Page 33 - Root Cause Failure Analysis

24 Root Cause Failure Analysis

data and information developed in the preceding steps. Should the event or a similar
one occur again, these records are an invaluable investigative tool.
A full investigation should be conducted on any event that has a history of periodic
recurrence, or a high probability of recurrence, and a significant impact in terms of
injury, reliability, or economics. In particular, all incidents that have the potential for
personal injury or regulatory violation should be investigated.

How Can Recurrence Be Prevented? Although this is the next logical question to
ask, it generally cannot be answered until the entire RCFA is completed. Note, how-
ever, that if this analysis determines it is not economically feasible to correct the prob-
lem, plant personnel may simply have to learn to minimize the impact.

Types of Interviews
One of the questions to answer in preparing for an interview is “What type of inter-
view is needed for this investigation?’ Interviews can be grouped into three basic
types: one-on-one, two-on-one, and group meetings.

One-on-One The simplest interview to conduct is that where the investigator inter-
views each person necessary to clarify the event. This type of interview should be
held in a private location with no distractions. In instances where a field walk-down is
required, the interview may be held in the employee’s work space.

Two-on-One When controversial or complex incidents are being investigated, it
may be advisable to have two interviewers present when meeting with an individual.
With two investigators, one can ask questions while the other records information.
The interviewers should coordinate their questioning and avoid overwhelming or
intimidating the interviewee.

At the end of the interview, the interviewers should compare their impressions of the
interview and reach a consensus on their views. The advantage of the two-on-one
interview is that it should eliminate any personal perceptions of a single interviewer
from the investigation process.

Group Meeting A group interview is advantageous in some instances. This type of
meeting, or group problem-solving exercise, is useful for obtaining an interchange of
ideas from several disciplines @e., maintenance, production, engineering, etc.). Such
an interchange may help resolve an event or problem.

This approach also can be used when the investigator has completed his or her evalu-
ation and wants to review the findings with those involved in the incident. The investi-
gator might consider interviews with key witnesses before the group meeting to verify
the sequence of events and the conclusions before presenting them to the larger group.
The investigator must act as facilitator in this problem-solving process and use a
sequence-of-events diagram as the working tool for the meeting.