Mar 03 - 04

The Inn at Ellis Square

Outline: 1. Problem reporting, root cause analysis, and corrective action system objectives 2. System model 3. System participant responsibilities - different types of participants 4. System capabilities 5. Problem data collection criteria 6. Standard data tables / Data to be collected, and why 7. Problem report format - electronic or paper 8. Problem statement - elements of information 9. Fact versus conclusion 10. Analysis for extent of problem 11. Operating experience 12. Risk-based initial screening of problem reports / Criteria for requiring root cause analysis 13. Risk, urgency and significance 14. Root, contributing and direct causes 15. Types of corrective actions a. Part corrective action b. Preventive or process corrective action c. Compensatory corrective action d. Ameliorative corrective action 16. Analysis for extent of preventive corrective action 17. Administration of root cause analysis - e.g., ownership, team constituency, charter 18. Interviewing techniques 19. Other data collection techniques 20. Root cause analysis techniques a. Change analysis b. Failure mode & effects analysis c. Hazard-barrier-effects analysis d. Fishbone diagram / Cause & effects analysis e. Time line analysis f. Event & fault tree analyses / Probabilistic risk or safety analysis g. Management & oversight risk tree (MORT) analysis 21. Hardware performance causes 22. Human error causal factors taxonomy 23. Human performance root causes 24. Corrective action commitment - elements of information 25. Preventive corrective action verification 26. Preventive corrective action effectiveness measurement / Performance indicators 27. Report & corrective action status tracking 28. Reports to management 29. Winning management support