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| case study for root cause analysis: Root Cause Analysis, Second Edition Bjørn Andersen, Tom Fagerhaug, 2006-01-01 This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates (that can also be found on an accompanying CD-ROM). The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief languagealmost keywordsand the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector. |
| case study for root cause analysis: Software Engineering Research, Management and Applications Roger Lee, 2018-10-11 This book presents the outcomes of the 16th International Conference on Software Engineering, Artificial Intelligence Research, Management and Applications (SERA 2018), which was held in Kunming, China on June 13–15, 2018. The aim of the conference was to bring together researchers and scientists, businessmen and entrepreneurs, teachers, engineers, computer users, and students to discuss the various fields of computer science, to share their experiences, and to exchange new ideas and information in a meaningful way. The book includes findings on all aspects (theory, applications and tools) of computer and information science, and discusses related practical challenges and the solutions adopted to solve them. The conference organizers selected the best papers from those accepted for presentation. The papers were chosen based on review scores submitted by members of the program committee and underwent a further rigorous round of review. From this second round, 13 of the conference’s most promising papers were then published in this Springer (SCI) book and not the conference proceedings. We eagerly await the important contributions that we know these authors will make to the field of computer and information science. |
| case study for root cause analysis: Root Cause Analysis Bjorn Andersen, Tom Fagerhaug, 2006-03-22 This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates. The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief language—almost keywords—and the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector. COMMENTS FROM OTHER CUSTOMERS Average Customer Rating: (4 of 5 based on 1 review) This book is a good intro to Root Cause Analysis tools. It is easy to read and laid out in a good format, with a picture and/or sample provided for every tool discussed, along with a checklist for its usage. There is the occasional spot of confusing information, and some of the explanations seem over-simplified or under-explained. But this is not highly prevalent, and the book does accomplish giving the reader a great introduction to these tools and techniques. It may be insufficient for those who are looking for more advanced or in-depth information on any of the tools and techniques. Beginners should find this a very helpful book and one that will be referenced often as they start practicing Root Cause Analysis. A reader in Bradenton, Florida |
| case study for root cause analysis: School Leader's Guide to Root Cause Analysis Paul Preuss, 2013-09-27 Don’t jump from problem to solution without first investigating root causes. This book helps you more accurately focus on school improvement issues, so you can avoid wasting precious time and resources. It is clearly written, contains lots of real examples, and is presented in a style and format designed for the non-expert. It will help you make decisions which will improve learning for all students. |
| case study for root cause analysis: Root Cause Analysis, Second Edition Duke Okes, 2019-02-06 This best-seller can help anyone whose role is to try to find specific causes for failures. It provides detailed steps for solving problems, focusing more heavily on the analytical process involved in finding the actual causes of problems. It does this using figures, diagrams, and tools useful for helping to make our thinking visible. This increases our ability to see what is truly significant and to better identify errors in our thinking. In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; cautions for analyzing data; and what to do if one cant find the causes. In its guidance on solution identification, biomimicry and TRIZ have been added as potential solution identification techniques. In addition, the appendices have been revised to include: an expanded breakdown of the 7 Ms, which includes more than 50 specific possible causes; forms for tracking causes and solutions, which can help maintain alignment of actions; techniques for how to enhance the interview process; and example responses to problem situations that the reader can analyze for appropriateness. |
| case study for root cause analysis: The ASQ Pocket Guide to Root Cause Analysis Bjørn Andersen, Tom Natland Fagerhaug, 2013-11-06 All organizations experience unintended variation and its consequences. Such problems exist within a broad range of scope, persistence, and severity across different industries. Some problems cause minor nuisances, others leads to loss of customers or money, others yet can be a matter of life and death. The purpose of this pocket guide is to provide you with easily accessible knowledge about the art of problem solving, with a specific focus on identifying and eliminating root causes of problems. Root cause analysis is a skill that absolutely everybody should master, irrespective of which sector you work in, what educational background you have, and which position in the organization you hold. The content in this little pocket guide can contribute to disseminating this skill a little further in the world. |
| case study for root cause analysis: The Practical Guide on How to Solve Ethics Case Study? For UPSC Civil Services & State PCS Main Examinations SUBHASH MISHRA, 2023-11-23 The Practical Guide on How to Solve Ethics Case Study? For UPSC Civil Services & State PCS Main Examinations. STEP-BY-STEP GUIDE ALL NOTES COVERED 2013-2023 UPSC MAIN CASES Qs. SOLVED. Author: Subhash Mishra, Gold Medalist and NET JRF, BHU Description: Unlock the secrets to mastering ethics case studies with this comprehensive guide by Subhash Mishra, a distinguished Gold Medalist and NET JRF from BHU. Tailored for aspirants of the UPSC Civil Services and State PCS Mains examinations, this book offers a meticulous and fully solved analysis of ethics case studies spanning the years 2013 to 2023. Key Features: Step-by-Step Approach: Navigate the complexities of ethics case studies with a systematic and step-by-step approach. Mishra's guide ensures you develop a structured and insightful method for dissecting and solving each case. In-Depth Analysis: Benefit from Mishra's profound insights as he delves into the ethical nuances of each case study. Explore the ethical dilemmas, principles, and legal considerations crucial for success in the examinations. Practical Application of Theories: Learn how to apply ethical theories such as utilitarianism, deontology, and virtue ethics to real-world scenarios. Mishra provides practical examples, making theoretical concepts accessible and applicable. Comprehensive Notes: Access meticulously crafted notes that cover the entire spectrum of ethical issues tested in UPSC and State PCS Mains examinations. Stay ahead with comprehensive coverage of key topics from 2013 to 2023. Case-Based Learning: Immerse yourself in fully solved case studies, offering a hands-on learning experience. Mishra's detailed explanations and reasoning ensure you not only solve cases but also understand the underlying ethical principles. Strategies for Success: Receive expert guidance on how to prioritize solutions, justify decisions, and address counterarguments. Develop strategies for effective implementation, ensuring your ethical resolutions stand out in the examination. Embark on your journey towards mastering ethics in competitive exams with Subhash Mishra's unparalleled expertise. This book is not just a guide; it's your key to unlocking success in UPSC Civil Services and State PCS Mains examinations. |
