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Jessica Peel

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Top 6 Sure-Fire Ways To Derail Your RCA Program

Posted by Jessica Peel on Thu, Nov 05, 2015 @ 07:11 AM

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Topics: rca success

"Incident Investigation" Training Versus "RCA Facilitator" Training

Posted by Jessica Peel on Thu, Oct 08, 2015 @ 08:10 AM

We occasionally receive questions to clarify the difference between our Incident Investigation training course and our RCA Facilitator course so we thought we would address some of the most commonly asked questions in this Q&A-style article. We hope you find it helpful. And if you have any questions, as always, please don’t hesitate to contact us.

How is the “Incident Investigation” course different from the “RCA Facilitator” course?

The Incident Investigation course covers the process of identifying, obtaining, documenting, and preserving the raw data related to an incident, then constructing a general timeline of the incident. 

The RCA Facilitator course then trains our students on how to sort through this data using cause and effect principles to identify causes that are relevant and formulate workable solutions, or preventative measures, to prevent recurrence. There is also emphasis in the RCA Facilitator course on facilitation skills necessary to conduct the Apollo Root Cause Analysis methodology process.

What are the benefits of the Incident Investigation course? bigstock-architecture-and-home-renovati-82683266_Resized

Without truly understanding the key elements and possessing the necessary skills to conduct a thorough, effective investigation, people run the risk of missing key causal factors of an incident while conducting the actual analysis. This could potentially result in not identifying all possible solutions including those that may be more cost effective, easier to implement, or more effective at preventing recurrence. The Incident Investigation course equips students with the knowledge and skills to conduct a proper investigation to prevent this from happening.

Why it is important for people to attend the Incident Investigation course?

Students will learn the key elements and develop the skills necessary to conduct and document a thorough, effective investigation ensuring all the pertinent information is available for the actual root cause analysis process. 

Students will learn:

  • The nature of undesirable incidents and why they often repeat
  • The value of a thorough, effective investigation – Why spend the time?
  • Investigation lead and team selection – Matching individual traits and skill sets to the needs of the investigation
  • The roles, or functions that must be filled to ensure thoroughness and reliability of data
  • Possible sources of incident information and how to optimize the value and reliability of incident facts and evidence
  • Demonstrations of misconceptions about the reliability of evidence and how to avoid them
  • Critical interviewing skills for discovering valuable incident information without inadvertently tainting the outcome
  • Options to ensure timely incident response so that valuable evidence can be preserved and collected
  • The value of developing and using standard templates for use throughout the investigation process
  • How to create an incident timeline using multiple sources of information
  • Importantly, scaling the investigation effort based on the significance of the incident to avoid wasting precious resources while ensuring investigation thoroughness
  • Hands-on individual and group exercises for practicing the key elements of the knowledge and skills listed above

Are there any prerequisites for the Incident Investigation course?

No. Students can take the Incident Investigation course on its own, or combine it with the RCA Facilitator course if they wish to learn the ins-and-outs of the Apollo Root Cause Analysis methodology as well. The Incident Investigation course is designed to stand on its own and depending on a person’s role, they may only need to attend one or the other, or both.

Is there an option to train my team in Incident Investigation via a private, onsite course?

Yes. We can work with a team within a company and create a customized Incident Investigation training course that takes into account their specific processes, triggers, industry, regulations, goals, stats of their HSE incidents, and incident severity tiers, and develop a course to their definitions and templates that can then be used to train staff across the company.

For more information, please contact us.

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How To Embed A Root Cause Analysis Program Into Your Organization

Posted by Jessica Peel on Wed, Sep 23, 2015 @ 03:09 AM

 Click on the infographic for a PDF version. 

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Five Problems Your Quality Control Department Might Not Realize They Have

Posted by Jessica Peel on Sat, Sep 19, 2015 @ 01:09 AM

Author: Jack Jager

When it comes to problems with quality in your operation, there are the obvious red flags—unhappy clients, defective products, poor reputation, delays, and exorbitant costs, to name a few. But there are other more subtle signs that your quality control department has room for improvement.

Your QC Department Looks Like a Firehouse

Those of us who work in quality control can easily fall into the pattern of fire fighting—running from one issue to the next, solving each problem in the near-term as it crops up. This can work okay for a time, but it’s not a great long-term strategy. When you only focus on solutions and never get down to the root causes that are creating your issues, you will find that the same types of issues keep occurring. “An ounce of prevention is worth a pound of cure” should be the mantra of every QC department. It’s worth the extra time up front to get at the root causes of an issue.

