Root Cause Analysis An Introduction 2007 Immel Resources

Root Cause Analysis: An Introduction 2007, Immel Resources LLC, Petaluma, California USA, www. immel. com

Overview • Common problems • Understanding causes • Problem definition • Identifying and implementing solutions 2007, Immel Resources LLC

Common Problems (1 of 4) Source: Apollo Root Cause Analysis, DL Gano, Apollonian Publications, Yakima, WA, 1999 • Only 20% of population are effective problem • solvers (up to 30% in some industries) Key: Do not ask people to change their minds, but expand on what they already know 2007. Immel Resources LLC

Common Problems (2 of 4) • People stop too soon, before they understand causes • “Root cause” myth – Assumes problem born from one source, and that causes are linear – Seeking solutions before knowing causes 2007, Immel Resources LLC

Common Problems (3 of 4) • “Illusion” of common sense and single reality – Everyone has unique perceptions, knowledge, strategies & conclusions • “Groovenation” – Too focused on being right, justifying beliefs • Storytelling – Ignores cause and effect, tells good story, exhibits group think 2007, Immel Resources LLC

Common Problems (4 of 4) • Poor writing – Poor problem-solving, rule-based thinking, “filling in a checklist” mentality • Categorical thinking – Prejudice; putting everything and everyone in a “box” 2007, Immel Resources LLC

Ineffective Problem Solving (1 of 2) • Incomplete problem definition – Boss or expert’s opinion simply accepted; busy tracking & trending but still failing miserably. Good problem-solving? Problem does not repeat. • Unknown causal relationships – Continue to ask “why” to point of ignorance; rather than rely on inferences or storytelling

Ineffective Problem Solving (2 of 2) • Focus on solutions – If problem not clearly defined, may solve wrong problem – Groovenation -- seeking what is familiar, favorite solution mindset -- preventing effective problem-solving – Authoritative and goal-driven individuals: Ready, Fire, Aim! mentality with categorical thinking/ groovenation 2007, Immel Resources LLC

Cause and Effect Principle • Each effect has at least two causes in form • • of actions and conditions An effect exists only if its causes exist at same point in time and space Causes and effects part of infinite continuum of causes 2007, Immel Resources LLC

Cause and Effect: An Example • Effects • Injury • Fall • Wet Surface • Leaky Valve • Seal Failure caused by caused by 2007, Immel Resources LLC Causes Fall Wet Surface Leaky Valve Seal Failure Improper Maintenance

Primary Effect or Event • Any effect of significance that we want to prevent from happening • Pain CB Injury CB 2007, Immel Resources LLC Fall CB Slipped CB Wet CB Leaky Surface Valve

Always at least Two Causes: Actions and Conditions • Primary effect caused by actions and conditions • Actions – Momentary causes bringing conditions together to cause an effect (action causes) • Conditions – Causes that exist over time prior to an action (preexisting conditions) 2007, Immel Resources LLC

Actions and Conditions • • Action • • Effect • Open Fire • • Condition Match Strike Dry Vegetation Caused By • • • 2007, Immel Resources LLC Condition Combustible Material Condition Oxygen

Support All Causes with Evidence or Use a Question Mark • Set a deadline to collect evidence • Incorporate as much knowledge as possible • • given time constraints Evidence: data that supports a conclusion 2007, Immel Resources LLC

Complete Problem Definition • • • What is the problem? When did it happen? Where did it happen? What is the significance of the problem? Not “who” or “why” Who places blame, Why is part of analysis 2007, Immel Resources LLC

Effective Problem-Solving • Define the problem • For major problems, create a cause and effect chart – Similar methods use logic trees, or fishbone diagrams • Identify effective solutions • Implement the best solutions 2007, Immel Resources LLC

Identify Effective Solutions üPrevent recurrence üBe within your control üMeet your goals and objectives ü Solution does not cause unacceptable problems ü Solution prevents similar occurrences, including at different locations ü Solution provides reasonable value for its cost 2007, Immel Resources LLC

Solution Guidelines • Solutions should always be specific actions • Don’t include solutions such as “review, • analyze, or investigate” (copout) Avoid denial and don’t say that you don’t know what the causes are. Implement mitigating solutions until you can investigate further. 2007, Immel Resources LLC

Avoid These Favorite Solutions • • • Punish Reprimand Replace broken part Investigate Revise the procedure Write a new procedure • Change management • • • program (re-engineer it) Redesign it Put up a warning sign Ignore it -- stuff happens 2007, Immel Resources LLC

What Favorite Solutions Mean • You may be in a rut • Chances are that the problem will repeat itself • Favorite solutions usually mean you have • identified your favorite causes Revisit your ideas -- may have missed something or made an assumption 2007, Immel Resources LLC

Word to the Wise • Sometimes solution may do nothing -- causes are • • unique, probability of repeating may be low Right solution is one that meets our criteria About 5 -6% of time, not capable of finding solution (knowledge of work processes we control about 95%) 2007, Immel Resources LLC

Realities • Sometimes we simply don’t know what • • happened (although we may know in time) We stop looking because task is too expensive, time consuming or difficult When this happens, devise plan to capture more information and causes, so if problem repeats, we will know more causes 2007, Immel Resources LLC

Review • Common problems • Understanding causes • Problem definition • Identifying and implementing solutions 2007, Immel Resources LLC