| case study for root cause analysis: The PROACT® Root Cause Analysis Kenneth C. Latino, Mark A. Latino, Robert J. Latino, 2020-09-10 Root Cause Analysis, or RCA, What is it? Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we’re applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence. In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include: Preserving evidence (data)/not allowing hearsay to fly as fact Organizing an appropriate team/minimizing potential bias Analyzing the events/reconstructing the incident based on actual evidence Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented Tracking bottom-line results/ensuring that identified, meaningful metrics were attained We explore, Why don’t things always go as planned? When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field. This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application. This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few. |
| case study for root cause analysis: Root Cause Analysis Mark A. Latino, Robert J. Latino, Kenneth Latino, 2016-04-19 What is RCA? It seems like such an easy question to answer, yet from novices to veterans and practitioners to providers, no one seems to have come to agreement or consensus on an acceptable definition for the industry. Now in its fourth edition, Root Cause Analysis: Improving Performance for Bottom-Line Results discusses why it is so hard to get su |
| case study for root cause analysis: Practical Root Cause Failure Analysis Randy Riddell, 2022-06-07 Root Cause Failure Analysis (RCFA) is a method used by maintenance and reliability industry professionals as one of the key tools to drive improvement. This book offers a quick guide to the applications involved in performing a successful RCFA by providing a foundational view of maintenance and reliability strategies. It also highlights the practical applications of RCFA and identifies how to achieve a successful RCFA, as well as discussing common equipment failures and how to solve them. Case studies on topics including pump system failure analysis and vibration analysis are included. Suggests examples on how to solve common failure on many types of equipment, including fatigue, pumps, bearings, and mechanical power transmission Highlights practical applications of RCFA Identifies key elements for how to achieve a successful RCFA Presents case studies on topics including pump system failure analysis and vibration analysis The book is a must-read for any reliability engineer, particularly mechanical reliability professionals. |
| case study for root cause analysis: Root Cause Failure Analysis Trinath Sahoo, 2021-05-18 Root Cause Failure Analysis Provides the knowledge and failure analysis skills necessary for preventing and investigating process equipment failures Process equipment and piping systems are essential for plant availability and performance. Regularly exposed to hazardous service conditions and damage mechanisms, these critical plant assets can result in major failures if not effectively monitored and assessed—potentially causing serious injuries and significant business losses. When used proactively, Root Cause Failure Analysis (RCFA) helps reliability engineers inspect the process equipment and piping system before any abnormal conditions occur. RCFA is equally important after a failure happens: it determines the impact of a failure, helps control the resultant damage, and identifies the steps for preventing future problems. Root Cause Failure Analysis: A Guide to Improve Plant Reliability offers readers clear understanding of degradation mechanisms of process equipment and the concepts needed to perform industrial RCFA investigations. This comprehensive resource describes the methodology of RCFA and provides multiple techniques and industry practices for identifying, predicting, and evaluating equipment failures. Divided into two parts, the text first introduces Root Cause Analysis, explains the failure analysis process, and discusses the management of both human and latent error. The second part focuses on failure analysis of various components such as bolted joints, mechanical seals, steam traps, gearboxes, bearings, couplings, pumps, and compressors. This authoritative volume: Illustrates how failures are associated with part integrity, a complete system, or the execution of an engineering process Describes how proper design, operation, and maintenance of the equipment help to enhance their reliability Covers analysis techniques and industry practices including 5-Why RCFA, fault tree analysis, Pareto charts, and Ishikawa diagrams Features a detailed case study of process plant machinery and a chapter on proactive measures for avoiding failures Bridging the gap between engineering education and practical application, Root Cause Failure Analysis: A Guide to Improve Plant Reliability is an important reference and guide for industrial professionals, including process plant engineers, planning managers, operation and maintenance engineers, process designers, chemical engineers, and instrument engineers. It is also a valuable text for researchers, instructors, and students in relevant areas of engineering and science. |
| case study for root cause analysis: Case Studies in Patient Safety Julie K. Johnson, Helen Haskell, Paul Barach, 2016 Resource added for the Nursing-Associate Degree 105431, Practical Nursing 315431, and Nursing Assistant 305431 programs. |
