Page 65 - Root Cause Failure Analysis

56 Root Cause Failure Analysis

Causes and Long-Term Corrective Actions
This section of the report should clearly describe the specific root cause(s) that hig-
gered the incident. It should detail specific recommendations for long-term corrective
actions.

Root Cause(s)
The root cause(s) description should be complete and provide enough detail and sup-
port data that the reader can fully understand and accept the rationale used to isolate
the root cause(s). This section should include all contributing factors, such as training
and supervision, that contributed to the incident.

Recommended Long-Term Corrective Actions
This section should provide a clear, complete description of the corrective actions
required to prevent recurrence of the incident or event. It should incorporate conclu-
sions derived from the cost-benefit analysis developed previously. The full analysis
should be included as part of the submittal package forwarded to management for
approval.

Exfernal Telephone Calls Made and Reports Filed
This section should document any external telephone calls placed and reports written
and filed. These requirements are summarized in Table 5-1 found in Chapter 5.

If the incident involves regulatory-compliance issues, telephone calls may have been
placed and reports filed to the local police and emergency response team, the Coast
Guard’s National Response Center (NRC), the state’s Emergency Response Commis-
sion, the local Emergency Planning Committee, the U.S. Environmental Protection
Agency (EPA) regional office, the U.S. Department of Transportation, or the state’s
water-pollution control agency.

Lessons Learned
This section should describe the lessons learned that should be passed on to the appro-
priate personnel. This information should be disseminated through formal training or
some other means, such as individual feedback or required reading. This section also
should designate the person (by name) responsible for ensuring that the lessons
learned are communicated, a completion date for the communication, and a list of the
specific plant personnel who should receive the communications.

References and Attachments
List all references and attachments used as part of the investigation. Copies or
excerpts of appropriate procedures, logs, computer printouts, instrument charts, and
statements of involved personnel should be included as appendices.