CAUSE ANALYSIS CA www.ioas.org

What do you know about CA? A tool for systematic investigation and analysis Reactive analysis Incident investigation – may apply to losses, failure, inefficiencies What went wrong? What were the causes? What changes should be made? Cause analysis helps identify what, how and why something happened, thus preventing recurrence. Diving deep to find the source of the problem - to avoid addressing just the symptom. Causes are underlying factors, are reasonably identifiable, can be controlled and allow for generation of recommendations. Various techniques may be used. www.ioas.org

Causes are those that can reasonably be identified. those management has control to fix. those for which effective recommendations for preventing recurrences can be generated. www.ioas.org

Inspector uses wrong version of the inspection form… The typical investigation would probably conclude “inspector error” was the cause, inform the inspector and give him the right form. But if the analysis stops here, it has not probed deeply enough to understand the reasons for the mistake. Not enough is known to prevent it from occurring again or to be sure it is not a widespread problem. An example www.ioas.org

There may be more than 1 cause of a problem… www.ioas.org

Many methodologies are employed in CA Complex Failure Modes and Effects Analysis (FMEA) Causal factor charting Statistical data analysis Fishbone or Ishikawa diagram Simple Five Whys May incorporate simple techniques from complex analysis simple cause and effect maps fishbone diagrams Complex analyses apply more to sectors such as health and safety, transportation industries, and manufacturing. Often employed by consultants who do not have an intimate knowledge of the company or industry Simple analyses are appropriate for sectors such as business processes where the person or team is very familiar with the entire system. A Cause Map provides a visual explanation of why an incident occurred.  It connects individual cause-and-effect relationships to reveal the system of causes within an issue.  A Cause Map can be very basic and it can be extremely detailed depending on the issue. www.ioas.org

5 Whys Problem Cause(s) Analysis Corrective actions www.ioas.org 5 Whys is a Cause Analysis Tool, not a problem solving technique. Focus on 5 Whys because it is appropriate for most of the types of issues we face in certification and accreditation which are generally less complex and the analysis is performed by people who are familiar with the system. The outcome of the analysis is one or several causes that ultimately identify the reason why a problem was originated. There are other similar tools that can be used simultaneously with the 5 Why’s to enhance the thought process and analysis. www.ioas.org

Why did the inspector use the wrong form? It was the only form he had. He has always used that form, no one ever commented. Why did he have only that form? The inspector manager did not provide inspectors with the revised versions. Why did the inspector manager not provide inspectors with revised versions? She doesn’t make the revisions. She doesn’t see reports. She didn’t know it was necessary. She never thought about it. Why did she not think about it? Not part of her training, job description, work instructions or procedures. www.ioas.org

The inspector has been using the wrong form for years The inspector has been using the wrong form for years. Why was this not caught? The review team did not know it was important. Why did they not know it was important? Use of current forms is not part of their training, was never mentioned before and they have no control over what the inspector does anyway. Why? Why? Why? www.ioas.org

In addition to asking why - writing it down may help the analysis. Wrong form Not noticed by reviewers Didn’t know it was important Didn’t have authority Inspector has old forms Manager did not know Write the problem down. Often it helps to use a cause-effect diagram Investigate, interview people, don’t rush to judgement or make assumptions. www.ioas.org

Fishbone diagram Had only old forms No one noticed Unaware of changes Reviewers not trained Unable to access current formats No one responsible Inspector uses wrong form Also referred to as Ishikawa diagram after the person who first used it. Cause 4 www.ioas.org Cause 3

5 Whys rules of thumb State the problem clearly. 5 is the number at which most causes are clearly identified. Do not worry about not meeting or exceeding 5 Whys. Follow your thought process to decide how many Why’s you need to get to the point where the cause is evident. This is an investigative process. You don’t need to answer all Whys at once. The outcome of 5 Whys (or other analysis) is a cause analysis, not the resolution. Corrective actions and effectiveness verification follow. A well defined problem is a half-solved problem www.ioas.org

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