Improving safety through root cause analysis

摘要

Operations at the US Department of Energy -- Savannah River Site (SRS) include such diverse facilities as reactors, fuel fabrication, chemical processing, coal burning power houses, analytical laboratories and research facilities. To enhance the safety of operations at SRS, a Root Cause Analysis process has been developed and is discussed in this document. Root Cause Analysis is a three-step process designed to evaluate and correct problems by identifying WHY an occurrence happened. Although this involves correction after a problem occurs, it is also used to prevent future problems by identifying the Root Causes. Root Causes are the most basic causes that can reasonably be identified, that management has control to fix and for which effective recommendations for preventing recurrence can be generated. Making corrective actions based upon Root Causes lowers the risk of future operation.