| case study for root cause analysis: Handbook of Materials Failure Analysis with Case Studies from the Oil and Gas Industry Abdel Salam Hamdy Makhlouf, Mahmood Aliofkhazraei, 2015-09-01 Handbook of Materials Failure Analysis: With Case Studies from the Oil and Gas Industry provides an updated understanding on why materials fail in specific situations, a vital element in developing and engineering new alternatives. This handbook covers analysis of materials failure in the oil and gas industry, where a single failed pipe can result in devastating consequences for people, wildlife, the environment, and the economy of a region. The book combines introductory sections on failure analysis with numerous real world case studies of pipelines and other types of materials failure in the oil and gas industry, including joint failure, leakage in crude oil storage tanks, failure of glass fibre reinforced epoxy pipes, and failure of stainless steel components in offshore platforms, amongst others. - Introduces readers to modern analytical techniques in materials failure analysis - Combines foundational knowledge with current research on the latest developments and innovations in the field - Includes numerous compelling case studies of materials failure in oil and gas pipelines and drilling platforms |
| case study for root cause analysis: Productivity and Reliability-Based Maintenance Management Matthew P. Stephens, 2010 With its easy-to-read writing style, Productivity and Reliability-Based Maintenance Management provides a strong yet practical foundation on Total Productive Maintenance (TPM). This comprehensive practical guide departs from the wait-failure-emergency repair cycle that plagues many industries today. Instead, this text takes a proactive and productive maintenance approach, focusing on how to avoid failure in the first place. By using real-world case studies in every chapter, the author reinforces the importance of sound and proactive maintenance practices. The use of end-of-chapter problems and discussion questions helps to solidify concepts presented. Productivity and Reliability-Based Maintenance Management is a powerful educational tool for students as well as maintenance professionals and managers. This volume was previously published under the same title in 2004 by Pearson Education, and has been reprinted with permission through an arrangement with the author. |
| case study for root cause analysis: Communities in Action National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, 2017-04-27 In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome. |
| case study for root cause analysis: The Cognitive Autopsy Pat Croskerry, 2020-05-22 Behind heart disease and cancer, medical error is now listed as one of the leading causes of death. Of the many medical errors that may lead to injury and death, diagnostic failure is regarded as the most significant. Generally, the majority of diagnostic failures are attributed to the clinicians directly involved with the patient, and to a lesser extent, the system in which they work. In turn, the majority of errors made by clinicians are due to decision making failures manifested by various departures from rationality. Of all the medical environments in which patients are seen and diagnosed, the emergency department is the most challenging. It has been described as a wicked environment where illness and disease may range from minor ailments and complaints to severe, life-threatening disorders. The Cognitive Autopsy is a novel strategy towards understanding medical error and diagnostic failure in 42 clinical cases with which the author was directly involved or became aware of at the time. Essentially, it describes a cognitive approach towards root cause analysis of medical adverse events or near misses. Whereas root cause analysis typically focuses on the observable and measurable aspects of adverse events, the cognitive autopsy attempts to identify covert cognitive processes that may have contributed to outcomes. In this clinical setting, no cognitive process is directly observable but must be inferred from the behavior of the individual clinician. The book illustrates unequivocally that chief among these cognitive processes are cognitive biases and other flaws in decision making, rather than knowledge deficits. |
| case study for root cause analysis: A Project Manager's Book of Tools and Techniques Cynthia Snyder Dionisio, 2018-02-21 A practical guide for putting PMBOK concepts to work A Project Manager’s Book of Tools and Techniques is an invaluable resource for students and working professionals alike. Whether you’re preparing for the PMP exam or just looking to optimize your project management skills, this book provides detailed explanations for over 100 essential tools described in the Project Management Institute’s A Guide to the Project Management Body of Knowledge (PMBOK Guide) Sixth Edition. Going beyond theory and concept to real-world practice, these tools and techniques are the “how” of effective project management; from planning, to implementation, to oversight, and beyond, all phases of the project are represented here to help you more effectively apply critical PMBOK concepts. Comprehensive examples illustrate real-world implementation, and detailed discussion provides expert guidance for both new and experienced project management professionals. Knowing what to do is much different from knowing how to do it; even perfect understanding of the PMBOK Guide doesn’t automatically translate into effective practice. This book is designed to help you bridge that gap and expertly apply current project management standards. Delve deeper into the practical tools described in the PMBOK Guide—Sixth Edition Follow detailed examples that illustrate effective project management methods Master project management applications in preparation for the PMP exam Graduate from theory to practice with powerful tools and techniques for success Concepts are only valuable once they are applied—and then they become a skill set that gets results. The PMBOK Guide is the ultimate authority on project management concepts, but translating those concepts into applicable skills requires a detailed understanding of the tools of the field. A Project Manager’s Book of Tools and Techniques is a practical manual for putting essential project management concepts into practice. |
| case study for root cause analysis: Basics of Health Care Performance Improvement Donald Lighter, 2011-11-15 Basics of Health Care Performance Improvement: A Lean Six Sigma Approach prepares future healthcare administrators to meet the challenges of a changing marketplace through the proven Lean Six Sigma method of quality improvement—straightforward principles and procedures that enhance how healthcare organizations operate. With an eye toward meeting consumers’ increasing demand for value in health care, this new volume provides in-depth information on planning and implementing a “Define-Measure-Analyze-Improve-Control” (DMAIC) initiative to reduce errors and improve performance in healthcare settings, and serves as an essential reference on the basics of Lean Six Sigma and its application in augmenting the quality of care. Key Features: Lean Six Sigma case studies drawn from the industry; A thorough exploration of DMAIC approach to quality improvement; Discussion questions in every chapter Instructor Resources: Instructor's Manual, PowerPoint Presentations, and a TestBank |
