The Role of Human Error in Root Cause Analysis

2011 ◽  
pp. 85-112
Keyword(s):  
Human Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

The Role of Human Error in Root Cause Analysis: Understanding Human Behavior

2019 ◽  
pp. 221-252
Author(s):  
Mark A. Latino ◽  
Robert J. Latino ◽  
Kenneth C. Latino
Keyword(s):  
Human Behavior ◽  
Human Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Human Error Root Cause Analysis

1996 ◽  
Vol 40 (24) ◽  
pp. 1272-1272
Author(s):  
Michael T. Collopy ◽  
Robert M. Waters
Keyword(s):  
Human Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Back to the Future Using Root Cause Analysis as a Proactive Risk Management Tool

2014 ◽  
Author(s):  
Phillip Nidd ◽  
Terence Thorn ◽  
Monica K. Porter
Keyword(s):  
Asset Management ◽  
Human Error ◽  
Root Cause Analysis ◽  
Management Tool ◽  
Management Tools ◽  
Cause Analysis ◽  
Root Cause ◽  
Management Standards ◽  
Underlying Causes ◽  
Definition Of

Root Cause Analysis (RCA) can be an effective proactive methodology to forecast or predict probable events even before they occur. It’s use has been embraced by regulators and can be found in the most advanced management tools such as the recently published ISO 55000 series of international management standards for asset management. An RCA identifies both the obvious and the underlying causes of an event so that specific solutions can be implemented. A complete RCA consists of a clear definition of the issue, a thorough analysis supported with evidence and a specific action plant for implementing solutions. In this respect, what may have appeared as a material failure or “human error,” can often be shown to be the result of an inadequate infrastructure management systems or the failure of management processes. Generally thought of as a reactive method of identifying the causes of past incidents, this paper will describe the elements of an RCA and how it can be a powerful tool to identify systems or behaviors that when modified or corrected, will prevent recurrence of similar outcomes.

Multiple Systemic Contributors versus Root Cause

2016 ◽  
Vol 60 (1) ◽  
pp. 264-264 ◽  
Author(s):  
Katherine E. Walker ◽  
David D. Woods ◽  
Michael F. Rayo
Keyword(s):  
Adverse Events ◽  
Human Error ◽  
Space Station ◽  
Root Cause Analysis ◽  
Near Miss ◽  
Specific Sequence ◽  
Cause Analysis ◽  
Extravehicular Activity ◽  
Root Cause ◽  
Sequence Of Events

In 2013 NASA nearly drowned an astronaut during an Extravehicular Activity (EVA 23) on the International Space Station due to spacesuit water leakage. Indicators of trouble on the preceding EVA (22) were discounted. NASA carried out an investigation of the near miss event that is a sample of how root cause analysis is carried out in actual organizations (National Aeronautics and Space Administration, 2013). This paper contrasts the root cause analysis with a new analysis the authors carried out that captures how multiple systemic contributors combined to create the conditions that led up to the near miss. The new analysis illustrates the original finding from the late 1980s that accidents arise from multiple factors each necessary but only jointly sufficient (Reason, 1990; Woods, 1990; Cook, 2000; Woods, Dekker, Cook, Johannesen, & Sarter, 2010). Many of these contributors are system factors that have been present (latent) in the organization for some time prior to the specific sequence of events. In other words, the accidents arose from organizational or systemic factors (Reason, 1997). In contrast, the traditional root cause analysis focuses on the human roles closest to the adverse event and only raises systemic issues in terms of vague generalities that are difficult to address in systemic improvements (Dekker, 2014; Woods et al., 2010). The paper provides this contrast for two purposes. The first goal of this paper is to provide a concrete technique and diagram for identifying systemic contributors to adverse events (Systemic Contributors Analysis and Diagram or SCAD). The second goal is to highlight how the current practice of root cause analysis is unable to come to grips with systemic issues, misses the interactions between contributors, and misses emergent system properties. Using this systemic technique reveals that adverse events are very often due to production pressure at the blunt end, not human error at the sharp end of systems.

