Based on Ishikawa Analysis, 12 main causes of the problem were identified.
From this list, 3 Quick Wins were determined.
Unclear escalation from IR situation to Emergency Situation
Unavailability of Emergency procedures
QUICK WIN #1 - Incomprehensive Emergency contact list
OTF unable to identify IR Triggering events
QUICK WIN #2 - Incomplete IFT Assessment for IRL
Unclear IRL role during Emergency Tier situation
Unclear demarcation between IRL PGCC vs IRL ABT roles
Unclear IR Trigger Criteria
QUICK WIN #3 - Incomprehensive IR Drill plan
Combined IR Situation Log & Post Review Log
Underutilized EAT
Unclear RM//SAP post IR situation
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