| case study for root cause analysis: Requirements Engineering: Foundation for Software Quality Joerg Doerr, Andreas L. Opdahl, 2013-03-25 This book constitutes the refereed proceedings of the 19th International Working Conference on Requirements Engineering: Foundation for Software Quality, REFSQ 2013, held in Essen, Germany, in April 2013. The papers are organized in 8 topical sections on requirements engineering and architecture; natural language requirements; requirements engineering and quality; traceability; requirements engineering and business/goals; requirements engineering and software development; requirements engineering in practice; product lines and product management. |
| case study for root cause analysis: Cases on Optimizing the Asset Management Process González-Prida, Vicente, Márquez, Carlos Alberto Parra, Márquez, Adolfo Crespo, 2021-10-15 It is critical to improve the asset management system implementation as well as economics and industrial decision making to ensure that a business may move smoothly internally. Maintenance management should be aligned to the activities of maintenance in accordance with key business strategies, which must be designed under the comprehensive approach of an asset management process. After transforming the priorities of the business into priorities of maintenance, maintenance managers will use their medium-team strategies to tackle potential weaknesses in the maintenance of the equipment in accordance with these objectives. Cases on Optimizing the Asset Management Process explains and summarizes the processes and the reference frame necessary for the implementation of the Maintenance Management Model (MMM). This book acts as an overview of the current state of the art in asset management, providing innovative tools and practices from the fourth industrial revolution. Presenting topics like criticality analysis, physical asset maintenance, and unified modelling language, this text is essential for industrial and manufacturing engineers, plant supervisors, academicians, researchers, advanced-level students, technology developers, and managers who make decisions in this field. |
| case study for root cause analysis: Handbook of Military and Defense Operations Research Natalie M. Scala, James P. Howard, II, 2024-08-21 Tracing its roots back to World War II, operations research (OR) has become a vital tool in military and defense strategy. The second edition of the Handbook of Military and Defense Operations Research highlights this evolution, showcasing how OR integrates with cutting-edge areas like artificial intelligence, cybersecurity, and big data analytics. This volume is more than a historical account; it is a practical guide. The volume features expert voices and offers insights into OR applications in modern security challenges. Readers will discover a blend of theory and real-world case studies, making it an essential resource for both newcomers and seasoned defense analysis professionals. Dive into this handbook to explore the rich, dynamic field of military and defense operations research, a discipline at the heart of global security and strategic decision-making. New to the second edition: Reorganized into a three-part structure Extensive revisions throughout Numerous new exercises, examples, and case studies Several new chapters |
| case study for root cause analysis: Advances in Industrial Safety Faisal I. Khan, Nihal Anwar Siddiqui, S. M. Tauseef, B. P. Yadav, 2020-09-18 This book presents the proceedings of the International Conference on Health, Safety, Fire, Environment, and Allied Sciences. It highlights latest developments in the field of science and technology aimed at improving health and safety in the workplace. The volume comprises content from leading scientists, engineers, and policy makers discussing issues relating to industrial safety, fire hazards and their management in industry, forests and other settings. Also dealt with are issues of occupational health in engineering, process and agricultural industry and protection against incidents of arson and terror attacks. The contents of this volume will be of interest to researchers, practitioners, and policy makers alike. |
| case study for root cause analysis: The Lean Entrepreneur Brant Cooper, Patrick Vlaskovits, 2013-02-26 Providing a step-by-step approach to best practices, and giving readers a business model analysis guide, the book is rich in cases studies, illustrative graphics, worksheets, and exercises for a truly immersive guide to starting or improving a company. Invaluable reading for all readers in all businesses, the book teaches entrepreneurs how to approach risk head-on and test market ideas immediately, foster stronger customer relations, test different business model risks, and create a customer funnel based on buyers' process in order to eliminate unnecessary time and effort.A lean entrepreneur has already bought into lean startup, customer development, design thinking, and other iterative, customer-centric methods of product development. The lean entrepreneur wants to know how to apply these to their business. In other words: how to get started tomorrow. This book shows the way. |
| case study for root cause analysis: Next Generation E-Governance Services For Effective People Participation Dr kumar D Dr panchanatham N, |
| case study for root cause analysis: Methods for Reliability Improvement and Risk Reduction Michael Todinov, 2018-12-10 Reliability is one of the most important attributes for the products and processes of any company or organization. This important work provides a powerful framework of domain-independent reliability improvement and risk reducing methods which can greatly lower risk in any area of human activity. It reviews existing methods for risk reduction that can be classified as domain-independent and introduces the following new domain-independent reliability improvement and risk reduction methods: Separation Stochastic separation Introducing deliberate weaknesses Segmentation Self-reinforcement Inversion Reducing the rate of accumulation of damage Permutation Substitution Limiting the space and time exposure Comparative reliability models The domain-independent methods for reliability improvement and risk reduction do not depend on the availability of past failure data, domain-specific expertise or knowledge of the failure mechanisms underlying the failure modes. Through numerous examples and case studies, this invaluable guide shows that many of the new domain-independent methods improve reliability at no extra cost or at a low cost. Using the proven methods in this book, any company and organisation can greatly enhance the reliability of its products and operations. |
