INCORPORATING ORGANIZATIONAL ISSUES INTO ROOT-CAUSE ANALYSIS

Many chemical process facilities incorporate root-cause analysis as an instrument to help identify and isolate key factors judged to be of s ignificance following an incident or accident. Identifying the princip al deficiencies can become very difficult when the event involves not only human and machine interaction, but possibly the underlying safety and quality culture of the organization. The current state of root-ca use analysis in many industrial facilities is to conclude the investig ation after identifying human and/or hardware failures. In this work, root-cause analysis is taken one step further by examining plant work processes and organizational factors. This extension is considered sig nificant to the success of the analysis, especially when management de ficiency is believed to contribute to the incident. The results of roo t-cause analysis can be most effectively implemented if the organizati on, as a whole, wishes to improve the overall operation of the plant b y preventing similar incidents from occurring again in the future. The study adds to the existing root-cause analysis the ability to localiz e the causes of undesirable events and to focus on those problems hidd en deeply within the work processes that are routinely followed in the operation and maintenance of the facility.