scholarly journals How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

2020 ◽  
Vol 29 (6) ◽  
pp. 524-531
Author(s):  
Jimmy Martin-Delgado ◽  
Alba Martínez-García ◽  
Jesús María Aranaz ◽  
José L. Valencia-Martín ◽  
José Joaquín Mira
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Human Error ◽  
Root Cause Analysis ◽  
Care Process ◽  
Cause Analysis ◽  
Root Cause ◽  
Communication Problems ◽  
Practical Usefulness ◽  
Common Causes

<b><i>Objectives:</i></b> The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). <b><i>Methods:</i></b> A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. <b><i>Results:</i></b> Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; <i>n</i> = 18), and the type of incident most analysed was AAEs, in 71% (<i>n</i> = 15) of the cases; 47% (<i>n</i> = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. <b><i>Conclusions:</i></b> RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

scholarly journals Human Factors in Incident Investigation

1989 ◽  
Vol 33 (15) ◽  
pp. 1024-1028 ◽  
Author(s):  
Mark E. Armstrong
Keyword(s):  
South Carolina ◽  
Human Factors ◽  
Human Error ◽  
Reporting System ◽  
Root Cause Analysis ◽  
Savannah River Site ◽  
Savannah River ◽  
Cause Analysis ◽  
Root Cause ◽  
River Site

The Savannah River Site (SRS), located in South Carolina, is a key Department of Energy production and research facility for nuclear materials. Incident investigations performed at the Savannah River Site showed the cause of approximately 75% of all operating incidents in non-reactor facilities to be human error. The technical incident reporting system in place required the investigator to list the cause of an incident in broad terms (i.e., Personnel Error, Equipment Error) and to categorize it according to subclassifications (i.e., Operator Error, Supervisor Error, Mechanic Error). The reporting system, using these classifications, tended to emphasize “what happened” during an incident and “who was involved”, instead of getting to the details of “why” an incident occurred. The high rate of human error as the cause of incidents indicated that further analysis was in order. Human factors personnel in the Facility Safety Evaluation Section (FSES - an oversight organization with emphasis on non-reactor facilities) wanted to determine the causes of human error in a way that would identify more precisely why the errors occurred. To satisfy these needs, FSES is implementing a root cause analysis program for SRS. Root cause analysis consists of two parts; the first being Events and Causal Factor (E&CF) Charting; and the second, Root Cause Coding using a Root Cause Tree. The objectives were to provide a systematic method for identifying the root causes of a given incident in order to make detailed recommendations for preventing its recurrence, and to provide a database of incident root causes for identifying problem areas across incidents. Root cause analysis would guide the incident investigator to state “why” an incident occurred using detailed cause codes (e.g., Incomplete Training, Labels Less Than Adequate). Root cause trending would enable FSES to track the causes of human error, recommend solutions, and track corrective actions. FSES developed a one day workshop to train several hundred incident investigators at SRS to perform investigations using the root cause analysis method. This presentation will discuss the development and implementation of the root cause analysis system at SRS by FSES human factors professionals.

scholarly journals Developing Frameworks to Understand Disaster Causation: From Forensic Disaster Investigation to Risk Root Cause Analysis

2016 ◽  
Vol 03 (02) ◽  
pp. 1650008 ◽  
Author(s):  
Arabella Fraser ◽  
Shona Paterson ◽  
Mark Pelling
Keyword(s):  
Root Cause Analysis ◽  
Disaster Risk ◽  
Analysis Framework ◽  
Cause Analysis ◽  
Root Cause ◽  
Sendai Framework ◽  
Starting Point ◽  
Core Elements ◽  
Support Policy

The Sendai Framework for Disaster Risk Reduction 2015–2030 calls for science to support policy move toward more holistic solutions to disaster risk. This paper outlines an original framework to promote inter-disciplinary research into disaster causation, identifying the basis for holistic solutions. The PEARL Risk Root Cause Analysis framework responds to limits identified in the established FORensic INvestigations of disasters (FORIN) approach to root cause analysis. The paper documents a systematic review of the FORIN approach as a starting point for the development of the PEARL framework. The proposed PEARL framework offers a broad and adaptable conceptual, methodological and practical approach. In particular, we demonstrate the centrality of governance, including the role of disaster risk management in risk creation, of bringing historical insights into contemporary and future scenarios planning and of integrating research methods. These core elements can assist in repositioning science to better support the goals of the Sendai Framework.

Root Cause analysis of SG tube ODSCC indications within the tube sheets of NPP biblis unit A

2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause
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