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Your Quality Folks Aren’t Talking Cents

The universal language of business is dollars and cents, so if your quality control department isn’t translating your issues into actual cost to the business, they might not be heard. For example, you might calculate the cost of the time it takes to close different types of exceptions and add that information to your efficiency evaluations.  

There Is a Veil Over the QC Department

Sometimes the quality department is treated differently than manufacturing, engineering, or facilities when it comes to accountability. But it’s very important that QC personnel and their equipment are held to certain standards, too. While QC is often responsible for finding solutions, they also need to be held responsible for their share of the causes—for instance, the impact to the supply chain if raw materials or final product testing is not completed effectively. If there has never been an evaluation of your QC department’s process, it’s definitely time to QC your QC.

Your QC Department Sits in an Ivory Tower

Quality folks can do a much better job if they receive training in other areas, including manufacturing, validation, and project management. When a quality person is too specialized, it can prevent them from seeing the whole picture and finding more comprehensive solutions. If your QC department tends to be resistant to change, that might be a sign that it’s time to expand their horizons with some additional training outside their primary field of expertise.

Anything Short of Total Failure Is Considered Success

Let’s say you work for a chemical plant that manufactures plastic bags. You make a polymer that requires water, but the water you’re using has a bad bacteria in it. There is a corporate requirement that the water be clean, so the bacteria is a problem. However, the finished material passes the test even though there was a deviation earlier in the manufacturing process. So is it really a problem after all? If your client sees a pattern of failure within your process, they will begin to believe that you aren’t truly concerned with quality, even if the final product technically meets the specifications. Make sure that you’re taking all issues seriously, even if they don’t seem to affect the final outcome at first glance.

If any of these scenarios sound familiar, download our eBook 11 Problems With Your RCA Process and How to Fix Them in which we provide best practice advice on using Apollo Root Cause Analysis to help eliminate problems in your QC process and beyond.

Auditing Your RCA Program

Posted by Jessica Peel on Thu, Aug 27, 2015 @ 03:08 AM

Author: Kevin Stewart

I recently wrote an article about auditing root cause analysis (RCA) investigations, and it only seemed appropriate to follow up with advice on auditing your overall RCA program. Let’s go back to the dictionary definition of “audit” -- a methodical examination and review. In my mind this definition has two parts: 1) the methodical examination and 2) the review. audit_your_rca_program_image

It might help to compare this process to a medical examination. In that case, the doctor would examine the patient, trying to find anything he can, either good or bad. This would include blood work, reflex test, blood pressure, etc. After that examination he would then review his findings against some standard to help him determine if any action should be taken. Auditing an RCA program is no different; first we must examine it and find out as much as we can about it, then we will need to review it against some standard or measure.

In my other article I discussed at length the measures against which an RCA investigation could be judged. Those still apply, and one of the program audit items can and should be the quality of the RCA investigation.

Now we are faced with determining the characteristics of a good program. A list of characteristics is given below:

  • Quality of RCA investigations
  • Trigger Levels are set and adhered to 
  • Triggers are reviewed on a regular basis and adjusted as required to drive improvement
  • A program champion has been designated, trained and is functioning
  • Upper management has been trained and provides invloved sponsorship of the program
  • Middle management has been trained and provides involved sponsorship of the program
  • The floor employees have been trained and are involved in the process
  • The solutions are implemented and tracked for completion 
  • The RCA effectiveness is tracked via looking for repeat incidents
  • Dedicated investigators / facilitators are in place 
    • Investigators are qualified and certified on an ongoing basis
  • All program characteristics are reviewed / defined / agreed to by management and include: An audit system is defined, funded, and adhered to
    • Resource requirements 
    • Triggers
    • Training requirements are in place and funded
    • Sponsorship statements and support
  • The RCA program is incorporated into the onboarding and continuous review training for new and existing employees

The next step in developing an audit is to generate a set of items that your program will be gauged against. This list can come from the items above, your own list, or a combination of the two. Once you have a final list of items to audit against, you need to generate a ratings scale. This can be a pass/fail situation or a scale that gives a rating from 0 to 5 for each item. This can allow you to give partial credit for some items that may not quite meet the full standard. You can also provide a weighting scale if deemed appropriate. This would mean that some of the items in the list had more importance or weight in the scoring based on the local feelings or culture of your facility. This scale can be anything you wish, but be cautious about making the scale too large. Can you really tell the difference between a 7 or 8 in a 10-point scale? Perhaps a 1 – 4 scale would be better?

