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RESOURCES: There are many publications describing in great detail how to use cause and effect
diagrams.1
COMMENTS:
EXAMPLES: An example of Cause and Effect Tool in action is illustrated at Figure 1.1.7A.
1 K. Ishikawa, Guide to Quality Control, Quality Resources, White Plains, New York, 12th Printing 1994.
FAA System Safety Handbook, Appendix F
December 30, 2000
F-19
Figure 1.1.7 Example of Cause and Effect
SITUATION: The supervisor of an aircraft maintenance operation has been receiving reports from Quality
Assurance regarding tools in aircraft after maintenance over the last six months. The supervisor has followed up
but each case has involved a different individual and his spot checks seem to indicate good compliance with tool
control procedures. He decides to use a cause and effect diagram to consider all the possible sources of the tool
control problem. The supervisor develops the cause and effect diagram with the help of two or three of his best
maintenance personnel in a group application.
NOTE: Tool control is one of the areas where 99% performance is not adequate. That would mean one in a
hundred tools are misplaced. The standard must be that among the tens (or hundreds) of thousands of individual
uses of tools over a year, not one is misplaced.
Motivation weak (reward, discipline) OI incomplete (lacks detail)
Training weak (procedures, consequences) Tool check procedures weak
Supervision weak (checks)
Management emphasis light
No tool boards, cutouts Many small, hard to see tools
Many places to lose tools in aircraft
Participate in development of new procedures Collective & individual awards
Self & coworker observation Detailed OI
Quick feedback on mistakes Good matrices
Commitment to excellence
Strong sustained emphasis Extensive use of toolboard cutouts
Using the positive diagram as a guide the supervisor and working group apply all possible and practical options
developed from it.
1.2 THE SPECIALTY HAZARD IDENTIFICATION TOOLS
The tools that follow are designed to augment the primary tools described in part 1.1. These tools have
several advantages:
Human Methods
Materials Machinery
Tool
misplaced
People Procedures
Policies Plant
Strong
Motivation
FAA System Safety Handbook, Appendix F
December 30, 2000
F-20
They can be used by nearly everyone in the organization, though some may require either training or
professional facilitation.
Each tool provides a capability not fully realized in any of the primary tools.
They use the tools of the less formal safety program to support the ORM process.
They are well supported with forms, job aids, and models.
Their effectiveness has been proven. In an organization with a mature ORM process, all personnel will be
aware of the existence of these specialty tools and capable of recognizing the need for their application.
While not everyone will be comfortable using every procedure, a number of people within the
organization will have experience applying one or another of them.
1.2.1 THE HAZARD AND OPERABILITY TOOL
FORMAL NAME: The Hazard and Operability Tool
ALTERNATIVE NAMES: The HAZOP analysis
PURPOSE: The special role of the HAZOP is hazard analysis of completely new operations. In these
situations, traditional intuitive and experiential hazard identification procedures are especially weak. This
lack of experience hobbles tools such as the "What If" and Scenario Process tools, which rely heavily on
experienced operational personnel. The HAZOP deliberately maximizes structure and minimizes the need
for experience to increase its usefulness in these situations.
APPLICATION: The HAZOP should be considered when a completely new process or procedure is
going to be undertaken. The issue should be one where there is significant risk because the HAZOP does
demand significant expenditure of effort and may not be cost effective if used against low risk issues. The
HAZOP is also useful when an operator or leader senses that “something is wrong” but they can’t
identify it. The HAZOP will dig very deeply into the operation and to identify what that “something” is.
METHOD: The HAZOP is the most highly structured of the hazard identification procedures. It uses a
standard set of guide terms (Figure 1.1) which are then linked in every possible way with a tailored set of
process terms (for example “flow”). The process terms are developed directly from the actual process or
from the Operations Analysis. The two words together, for example “no” (a guideword) and “flow” (a
process term) will describe a deviation. These are then evaluated to see if a meaningful hazard is
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