Root Cause Analysis

Time Tools (Change Analysis)

The following tools may be most effective for events that are time based or
involve sequential events.

Sequence of Events Analysis

Figure 10 : Sequence of Events Analysis Quick Facts

This method of RCA is used by displaying the sequence of events leading to a
particular failure or event in a graphical manner on a single path. It works well
for events where the time sequence is considered important for the

evaluation of combined contributing factors. It may use information from

Video, Data Logs, PLCs and DCS.

Event & Causal Factor (ECF) Analysis

Figure 11 : ECF Analysis Quick Facts

This method of RCA works in much the same manner as the Sequence of

Events but does so by describing the time sequence of contributing events and

existing conditions associated with a particular event in a graphical format on

multiple paths. It is used for analysis of accidents and undesirable events. It is

especially effective for events that have both primary and secondary events.

Introduction

Accidents are investigated to identify the causes of their occurrence and to

determine the actions that must be taken to prevent recurrence. It is essential

that the accident investigators probe deeply into both the events and the

conditions that create accident situations, and also the managerial control

systems that let them develop so that the root accident causes can be

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