TYPICAL RECOMMENDATIONS

Recommendations that address causal factors are typically Level 1 recommendations. They fix the specific failure or error that occurred.

Example 1

  • Situation: Operator did not take a sample prior to transferring material from a product tank to a storage tank.
  • Level 1 Recommendation: Take a sample from the storage tank to verify that the product is acceptable.

Example 2

  • Situation: The outboard fan bearing on a fan failed.
  • Level 1 Recommendation: Replace the bearing.

Example 3

  • Situation: The mechanic failed to close the sample valve following maintenance.
  • Level 1 Recommendation: Close the sample valve.

Example 4

  • Situation: The reactor feed pump supplied 27 gallons per minute of catalyst to the reactor.
  • Level 1 Recommendation: Adjust the reactor feed pump so it supplies 27 gallons per minute of catalyst to the reactor.
  • Levels 2, 3, and 4 recommendations address the lower levels of the Root Cause Map™
    (See Section 6 of the Root Cause Analysis Handbook for details on recommendation levels)
Back to top