| case study for root cause analysis: Disaster Forensics Anthony J. Masys, 2016-09-03 This book aims to uncover the root causes of natural and man-made disasters by going beyond the typical reports and case studies conducted post-disaster. It opens the black box of disasters by presenting ‘forensic analysis approaches’ to disasters, thereby revealing the complex causality that characterizes them and explaining how and why hazards do, or do not, become disasters. This yields ‘systemic’ strategies for managing disasters. Recently the global threat landscape has seen the emergence of high impact, low probability events. Events like Hurricane Katrina, the Great Japan Earthquake and tsunami, Hurricane Sandy, Super Typhoon Haiyan, global terrorist activities have become the new norm. Extreme events challenge our understanding regarding the interdependencies and complexity of the disaster aetiology and are often referred to as Black Swans. Between 2002 and 2011, there were 4130 disasters recorded that resulted from natural hazards around the world. In these, 1,117,527 people perished and a minimum of US$1,195 billion in losses were reported. In the year 2011 alone, 302 disasters claimed 29,782 lives; affected 206 million people and inflicted damages worth a minimum of estimated US$366 billion. |
| case study for root cause analysis: Business analyst: a profession and a mindset Yulia Kosarenko, 2019-05-12 What does it mean to be a business analyst? What would you do every day? How will you bring value to your clients? And most importantly, what makes a business analyst exceptional? This book will answer your questions about this challenging career choice through the prism of the business analyst mindset — a concept developed by the author, and its twelve principles demonstrated through many case study examples. Business analyst: a profession and a mindset is a structurally rich read with over 90 figures, tables and models. It offers you more than just techniques and methodologies. It encourages you to understand people and their behaviour as the key to solving business problems. |
| case study for root cause analysis: Why Startups Fail Tom Eisenmann, 2021-03-30 If you want your startup to succeed, you need to understand why startups fail. “Whether you’re a first-time founder or looking to bring innovation into a corporate environment, Why Startups Fail is essential reading.”—Eric Ries, founder and CEO, LTSE, and New York Times bestselling author of The Lean Startup and The Startup Way Why do startups fail? That question caught Harvard Business School professor Tom Eisenmann by surprise when he realized he couldn’t answer it. So he launched a multiyear research project to find out. In Why Startups Fail, Eisenmann reveals his findings: six distinct patterns that account for the vast majority of startup failures. • Bad Bedfellows. Startup success is thought to rest largely on the founder’s talents and instincts. But the wrong team, investors, or partners can sink a venture just as quickly. • False Starts. In following the oft-cited advice to “fail fast” and to “launch before you’re ready,” founders risk wasting time and capital on the wrong solutions. • False Promises. Success with early adopters can be misleading and give founders unwarranted confidence to expand. • Speed Traps. Despite the pressure to “get big fast,” hypergrowth can spell disaster for even the most promising ventures. • Help Wanted. Rapidly scaling startups need lots of capital and talent, but they can make mistakes that leave them suddenly in short supply of both. • Cascading Miracles. Silicon Valley exhorts entrepreneurs to dream big. But the bigger the vision, the more things that can go wrong. Drawing on fascinating stories of ventures that failed to fulfill their early promise—from a home-furnishings retailer to a concierge dog-walking service, from a dating app to the inventor of a sophisticated social robot, from a fashion brand to a startup deploying a vast network of charging stations for electric vehicles—Eisenmann offers frameworks for detecting when a venture is vulnerable to these patterns, along with a wealth of strategies and tactics for avoiding them. A must-read for founders at any stage of their entrepreneurial journey, Why Startups Fail is not merely a guide to preventing failure but also a roadmap charting the path to startup success. |
| case study for root cause analysis: Revival: Safety and Reliability in the 90s (1990) M.H. Walter, R.F. Cox, 2019-09-09 Reliability-based design is relatively well established in structural design. Its use is less mature in geotechnical design, but there is a steady progression towards reliability-based design as seen in the inclusion of a new Annex D on Reliability of Geotechnical Structures in the third edition of ISO 2394. Reliability-based design can be viewed as a simplified form of risk-based design where different consequences of failure are implicitly covered by the adoption of different target reliability indices. Explicit risk management methodologies are required for large geotechnical systems where soil and loading conditions are too varied to be conveniently slotted into a few reliability classes (typically three) and an associated simple discrete tier of target reliability indices. |
| case study for root cause analysis: Case Studies in System of Systems, Enterprise Systems, and Complex Systems Engineering Alex Gorod, Brian E. White, Vernon Ireland, S. Jimmy Gandhi, Brian Sauser, 2014-07-01 Suitable as a reference for industry practitioners and as a textbook for classroom use, Case Studies in System of Systems, Enterprise Systems, and Complex Systems Engineering provides a clear understanding of the principles and practice of system of systems engineering (SoSE), enterprise systems engineering (ESE), and complex systems engineering (CSE). Multiple domain practitioners present and analyze case studies from a range of applications that demonstrate underlying principles and best practices of transdisciplinary systems engineering. A number of the case studies focus on addressing real human needs. Diverse approaches such as use of soft systems skills are illustrated, and other helpful techniques are also provided. The case studies describe, examine, analyze, and assess applications across a range of domains, including: Engineering management and systems engineering education Information technology business transformation and infrastructure engineering Cooperative framework for and cost management in the construction industry Supply chain modeling and decision analysis in distribution centers and logistics International development assistance in a foreign culture of education Value analysis in generating electrical energy through wind power Systemic risk and reliability assessment in banking Assessing emergencies and reducing errors in hospitals and health care systems Information fusion and operational resilience in disaster response systems Strategy and investment for capability developments in defense acquisition Layered, flexible, and decentralized enterprise architectures in military systems Enterprise transformation of the air traffic management and transport network Supplying you with a better understanding of SoSE, ESE, and CSE concepts and principles, the book highlights best practices and lessons learned as benchmarks that are applicable to other cases. If adopted correctly, the approaches outlined can facilitate significant progress in human affairs. The study of complex systems is still in its infancy, and it is likely to evolve for decades to come. While this book does not provide all the answers, it does establish a platform, through which analysis and knowledge application can take place and conclusions can be made in order to educate the next generation of systems engineers. |
