What Really Went Wrong? Root Cause Determination Study and Improvement Initiative Results

摘要

Many incident investigations stop before identifying the real root cause or all root causes.In 2004 with the implementation of a new corporate-wide incident reporting electronic database,an evaluation was made possible as to the quality of incident investigations and reports at all sites within the case study organization.After reviewing almost 1000 incident reports,the Occupational and Process Safety expertise teams in this organization determined that a need for improvement in the determination of the real Root Causes of the incidents and development of appropriate Corrective Actions.A communication and training initiative across rriultiple functional groups ensued to enable all sites within the organization to better understand why incidents were happening and to develop Corrective Actions to successfully prevent recurrence of the same or related incidents.This paper will give a brief background of the initiative,demonstrate what activities were undertaken and illustrate the success of this approach.