Root Cause MapTM

.
I
Equipment Equipment Reliability Program Problem

Start here with each causal factor

Personnel

u
Other Difficulty Contract Employee
I

Equipment Design Problem

p-

Installation/ Fabrication
I

Equipment Misuse

Administrative/

F
I

Company Employee
I

Natural Phenomena
11

Sabotage/ Horseplay
12

External Events
13

Other
14

Procedures

Design Input LTA @ Design output 0 LTA

t
I -

Equipment Design Records LTA @ Equipment Operating/ Maintenance History LTA @

No Program @
Program LTA @ Analysis/Design Procedure LTA Inappropriate Type of Maintenance Assigned Q Risk Acceptance Criteria LTA 8 Allocation of Resources LTA

-Corrective Maintenance LTA @ Troubleshooting/ Corrective Action LTA @@ Repair Implementation LTA -Preventive Maintenance LTA @ Frequency LTA Q Scow LTA @ Activity Implementation LTA @ Predictive -Maintenance LTA @ Detection LTA @ Monitoring LTA @ Troubleshooting/ Corrective Action LTA @ Activity Implementation LTA

F I
- Maintenance LTA @
Event Specification LTA @ Monitoring LTA Scope LTA Activity Implementation LTA @ - Failure Finding Maintenance LTA @ Frequency LTA Scope LTA @ Troubleshooting/ Corrective Action LTA Repair Implementation0 - Routine Equipment Rounds LTA 0 Frequency LTA @ Proactive

Engineeringd
L

- Preparation @ No Preparation @
Job Plan LTA @ Instructions to Workers LTA @ Walkthrough LTA @ Scheduling LTA @ Worker Selection/ Assignment LTA @) - Supervision During Work @ Supervision LTA @ Improper Performance & Not Corrected @ Teamwork LTA @ No Communication or Not Timely @ Method Unavailable or LTA @ Communication Between Work Groups LTA Communication Between Shifts and Management LTA @ Communication with Contractors LTA @ Communication with Customers LTA @

1*f,tude/Attention

Problem Detection LTA *Sensory/ Perceptual Capabilities LTA *Reasoning Capabilities LTA *Motor/Physical Capabilities LTA

"RestlSleep LTA (Fatigue)@ *Personal/ Medication Problems

Activity Implementation LTA

Standards, Policies, or Administrative Controls (SPACs) LTA @ No SPACs Not Strict Enough Confusing, Contradictory, or Incomplete 8 *Technical Error 8 Responsibility for Item/Activity Not Adequately Defined 8 Planning, Scheduling, or Trackina of Work Activities LTA Rewards/ Incentives LTA 8 Employee Screening/Hiring LTA @@

Standards, SafetyRlazardlRisk Review @ Policies, or Administrative Review LTA or Not Controls (SPACs) Performed @ Not Used @ Recommendations Communication of Not Yet ' SPACs LTA Implemented Q Recently C h a n g e d m Risk Acceptance Enforcement LTA Criteria LTA 8 Review Procedure LTA

Problem Identification/ Control @ Problem Reporting LTA @ Problem Analysis LTA

*Audits LTA @ Corrective Action LTA @ Corrective Actions Not Yet Implemented @

Product/Material Control @ Handling LTA @ Storage LTA @ Packaging/ Shipping LTA Unauthorized Material Substitution Product Acceptance Criteria LTA @ Product Inspections LTA @

Procurement Document and Customer @ Control Configuration Interface/Services Purchasing Control @ .Customer Specifications LTA @ Change Not Requirements Not Control of Identified @ Identified @ Changes to *Verification of Customer Needs Procurement DesignIField Not Addressdoos) Specifications LTA Changes LTA Implementation Material (NO PSSR) @ LTA Acceptance Documentation Requirements LTA @ Content Not Kept Material Up-to-Date @ Inspections LTA Control of Official Contractor Documents LTA @ Selection LTA @

C B

Standard Terminology Not Used @E) Verification/ Repeat-back Not Used @ Long Message @@

Within Shifts LTA @$ Communication Between Shifts LTA @?)

NoTrainiAg @ Decision Not to Train @ Training Requirements Not Identified @

Training Records System LTA *Training Records Incorrect @@ *Training Records Not Up-to-Date6

a
I
( >

Shape

Description

Primary Difficulty Source Problem Category

Root Cause Category

Near Root Cause

Not Used @ Not Available or Inconvenient to Obtain @ Procedure Difficult to Use Use Not Required but Should Be No Procedure for Task

Root Cause

Note: LTA = Less Than Adequate

Copyrighted 1995, 1997, 1999, 2000, 2001 Rev. 8 (8101)

MisleadinglConfusing 0 Format Confusing or LTA More Than One Action per Step No Checkoff Space Provided but Should Be Q Inadequate Checklist @ Graphics LTA @ Ambiguous or Confusing Instructions/Requirements@ DatdComputations Wrong/ Incomplete@ Insufficient or Excessive References 8 Identification of Revised Steps LTA @ Level of Detail LTA @@ Difficult to Identify @@

Wrong/lncomplete Typographical Error @ Sequence Wrong Q Facts Wrong/ Requirements Not Correct Q Wrong Revision or Expired Procedure Revision Used @ Inconsistency Between Requirements Q Incomplete/Situation Not Covered 8 Overlap or Gaps Between Procedures @?) *Note:

Workplace Layout @ Work Environment @ Workload @ Intolerait System Controls/Displays Housekeeping LTA @ Excessive Control Errors Not LTA @ *Tools LTA @ Action Detectable 8 ControVDisplay Protective Requirements @ Errors Not Integration/ Clothing/ Unrealistic Correctable G@ Monitoring Arrangement LTA @ Equipment LTA Location of Ambient Requirements Q Knowledge-based ControlslDisplays Conditions LTA @ LTA @ Other Decision Required @ Conflicting Environmental Excessive Layouts ( 3 Stresses Calculation or Equipment Excessive @ Data Manipulation Location LTA @ Required @ Labeling of Equipment or Locations LTA @?)
i

Training LTA @3 Job/Task Analysis LTA Program Design/ Objectives LTA Q Lesson Content LTA @ On-the-Job Training LTA Q Qualification Testing LTA @ Continuing Training LTA Q Training Resources LTA @ Abnormal Events/ Emergency Training LTA @

:V:'.'.-r'i:JJ

IX? m-?ILt.l L

These nodes are for descriptive purposes only. Code Only to Personal Performance (Node 208).

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