| case study for root cause analysis: Hydrogen Safety Fotis Rigas, Paul Amyotte, 2012-07-09 Hydrogen Safety highlights physiological, physical, and chemical hazards associated with hydrogen production, storage, distribution, and use systems. It also examines potential accident scenarios that could occur with hydrogen use under certain conditions. The number of potential applications for hydrogen continues to grow—from cooling power station generators to widespread commercial use in hydrogen fuel-cell vehicles and other fuel-cell applications. However, this volatile substance poses unique challenges, including easy leakage, low ignition energy, a wide range of combustible fuel-air mixtures, buoyancy, and its ability to embrittle metals that are required to ensure safe operation. Focused on providing a balanced view of hydrogen safety—one that integrates principles from physical sciences, engineering, management, and social sciences—this book is organized to address questions associated with the hazards of hydrogen and the ensuing risk associated with its industrial and public use. What are the properties of hydrogen that can render it a hazardous substance? How have these hazards historically resulted in undesired incidents? How might these hazards arise in the storage of hydrogen and with its use in vehicular transportation? The authors address issues of inherently safer design, safety management systems, and safety culture. They highlight hydrogen storage facilities —which pose greater hazards because of the increased quantities stored and handled—and the dangers of using hydrogen as a fuel for transport. Presented experiments are included to verify computer simulations with the aid of computational fluid dynamics (CFD) of both gaseous and liquefied hydrogen. The book also provides an overview of the European Commission (EC) Network of Excellence for Hydrogen Safety (HySafe) and presents various case studies associated with hydrogen and constructional materials. It concludes with a brief look at future research requirements and current legal requirements for hydrogen safety. |
| case study for root cause analysis: Advanced Information Systems Engineering Pascal van Eck, Jaap Gordijn, Roel J. Wieringa, 2009-06-06 This book constitutes the refereed proceedings of the 21st International Conference on Advanced Information Systems Engineering, CAiSE 2009, held in Amsterdam, The Netherlands, on June 8-12, 2009. The 36 papers presented in this book together with 6 keynote papers were carefully reviewed and selected from 230 submissions. The topics covered are model driven engineering, conceptual modeling, quality and data integration, goal-oriented requirements engineering, requirements and architecture, service orientation, Web service orchestration, value-driven modeling, workflow, business process modeling, and requirements engineering. |
| case study for root cause analysis: Effect of Operational Variables on Nitrogen Transformations in Duckweed Stabilization Ponds Julia Rosa Caicedo Bejarano, 2005-03-24 There is an urgent need to develop and improve low cost technologies for wastewater treatment. Simultaneously treating wastewater and producing duckweed in a pond system is, therefore, an attractive solution contributing to both environmental protection and food production. Duckweed has excellent qualities: a high protein content, a high growth rate and is an easy crop to handle. The small plant turns nitrogen from wastewater into a food source. This thesis reports on the effect of different operational variables, like anaerobic pre-treatment, the combination of algae and duckweed ponds and pond depth. Improved nitrogen removal was obtained through the combination of duckweed ponds with algae ponds. Duckweed pond systems could be designed with shallow depth without affecting nitrogen removal efficiency. This research is the result of the cooperative effort between the EIDENAR, Univalle, Cali, Colombia and the UNESCO-IHE Institute for Water Education in Delft, the Netherlands. |
| case study for root cause analysis: Lean Manufacturing William M Feld, 2000-09-28 There are some very good books available that explain the Lean Manufacturing theory and touch on implementing its techniques. However, you cannot learn how to be lean from merely reading the theory. And to be successful in the real-work environment you need a clear comprehension of how lean techniques work, rather than just a remote understanding |
| case study for root cause analysis: Cloud Computing and Services Science Donald Ferguson, Markus Helfert, Claus Pahl, 2023-01-01 This book constitutes the refereed proceedings of the 11th International Conference on Cloud Computing and Services Science, CLOSER 2021, Virtual Event, during April 28–30, 2021. The 5 full papers included in this book were carefully reviewed and selected from 51 submissions. The proceedings deal with the topics of data processing, cloud computing environments, and services science. |
| case study for root cause analysis: The Art of Application Performance Testing Ian Molyneaux, 2014-12-15 Because performance is paramount today, this thoroughly updated guide shows you how to test mission-critical applications for scalability and performance before you deploy them—whether it’s to the cloud or a mobile device. You’ll learn the complete testing process lifecycle step-by-step, along with best practices to plan, coordinate, and conduct performance tests on your applications. Set realistic performance testing goals Implement an effective application performance testing strategy Interpret performance test results Cope with different application technologies and architectures Understand the importance of End User Monitoring (EUM) Use automated performance testing tools Test traditional local applications, web applications, and web services Recognize and resolves issues often overlooked in performance tests Written by a consultant with over 15 years’ experience with performance testing, The Art of Application Performance Testing thoroughly explains the pitfalls of an inadequate testing strategy and offers a robust, structured approach for ensuring that your applications perform well and scale effectively when the need arises. |
