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 Categorical thinking 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 Causes Injury caused by Fall Fall caused by Wet Surface Wet Surface caused by Leaky Valve Leaky Valve caused by Seal Failure Seal Failure caused by Improper Maintenance 2007, Immel Resources LLC

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

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 (pre-existing conditions) 2007, Immel Resources LLC

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

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 Prevent recurrence Be within your control Meet your goals and objectives Solution does not cause unacceptable problems Solution prevents similar occurrences, including at different locations 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 Change management program (re-engineer it) Reprimand Redesign it Replace broken part Put up a warning sign Investigate Ignore it -- stuff happens Revise the procedure 2007, Immel Resources LLC Write a new procedure

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