Root Cause Analysis Charter Statement

Image for Root Cause Analysis Charter Statement

Type:  Lessons Learned

Publisher:  Bechtel - DOE Contracts, Hanford Waste Treatment Plant - WTP/WTCC (Various Locations)

Published As:  Public


Topics:  Management Systems, Quality Assurance, Oversight

Lesson Learned Statement:
The scope and the charter statement for a Root Cause Analysis (RCA) should be stand alone and clearly direct causal analysis only.

Discussion of Activities:
BNI performed a root cause analysis (RCA) in response to a DOE assessment, which contained 20 issues that were grouped into four findings. The four findings were then grouped into a single finding and labeled "Procurement Related Management Concern". This single finding was based on 20 unrelated events that had occurred over a time span of several years. The events were associated with procurement of equipment that had been delivered to the site or field subcontracts that have been closed out. Some of the issues, upon investigation, were found to have resulted from less than adequate communication and less than adequate support provided to the assessment team. In addition, BNI had committed to do an "assessment" prior to initiating the RCA. This assessment was to have evaluated all the causal analyses performed for similar (i.e. procurement related) issues discovered in other DOE assessments as well as findings of the Reliability Validation Project (RVP) team to determine the extent to which the issues identified in DOE assessment had been addressed. The RCA was to be limited only to the gaps discovered from this assessment. This assessment or the gap analysis was not performed prior to commissioning the RCA team to do its work. The RCA charter, for its scope referred to the document that defined the scope of assessment to be performed prior to the assessment. The RCA team completed the analysis and reached its conclusions based on available data at which point it became apparent that the RCA sponsor expected the RCA to address all items referenced in the assessment or to identify gaps if these items were not addressed. The issuance of the final report was delayed because an appendix had to be added to the RCA to describe RCA activities relevant to the "assessment" scope to resolve the difference in expectation of the scope.

The RCA charter did not contain a clear stand alone statement. Instead it referred to another document for the approach and evaluation of the issue. This document contained activities preceding the RCA that had not been performed. The RCA team was thus placed in a difficult situation to complete the analysis as outlined in the charter. Also, investigation of 20 different events, that had occurred over many years, and finding their causes took more than 4 weeks that were allotted in the schedule to complete this work.

Actions or Recommendations:
i. Develop RCA charter statements that are stand alone, clear and concise without reference to other documents that may contain commitments that may not be consistent with the RCA mission.

ii The RCA scope should be limited to an occurrence or related occurrences that have occurred in a recent time window and based on actual incidences as opposed to events that have occurred several years in the past and factually unverified.

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