ROOT CAUSE GUIDANCE 根本原因指南

KEY POINTS 关键点

• Root Cause Analysis is a useful process for understanding and solving a problem.

• Figure out what negative events are occurring. Then, look at the complex systems around those problems,and identify key points of failure. Finally, determine solutions to address those key points, or root causes.

• you can use many tools to support your Root Cause Analysis process. Cause and Effect Diagrams and 5 Whys are integral to the process itself.

• As an analytical tool, Root Cause Analysis is an essential way to perform a comprehensive, system- wide review of significant problems as well as the events and factors leading to them.

PERFORMAING THE INVESTIGATION 进行调查

DEFINE THE PROBLEM AND COLLECT DATA

Define the problem by developing a clear, complete and concise Problem Statement which includes what the problem is, who was involved (not attributing blame), where it occurred or was identified, when it occurred or was identified and the magnitude (e g , frequency, impact) operating conditions or precursor information which may provide additional details for consideration might also be required.

This problem statement will become more refined and detailed as the analysis is conducted to define the problem we will have to collect data, such as the ones listed in the following table, through interviews, review of documents, observation, statistical data sources, surveys, or other sources always remember that during an investigation, people can forget, overlook, or misinterpret information therefore the more thorough we can be, the better

DESCRIPTIVE FACTS ABOUT A PROBLEM