Page 29 - Root Cause Failure Analysis

20 Root Cause Failure Analysis

Regulatory Compliance
Any regulatory compliance event can have a potential impact on the safety of work-
ers, the environment, as well as the continued operation of the plant. Therefore, any
event that results in a violation of environmental permits or other regulatory-compli-
ance guidelines (eg, Occupational Safety and Health Administration, Environmental
Protection Agency, and state regulations) should be investigated and resolved as
quickly as possible. Since all releases and violations must be reported-and they have
a potential for curtailed production or fines or both-this type of problem must
receive a high priority.

DATA GATHERING

The data-gathering step should clarify the reported event or problem. This phase of
the evaluation includes interviews with appropriate personnel, collecting physical evi-
dence, and conducting other research, such as performing a sequence-of-events analy-
sis, which is needed to provide a clear understanding of the problem. Note that this
section focuses primarily on equipment damage or failure incidents.

Interviews

The interview process is the primary method used to establish actual boundary condi-
tions of an incident and is a key part of any investigation. It is crucial for the investiga-
tor to be a good listener with good diplomatic and interviewing skills.

For significant incidents, all key personnel must be interviewed to get a complete pic-
ture of the event. In addition to those directly involved in the event or incident, indi-
viduals having direct or indirect knowledge that could help clarify the event should be
interviewed. The following is a partial list of interviewees:

All personnel directly involved with the incident (be sure to review any
written witness statements).
Supervisors and managers of those involved in the incident (including con-
tractor management).
Personnel not directly involved in the incident but who have similar back-
ground and experience.
Applicable technical experts, training personnel, and equipment vendors,
suppliers, or manufacturers.

Note that it is extremely important for the investigator to convey the message that the
purpose of an interview is fact finding not fault finding. The investigator’s job is sim-
ply to find out what actually happened and why it happened. It is important for the
interviewer to clearly dejne the reason for the evaluation to the interviewee at the
beginning of the interview process. Plant personnel must understand and believe that
the reason for the evaluation is to find the problem, If they believe that the process is
intended to fix blame, little benefit can be derived.