| case study for root cause analysis: Materials and Process Selection for Engineering Design Mahmoud M. Farag, 2020-12-30 Introducing a new engineering product or changing an existing model involves developing designs, reaching economic decisions, selecting materials, choosing manufacturing processes, and assessing environmental impact. These activities are interdependent and should not be performed in isolation from each other. This is because the materials and processes used in making a product can have a major influence on its design, cost, and performance in service. This Fourth Edition of the best-selling Materials and Process Selection for Engineering Design takes all of this into account and has been comprehensively revised to reflect the many advances in the fields of materials and manufacturing, including: Increasing use of additive manufacturing technology, especially in biomedical, aerospace and automotive applications Emphasizing the environmental impact of engineering products, recycling, and increasing use of biodegradable polymers and composites Analyzing further into weight reduction of products through design changes as well as material and process selection, especially in manufacturing products such as electric cars Discussing new methods for solving multi-criteria decision-making problems, including multi-component material selection as well as concurrent and geometry-dependent selection of materials and joining technology Increasing use of MATLAB by engineering students in solving problems This textbook features the following pedagogical tools: New and updated practical case studies from industry A variety of suggested topics and background information for in-class group work Ideas and background information for reflection papers so readers can think critically about the material they have read, give their interpretation of the issues under discussion and the lessons learned, and then propose a way forward Open-book exercises and questions at the end of each chapter where readers are evaluated on how they use the material, rather than how well they recall it, in addition to the traditional review questions Includes a solutions manual and PowerPoint lecture materials for adopting professors Aimed at students in mechanical, manufacturing, and materials engineering, as well as professionals in these fields, this book provides the practical know-how in order to choose the right materials and processes for development of new or enhanced products. |
| case study for root cause analysis: Reliability Engineering Edgar Bradley, 2016-11-03 Reliability Engineering – A Life Cycle Approach is based on the author’s knowledge of systems and their problems from multiple industries, from sophisticated, first class installations to less sophisticated plants often operating under severe budget constraints and yet having to deliver first class availability. Taking a practical approach and drawing from the author’s global academic and work experience, the text covers the basics of reliability engineering, from design through to operation and maintenance. Examples and problems are used to embed the theory, and case studies are integrated to convey real engineering experience and to increase the student’s analytical skills. Additional subjects such as failure analysis, the management of the reliability function, systems engineering skills, project management requirements and basic financial management requirements are covered. Linear programming and financial analysis are presented in the context of justifying maintenance budgets and retrofits. The book presents a stand-alone picture of the reliability engineer’s work over all stages of the system life-cycle, and enables readers to: Understand the life-cycle approach to engineering reliability Explore failure analysis techniques and their importance in reliability engineering Learn the skills of linear programming, financial analysis, and budgeting for maintenance Analyze the application of key concepts through realistic Case Studies This text will equip engineering students, engineers and technical managers with the knowledge and skills they need, and the numerous examples and case studies include provide insight to their real-world application. An Instructor’s Manual and Figure Slides are available for instructors. |
| case study for root cause analysis: Multivariate Data Analysis for Root Cause Analyses and Time-of-Flight Secondary Ion Mass Spectrometry Danica Heller-Krippendorf, 2019-10-31 Danica Heller-Krippendorf develops concepts and approaches optimizing the applicability of MVA on data sets from an industrial context. They enable more time-efficient MVA of the respective ToF‐SIMS data. Priority is given to two main aspects by the author: First, the focus is on strategies for a more time-efficient collection of the input data. This includes the optimal selection of the number of replicate measurements, the selection of input data and guidelines for the selection appropriate data preprocessing methods. Second, strategies for more efficient analysis of MVA results are presented. About the Author: Danica Heller-Krippendorf did her research and dissertation at the University of Siegen, Germany, in collaboration with a German analytical service company. Now she is engineer in analytics at a DAX company. |
| case study for root cause analysis: Data Quality Fundamentals Barr Moses, Lior Gavish, Molly Vorwerck, 2022-09 Do your product dashboards look funky? Are your quarterly reports stale? Is the data set you're using broken or just plain wrong? These problems affect almost every team, yet they're usually addressed on an ad hoc basis and in a reactive manner. If you answered yes to these questions, this book is for you. Many data engineering teams today face the good pipelines, bad data problem. It doesn't matter how advanced your data infrastructure is if the data you're piping is bad. In this book, Barr Moses, Lior Gavish, and Molly Vorwerck, from the data observability company Monte Carlo, explain how to tackle data quality and trust at scale by leveraging best practices and technologies used by some of the world's most innovative companies. Build more trustworthy and reliable data pipelines Write scripts to make data checks and identify broken pipelines with data observability Learn how to set and maintain data SLAs, SLIs, and SLOs Develop and lead data quality initiatives at your company Learn how to treat data services and systems with the diligence of production software Automate data lineage graphs across your data ecosystem Build anomaly detectors for your critical data assets |
Root Cause Analysis in Healthcare A Case Study - DFWHC …
Effective root cause analysis for Causal Factor to find fixable root causes. Definition of a Root Cause : The absence of a best practice or knowledge that would have prevented the problem …
60 Empirical Case Studies of the Root Cause Analysis Method …
Root-cause analysis is a seven-step methodology that proposes multiple tools per step, which are designed to identify and eliminate the root cause of a reoccurring problem.
