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BS EN 62740:2015

BS EN 62740:2015

$215.11

Root cause analysis (RCA)

Published By Publication Date Number of Pages
BSI 2015 72
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This International Standard describes the basic principles of root cause analysis (RCA) and specifies the steps that a process for RCA should include.

This standard identifies a number of attributes for RCA techniques which assist with the selection of an appropriate technique. It describes each RCA technique and its relative strengths and weaknesses.

RCA is used to analyse the root causes of focus events with both positive and negative outcomes, but it is most commonly used for the analysis of failures and incidents. Causes for such events can be varied in nature, including design processes and techniques, organizational characteristics, human aspects and external events. RCA can be used for investigating the causes of non-conformances in quality (and other) management systems as well as for failureanalysis, for example in maintenance or equipment testing.

RCA is used to analyse focus events that have occurred, therefore this standard only covers a posteriori analyses. It is recognized that some of the RCA techniques with adaptation can be used proactively in the design and development of items and for causal analysis during risk assessment; however, this standard focuses on the analysis of events which have occurred.

The intent of this standard is to describe a process for performing RCA and to explain the techniques for identifying root causes. These techniques are not designed to assign responsibility or liability, which is outside the scope of this standard.

PDF Catalog

PDF Pages PDF Title
6 English
CONTENTS
10 INTRODUCTION
11 1 Scope
2 Normative references
3 Terms, definitions and abbreviations
3.1 Terms and definitions
14 3.2 Abbreviations
4 RCA – Overview
15 5 The RCA process
5.1 Overview
Tables
Table 1 – Steps to RCA
16 5.2 Initiation
Figures
Figure 1 – RCA process
17 5.3 Establishing facts
19 5.4 Analysis
5.4.1 Description
20 5.4.2 The analysis team
21 5.5 Validation
5.6 Presentation of results
22 6 Selection of techniques for analysing causes
6.1 General
6.2 Selection of analysis techniques
23 6.3 Useful tools to assist RCA
24 Annexes
Annex A (informative) Summary and criteria of commonly used RCA techniques
A.1 General
A.2 RCA techniques
Table A.1 – Brief description of RCA techniques
25 A.3 Criteria
Table A.2 – Summary of RCA technique criteria
27 Table A.3 – Attributes of the generic RCA techniques
28 Annex B (informative) RCA models
B.1 General
B.2 Barrier analysis
B.2.1 Overview
Figure B.1 – Broken, ineffective and missing barriers causing the focus event
29 B.2.2 Strengths and limitations
B.3 Reason’s model (Swiss cheese model)
B.3.1 Overview
Table B.1 – Examples of barriers
Table B.2 – Example of the barrier analysis worksheet
30 B.3.2 Strengths and limitations
B.4 Systems models
31 B.5 Systems theoretic accident model and processes (STAMP)
B.5.1 Overview
B.5.2 Strengths and limitations
32 Annex C (informative) Detailed description of RCA techniques
C.1 General
C.2 Events and causal factors (ECF) charting
C.2.1 Overview
33 C.2.2 Process
C.2.3 Strengths and limitations
Figure C.1 – Example of an ECF chart
34 C.3 Multilinear events sequencing (MES) and sequentially timed events plotting (STEP)
C.3.1 Overview
C.3.2 Process
Figure C.2 – Data in an event building block
35 C.3.3 Strengths and limitations
36 Figure C.3 – Example of a time-actor matrix
37 C.4 The ‘why’ method
C.4.1 Overview
Figure C.4 – Example of a why tree
38 C.4.2 Process
C.4.3 Strengths and limitations
C.5 Causes tree method (CTM)
C.5.1 Overview
39 Figure C.5 – Symbols and links used in CTM
40 Figure C.6 – Example of a cause tree
41 C.5.2 Process
C.5.3 Strengths and limitations
C.6 Why-because analysis (WBA)
C.6.1 Overview
43 Figure C.7 – Example of a WBG
44 C.6.2 Process
C.6.3 Strengths and limitations
C.7 Fault tree and success tree method
C.7.1 Overview
45 C.7.2 Process
Figure C.8 – Example of a fault tree during the analysis
46 C.7.3 Strengths and limitations
C.8 Fishbone or Ishikawa diagram
C.8.1 Overview
47 C.8.2 Process
Figure C.9 – Example of a Fishbone diagram
48 C.8.3 Strengths and limitations
C.9 Safety through organizational learning (SOL)
C.9.1 Overview
C.9.2 Process
49 C.9.3 Strengths and limitations
Table C.1 – Direct and indirect causal factors
50 C.10 Management oversight and risk tree (MORT)
C.10.1 Overview
C.10.2 Process
C.10.3 Strengths and limitations
Figure C.10 – Example of a MORT diagram
51 C.11 AcciMaps
C.11.1 Overview
C.11.2 Process
52 Figure C.11 – Example of an AcciMap
53 C.11.3 Strengths and limitations
C.12 Tripod Beta
C.12.1 Overview
54 C.12.2 Process
C.12.3 Strengths and limitations
Figure C.12 – Example of a Tripod Beta tree diagram
55 C.13 Causal analysis using STAMP (CAST)
C.13.1 Overview
57 Figure C.13 – Control structure for the water supply in a small town in Canada
58 C.13.2 Process
Figure C.14 – Example CAST causal analysis for the local Department of health
Figure C.15 – Example CAST causal analysis for the local public utility operations management
59 C.13.3 Strengths and limitations
60 Annex D (informative) Useful tools to assist root cause analysis (RCA)
D.1 General
D.2 Data mining and clustering techniques
D.2.1 Overview
D.2.2 Example 1
D.2.3 Example 2
61 D.2.4 Example 3
62 Annex E (informative) Analysis of human performance
E.1 General
E.2 Analysis of human failure
63 E.3 Technique for retrospective and predictive analysis of cognitive errors (TRACEr)
E.3.1 Overview
Figure E.1 – Example of an TRACEr model [25]
64 E.3.2 Process
Figure E.2 – Generation of internal error modes
65 E.4 Human factors analysis and classification scheme (HFACS)
E.4.1 Overview
E.4.2 Process
Table E.1 – External error modes
Table E.2 – Psychological error mechanisms
66 Figure E.3 – Level 1: Unsafe acts
Figure E.4 – Level 2: Preconditions
67 Figure E.5 – Level 3: Supervision Issues
Figure E.6 – Level 4: Organizational Issues
68 Bibliography

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BS EN 62740:2015
$215.11