Affiliation(s)
1. Conger Enterprises LLC, 4535 Ponte Vedra Drive, Marietta, GA 30067, USA
2. APOSS, Repovec 23B, Zabok 49210, Croatia
ABSTRACT
The paper discusses the framework for a risk-informed root cause analysis
process. Such process enables
scaling of the analysis performed based on the risk associated with the
undesired event or condition, thereby creating tiers of analysis where the
greater the risk, the more sophisticated the analysis. In a risk-informed root
cause analysis process, a situation is
normally not analyzed at a level less than what actually occurred. However, a
situation may be investigated as though the consequence were greater than
actually happened, especially if only slight differences in circumstances could
result in a significantly higher consequence. While operational events or safety issues are normally expected to
result only with negligible or marginal actual consequences, many of those
would actually have certain potential to develop or propagate into catastrophic events. This potential can be expressed
qualitatively or quantitatively. Risk-informing of root cause analysis relies
on mapping the event or safety issue into a risk matrix which, traditionally,
is a two-dimensional probability-consequence matrix. A new concept employed in
the risk matrix for root cause analysis is that, while the probability reflects
the observed or expected range of values (retaining, thus, its “traditional”
meaning), the consequence reflects not only the observed or materialized impact
(such as failure of equipment) but, also, its potential to propagate or develop
into highly undesirable final state. The paper presents main elements of
risk-informed root cause analysis process and discusses qualitative and
quantitative aspects and approaches to determination of risk significance of
operational events or safety issues.
KEYWORDS
Root cause, risk-inform, risk, probability, cause analysis, safety
precedence, significance determination, risk matrix, probabalistic margin,
conditional probability, conditional risk, analyst, training, methods.
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