Root Cause Analysis Toolkit for Long Term Care
Root Cause Analysis (RCA) is a problem solving method to investigate an actual or potential problem, incident or concern. A team looks beyond an immediate solution to understand the …
Root Cause Analysis - qualityhealth.org
Apr 2, 2018 · The goal of a Root Cause Analysis is a Root Solution • What happened? • Why did it happen? • What can you do to prevent it from happening again? What is RCA
Adverse event reporting and root cause analysis
By ensuring an effective incident re-porting system is in place and engaging staff in root cause analysis (RCA), leaders can cre-ate a collaborative environment where nurses feel free to …
Centrifugal Compressor Root Cause Analysis and Case Study …
C) Case Study. Analysis – Determine Causes Evaluate Possible Root Causes of Vibration •Conduct an “Operating Deflected Shape (ODS)” analysis • Identify relative vibration …
Case study: Root cause analysis of environmental incidents
The purpose of root cause analysis of the kind described here is to learn lessons and take actions to prevent further failures and repeat successes. This requires
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identification and elimination of the root cause/s responsible for malfunctioning of the fuel pump in customers‟ cars. From the Check sheet and Pareto analysis, two major defects were identified
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Root cause analysis (RCA) of fractured ASTM A53 carbon steel pipe at oil & gas company
Smarter Root Cause Analysis with a leading pharma company
Aizon’s smarter root cause analysis revealed that the incidents were caused by many factors, including the time of year, the humidity and temperature of the environment and the operator …
A Case Study in Root Cause Defect Analysis - University of …
We report a retrospective root cause defect analysis study of the defect Modification Requests (MRs) . , discovered while building, testing, and deploying a release of a transmission network …
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The IT department utilized Root Cause Analysis to: • Reduce or eliminate costs associated with interruptions in IT service. • Reduce the risk of IT problem recurrence. • Maintain internal …
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A Root Cause Analysis (RCA) is an analysis, which focuses on finding root causes of problems. According to Rooney & Vanden Heuvel (2004), analysing a root cause helps discover what, …
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The intent of this paper is to articulate improvements in Root Cause Investigation (RCI) and follow-up process that engage leadership and change the culture to prevent repetitive incidents.
Practical Root Cause Analysis Using Cause Mapping
Root Cause Analysis (RCA) is a useful way to achieve this goal. There are three common barriers that need to be overcome in order for RCA to be effectively used. This paper provides an …
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Salmaddiina et al., / Root Cause Analysis: Solid Waste Management (Case Study on Market) 27 recorded at 561 tonnes/day. Derived from data above, this research chooses to conduct an …
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Case study: Root cause analysis of environmental incidents
2 Root cause analysis process The steps in a simple root cause analysis process for examining a success or a failure are outlined in Figure 1. The steps were modified slightly for this case. …
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on its criticality using C-I-N analysis. Further, root cause analysis was done for the failures occurred in the machineries used in the open cast mines.This study was carried out at the …
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Framework For Root Cause Analysis And Corrective Actions*
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Ishikawa diagram for root cause analysis of critical low pressure hose nonconformance [own study with the use of Statistica 13.3 software] It can be seen from the diagram that most of the factors ...
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Bearing Root Cause Failure Analysis
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Gear Pump Root Cause Failure Analysis Using Vibrations
Gear Pump Root Cause Failure Analysis Using Vibrations Analysis and Signal Processing Ali Hemati . Alireza Shooshtari Submitted: 27 February 2020/in revised form: 15 July …
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Case study 1: Duodenoscope contamination Step 1. Outline Patients infected, killed by superbug, scopes contaminated, unable to be sterilized ... Problem Solving • Incident Investigation •Root …
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each “root cause” by placing the number of the recommendation(s) on the line provided. More than one recommendation can apply to a root cause. Root Causes Recommendations A. …
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Using Root Cause Analysis. A Case Study. Christian Ighohor Okonta and Raphael Olumese Edokpia. Department of Industrial and Production Engineering . University of Benin . Edo …
