Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation, Third Edition

Appendix E: Root Cause Map Guidance

E.1 Instructions for Using This Appendix with the Root Cause Map

E.1.1 Types of Information Provided

This appendix provides detailed information about the use of ABS Consulting s Root Cause Map (which can be found in Appendix F of this handbook). A larger color version is also inserted in the handbook. Using the Root Cause Map will assist the investigator in identifying additional root causes and trending root causes.

The Root Cause Map has many shapes, which are generically referred to as nodes. For each node, general information is provided under the heading of Definition/Typical Issues. Definition/Typical Issues can help the investigator distinguish between similar items on the map and appropriately code each root cause. Figure E.1 shows a sample section of the Root Cause Map and its nodes.


Figure E.1: Section of the Root Cause Map

For most items, detailed information beyond Definition/Typical Issues is given. The categories of information include:

  • Examples

  • Potential recommendations

  • Notes related to the use of the node

  • Notes regarding commonly confused items/nodes

  • Cross-reference to OSHA process safety management (PSM) elements (29 CFR 1910.119)

  • Cross-reference to Risk Based Process Safety (RBPS) elements (a book written by ABS Consulting and published by the American Institute of Chemical Engineer s Center for Chemical Process Safety, ISBN 978-0-470-16569-0)

  • Cross-reference to:

    • Nodes on previous versions of the Root Cause Map

    • Nodes on the Maritime Root Cause Map

Figure E.2 shows a portion of a page...

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