112: Investigation Issue
Definition/Typical Issues
Was the problem misdiagnosed? Was there a failure to involve knowledgeable personnel in the problem analysis? Was insufficient emphasis placed on problem diagnosis? Was there a failure to identify the underlying causes?
Was the information needed to perform the investigation unavailable? Were personnel unavailable for interviews?
Was there a failure to perform an investigation or analysis of the incident or problem? Was a near miss reported but not investigated?
Note 1: This node addresses situations where the analysis identified the wrong causes of the problem. Situations where the correct causes were identified but incorrect or ineffective recommendations were specified are addressed by the Recommendation Identification Issue (#113) node.
Examples
Example 1
- An accident occurred in a reactor vessel. The incident investigation team guessed that the explosion was caused by a lack of grounding on the tank. After a second event, it was determined that the wrong materials were being fed into the tank and that this had triggered both explosions.
Example 2
- A root cause analysis team determined that spurious shutdowns of a mixing line were caused by operator errors. Subsequent shutdowns indicated that electronic spikes were causing pressure spikes that caused a safety system to actuate and shut down the line. The operator errors were not the cause of the shutdowns after all.
Example 3
- Following a "root cause analysis," an operator was fired for poor performance. The operator had produced a number of bad batches. An experienced operator was moved into this position and also produced a number of bad batches. When a more formalized root cause analysis was performed, it was determined that the control system was poorly designed and could not be easily controlled.
Example 4
- During the investigation of a performance problem, detailed documentation on the design of the electrical distribution system was not available on the back shift. As a result, personnel could not easily identify the source of the problem and extensive troubleshooting was needed to restore power to one of the facility's computer systems.
Example 5
- Operators reported that large temperature excursions were occurring in some batch reactors processing reactive chemicals. No investigations of the causes were performed. A few months later, a vessel ruptured when a runaway reaction occurred in one of the reactors.
Typical Recommendations
- Develop generic methods for problem analysis, such as the cause and effect tree technique and/or causal factor charting.
- Train all personnel to some level of troubleshooting.
- Provide appropriate experts to assist analysis teams.
- Have the results of the analysis reviewed by someone outside the organization where the incident occurred.
- Review contractor incident and near-miss investigation practices and reports.
- Provide root cause analysis and forensics training to incident investigation leaders, focusing on the skills needed to lead an investigation team and the use of root cause analysis techniques.
- Establish a formal investigation review process for teams to use at the conclusion of each investigation.
- Develop a list of information, data, interviews, and records that incident investigators typically consider collecting during investigations.
- Use consistent and effective methods (i.e., interviewing techniques and physical data analysis plans) to collect data.
- Provide data-collection guidance and methods to perform incident investigations to facilitate rigorous analysis of the data collected.
- Analyze each incident in accordance with the analysis levels (i.e., apparent cause analysis versus root cause analysis) defined in the investigation program.
- Ensure that the investigation team approaches the investigation with an open mind and considers all evidence.
- Assign personnel who have expertise in investigation methodologies to perform investigations.
- Review near-miss reports and verify that they have been investigated.
- Set a goal of performing 10 near-miss investigations for each accident investigation.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 81 | Problem Analysis LTA |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 91 | Problem Analysis Issue |