Simplifying cause analysis : a structured approach / Chester D. Rowe ; Kristen Noakes-Fry, editor.

Format:

Book

Author/Creator:

Rowe, Chester D., author.

Contributor:

Noakes-Fry, Kristen, editor.

Language:

English

Subjects (All):

Methodology.

Physical Description:

1 online resource (226 pages) : illustrations (some color), charts, tables

Edition:

1st ed.

Place of Publication:

Brookfield, Connecticut : Rothstein Publishing, 2018.

Summary:

When the challenge is to get to the heart of a problem, you need a simple and efficient cause investigation methodology. And what would make a real difference would be an interactive map to lead you to the answer every time. Chester Rowe's Simplifying Cause Analysis: A Structured Approach is your instruction book combined with the included downloadable Interactive Cause Analysis Tool you have been looking for.

Contents:

Cover

Title Page

Copyright

Dedication

Acknowledgments

Table of Contents

Introduction

References

Chapter 1: Getting Started

1.1 Two Tools to Begin the Investigation

1.1.1 Investigation Effort and Rigor Assessment Tool

1.1.2 Checklist Tool

Chapter 2: The Cause Road Map Taxonomy

2.1 Conceptual Basis for the Cause Road Map

2.1.1 Find the Cause Model Compared to Swiss Cheese Model

2.2 Introducing the Cause Road Map

2.2.1 Major Causal Factor Groups (Map 1) of Cause Road Map

2.3 Cause Road Map Defined as a Taxonomy

2.4 Cause Road Map as a Data Trending Source

Chapter 3: Human Performance Related Maps

3.1 Human Performance Related Maps

3.1.1 Cause Road Map - Map 2 (Human Errors)

3.1.2 Cause Road Map - Map 3 (Error Drivers)

3.1.3 Cause Road Map - Map 4 (Flawed Defenses)

3.1.4 Cause Road Map - Map 5 (Failed Oversight/Flawed Assessments)

3.1.5 Cause Road Map - Map 6 (Latent Errors/Flawed Decisions)

Chapter 4: Machine/Material/Hardware Failure Maps

4.1 Machine/Material/Hardware Failure Related Maps

4.1.1 Machine/Material/Hardware Failure Related Map A

4.1.2 Machine/Material/Hardware Failure Related Map B

Chapter 5: Using the Cause Road Map

5.1 Using the Cause Road Map

5.1.1 Step 1

5.1.2 Step 2 - Human Error

5.1.3 Step 3 - Error Drivers

5.1.4 Step 4 - Flawed Organizational or Programmatic Defenses

5.1.5 Step 5 - Flawed Assessment Capability

5.1.6 Step 6 - Latent Management Practice Weaknesses

5.1.7 Step 7 - Repeat for another observation

5.1.8 Step 8 - Safety Culture

5.2 Displaying the Results

5.2.1 Human Performance Evaluation Briefing Report

5.2.2 Hardware/Material/Design Failure Evaluation Briefing Report

5.2.3 Human Performance Evaluation driven from previous Failure Evaluation.

5.3 Capturing the Details

Chapter 6: Human Performance Basics

6.1 Theoretical frame

6.1.1 Skill-Based

6.1.2 Rule-Based

6.1.3 Knowledge-Based

6.1.4 Slips, Mistakes, and Violations

6.2 Tools &amp

Interventions Supporting this Theoretical Framework

6.2.1 Skill-Rule-Knowledge (Balance Beam) Tool

6.2.1.1 Corrective Actions Checklist for Skill-Based Errors

6.2.1.2 Corrective Actions Checklist for Rule-Based Errors

6.2.1.3 Corrective Actions Checklist for Knowledge-Based Errors

6.2.2 Substitution Test Tool

Chapter 7: Effective Interviewing

7.1 Planning the Interview

7.2 Opening the Interview

7.3 Conducting the Interview

7.3.1 Open-ended Questions

7.3.2 Closed-ended Questions

