Incident Investigation

2. Introduction to Root Cause Analysis Methodology

© DSMA Repsol YPF 2011

 Course Contents
0. Introduction
1. Incident Investigation Procedure
2. Introduction to Root Cause Analysis Methodology
3.1. Incident Reality and Definition
3.2. Incident Definition within Repsol YPF
4. The Principle of Cause and Effect
5. Cause and Effect Analysis
6. Evidence
7. Effective Solutions
8. Conclusions
9. Committee of Inquiry Management
10. Interviews
11. Human Error
12. HGI
13. GAMA Investigation
14. Case Study
15. Conclusions

2
© DSMA Repsol YPF 2011
 Unit Contents

2. Introduction to Root Cause Analysis Methodology

2.1. Objectives of a Good Investigation
2.2. RCA Methodology
2.2.1. RCA Techniques
2.2.2. RCA within Repsol

3
© DSMA Repsol YPF 2011
 2.1. Objectives of a Good Investigation

• A good investigation aims to:

• Establish the events that surround the incident.
• Identify the factors that have contributed to the incident and its causes.
• Review the adequacy of existing controls.
• Recommend preventive and corrective actions to prevent recurrence of
the incident.
• Identify findings and learned lessons, and spread them.

• Evidenced impartiality and transparency are also needed.

RCA methodology allows translating information about the

event into a series of underlying causes.

4
© DSMA Repsol YPF 2011
 2.2. RCA Methodology
• RCA = Root Cause Analysis
• Structured method for problem solving based on the understanding of causes to
prevent their recurrence.
• It is not a unique methodology, nor is it minutely defined.
• It covers multiple tools, processes and different philosophies, but there are
common characteristics to all RCA.

OBJECTIVE Events
INFORMATION RCA Factors
ABOUT THE
INCIDENT Conditions

ROOT
CAUSES
Root cause: Aspects which are at the origin of the incident.
If this cause/s is/are eliminated, the consequence should not reappear.

In this way, problems may be tackled by eliminating or correcting their causes, minimising
the possibility of recurrence.

5
© DSMA Repsol YPF 2011
 2.2.1. RCA Techniques

• There are many different techniques for Cause and Effect

Analysis:
• Pareto Analysis:
It is not a RCA, statistical approach.

• Cause and Effect diagrams or Ishikawa:

Predefined list of potential causes.

• Fault Tree Analysis:

Supports RCA.

• The Whys

• …
• Based on a previous study of existing techniques, Repsol has adopted
a methodology which is based on a method (Apollo) that constitutes
Repsol’s Incident Investigation Method.
6
© DSMA Repsol YPF 2011
 2.2.1. RCA Techniques
The choice was made based on a comparative study.

7
© DSMA Repsol YPF 2011
 2.2.1. RCA Techniques
The choice was made based on a comparative study.

8
© DSMA Repsol YPF 2011
 2.2.2. RCA within Repsol

• It is based on the Principle of Cause and Effect.

• It does not start from a predefined list of causes, but instead allows
to create a reality for each case.

• It uses cause and effect diagrams (HGI) to analyse the event.

• It is directed to an effective resolution of the incident / problem

(HSE incidents).

9
© DSMA Repsol YPF 2011
 2.2.2. RCA within Repsol

It consists of 4 stages:

• Defining the incident (final problem / consequence).

• Creating the cause and effect diagram.

• Identifying effective solutions.

• Implementing the best solutions.

10
© DSMA Repsol YPF 2011
 2.2.2. RCA within Repsol

11
© DSMA Repsol YPF 2011
 2.2.2. RCA within Repsol
INCIDENT Defined incident
Incident
DEFINITION
What, when, where? Necessary resources
Importance, risk

INCIDENT
Defined incident Network of causes
INVESTIGATION
Cause tree based on evidence

Management
(cause and effect diagram)

Incident
PROPOSAL OF
Network of causes IAR
SOLUTIONS

Brainstorming

IDENTIFICATION OF
IAR Root Causes
ROOT CAUSES

Company EHS
IAR- Root Causes association

Management
SYSTEMATIC ERRORS
Root Causes EHS errors typology
IDENTIFICATION

Grouping of Root Causes

12
© DSMA Repsol YPF 2011
 2.2.2. RCA within Repsol

An effective process must meet 6 criteria:

1. Clearly define the problem (final consequence) and its relevance for its owners.

2. Define the causal relationships which, combined, cause the problem.

3. Establish causal relationships between the root cause(s) and the defined
problem.

4. Clearly present the evidences used to support the existence of the identified
causes.

5. Explain how the solutions (Improvement Actions) will prevent the recurrence of
the defined problem.

6. Clearly document the previous criteria in a RCA Report (Final Investigation

Report) for the follow-up by third parties.

13
© DSMA Repsol YPF 2011
 2.2. RCA Methodology

Main causes of non-effective problem resolution

• Incomplete Problem Definition

“It’s obvious”, “It’s common sense”.

• Unknown Causal Relationships

“Whys” are missing, we infer conclusions from the story without well-
established causal relationships.

• RCA Focused on Solutions

We look for solutions before defining the problem.

• Family solutions are favourites.

14
© DSMA Repsol YPF 2011
 2.2. RCA Methodology

Cause Categories

• People

• Procedures

• Equipment

• Nature

In the search for root causes, it is important to consider all four categories.

15
© DSMA Repsol YPF 2011
 2.2. RCA Methodology

Cause Categories

Not knowing how to Not being able to

• Skills • Physical and mental conditions

• Knowledge • Engineering and equipment controls
• Communication • Standards and procedures
• Roles and responsibilities • Conditions of site

Not choosing to Not being allowed to

• Motivation & attitude • Perception & attention

• Leadership, supervision & management • Mental stress
• Work planning
• Change Management

16
© DSMA Repsol YPF 2011
 2. RCA Methodology

Questions?
Doubts?

17
© DSMA Repsol YPF 2011