7.3.3 Follow-up Questions or Questioning to the Void

7.3.4 Other Tips to a Successful Interview

7.4 Closing the Interview

7.5 Recording

Chapter 8: Analysis Tools and Techniques

8.1 Tool Types and Use Matrix

8.2 Comparative Event Line

8.3 Failure Modes and Effects Analysis

8.4 Barrier Analysis

8.4.1 Classifying Barrier Functions

8.4.2 Typical Barrier Analysis Checklist Questions

8.4.3 Barrier Analysis Display Format

8.4.4 Advantages and Weaknesses of Barrier Analysis Tool

8.5 Change Analysis

8.5.1 The Five Steps in Change Analysis

8.5.2 A Cause Analysis Example

8.5.3 Advantages and Weaknesses of Change Analysis Tool

8.6 Task Analysis

8.6.1 Two Types of Task Analysis

8.6.2 Steps in Task Analysis

8.6.3 Task Analysis Example

8.6.4 Advantages and Weaknesses of Task Analysis Tool

8.7 Common Cause Analysis

8.7.1 Using Common Cause Analysis: Nuclear Power Station Example

8.7.1.1 Approach to the Seven Events

8.7.1.2 Suggested Common Cause Analysis Method

8.8 The 5 Why's/Why Staircase

References.

Chapter 9: Event Modeling and Analysis Tools

9.1 Causal Factor Trees

9.1.1 Advantages and Disadvantages of Causal Factor Tree

9.2 Events and Causal Factors (E&amp

CF) charts

9.2.1 Defining Problems

9.2.2 Considerations

9.2.3 How to Develop the E&amp

CF Chart

9.2.4 Formatting

9.2.5 The Dump Truck Accident E&amp

9.2.6 E&amp

CF Charting Advantages and Disadvantages

Chapter 10: Event Modeling and Analysis Tools

10.1 Investigation Tools Integration Protocol

10.2 Commonalities Matrix

Chapter 11: Extent of Condition and Extent of Cause

11.1 Examining the Broader Implications of an Event

11.1.1 Three-Step Approach to Implications

11.2 Step 1: Define Same and Similar Conditions

11.2.1 Extent of Condition Assessment

11.2.2 Extent of Cause Assessment

11.3 Step 2: Determine the Potential Consequences and Risks

11.4 Step 3: Actions Matrix

Chapter 12: Corrective Actions

12.1 Eight Basic Elements of Corrective Actions

12.2 Effective Corrective Action Structure Elements

12.3 Ten Criteria for Effective Corrective Actions

12.4 SMART Corrective Actions

12.5 Specific Corrective Actions

12.6 Relative Effectiveness of Types of Corrective Actions

12.7 Measurable Corrective Actions

12.8 Assigned and Accepted Corrective Actions

12.9 Realistic Corrective Actions

12.10 Timely Corrective Actions

12.11 Comprehensive Effectiveness Review Plan

12.11.1 Assigning Effectiveness Reviews

Recommended Reading

Chapter 13: Documentation and Reporting

13.1 Points to Remember when Reporting Investigation Results

13.2 Use of Graphics and Pictures in Reports

13.3 Report Specifics

13.3.1 Executive Summary

13.3.2 Problem Statement

13.3.3 Investigation Scope

13.3.4 Event Discussion

13.3.5 Compensatory and Immediate Actions.

13.3.6 Extent of Condition/Cause

13.3.7 Event Significance

13.3.8 Review of Operating Experience

13.3.9 Presenting Results

13.3.9.1 Before the Presentation

13.3.9.2 Presentation Scenarios

13.3.10 Use of Charts and Graphics

13.3.11 Commonalities Matrix

13.3.12 Human Performance Précis

Chapter 14: Final Thoughts

About the Author

Credits

How to Get Your Free Download.

Notes:

Description based on print version record.

Includes bibliographical references at the end of each chapters.

ISBN:

9781944480479

1944480471

OCLC:

1013821689