Next, develop a score sheet with each item listed and a place to put a score for each one. It’s handy to add some guidelines with each item to give the reviewer a gauge on how to score the item. A sample of such guidelines might look like:

0    Does not exist

1    Some are in place but not correct

2    Many are in place and some are correct

3    All are in place but only some are correct

4    All are in place and most are correct

5    All are in place and correct

Don’t forget to leave a space for notes from the reviewer to explain the reasons for partial credit. With this in place either next to each item or easily available as a reference, it helps ensure consistency in the scoring, especially if multiple people will be scoring your RCA program.

The goal for a standardized audit process would be that several different people could independently review and score a program and would come up with essentially the same score. This may seem like a simple thing, but it turns out to be the largest issue because everyone interprets the questions slightly differently. There are several things you can do to minimize discrepancies:

  1. Provide the information above to help.
  2. Require the auditors to be trained and certified by the same process / people and then have them provide a sample audit and check it against the standard. Review and adjust any discrepancies until you are sure they will apply the same thinking against the real audit.
  3. Always ensure that if multiple auditors are used in a program review, at least one has significant experience to provide continuity. In other words, don’t allow an audit to be done with all first-time auditors.

With these measures in place, all you have to do is review the RCA program against your list, score it, and have some sort of minimum for passing. Likewise you’ll want to have some sort of findings report where the auditor can provide improvement opportunities against the individual items instead of simply saying: “did not pass.”

These measures will ensure that the program is gauged against a consistent standard and can be repeated by multiple auditors. There will always be differences if multiple people are auditing an RCA program, but by utilizing the steps above these differences can be minimized to provide the highest level of credibility for the audit.

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Nine Thought-Provoking Questions To Ask About Your Safety Program

Posted by Jessica Peel on Tue, Aug 11, 2015 @ 00:08 AM

According to a definition applicable to the insurance industry, an accident is an event which is not deliberately caused and which is not inevitable[1]. A typical insurance policy has a significant number of exclusions that are the “evitable” circumstances.

Logically, any situation which is reasonably evitable and which likely has harmful consequences ought to have been identified.

Those of us who are the safety leads at our organizations have a lot riding on our shoulders. That pressure gives us a constant incentive to improve, because we can never do our job too well. This post highlights some of the questions we ask ourselves that ultimately ladder up to the larger question, “How can we do better?” 

For example:

bigstock-work-injury-claim-form-86169068_small1. How many injuries have been recorded at your location(s) in the past year? 

The often cited adage “you can’t manage what you don’t measure” is pertinent here. 

Data is king; knowing how many injuries have been recorded at all locations for your enterprise will not only enable comparisons between sites and an analysis of the common and different causes, but also can be used to motivate greater improvements at the lesser site(s).

2. Does that number include the near misses? Or aren’t they reported? 

The expression “near miss” clearly indicates a close call, but all too frequently it occasions relief rather than analysis. This is because people look on the bright side and put the escape down to good luck. Overcoming this complacency is a challenge. The issue for the organization is that all too often these events are simply not reported, or reported too long after the event to enable an accurate re-construction of the event. This compromises the ability to derive any “lessons learned” that could generate appropriate improvements.

3. Would you know if the near misses hadn’t all been captured? 

The simple fact is that “you don’t know what you don’t know”; this situation calls for a process of acknowledgement, if not reward, so that the incident participants have no fear of punitive measures being applied when they report the circumstances of the near miss. This necessitates the clear communication of a “no blame” philosophy. If employees feel that they will suffer some negative consequence they will be loath to volunteer information about the near-miss incidents.    

 4. Is your record improving?

Unless the data is being promptly collected, accurately recorded, and analyzed, trending will not be possible and improvement not apparent. The objective is to have a demonstrable improvement evidenced by the statistical record. The accuracy of this data will depend not only on the creation of the “no blame” culture but also on the refinement of the methodology and tools employed in the investigation of incidents. 

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5. Have you set targets for improvement? 

Establishing fresh targets and goals periodically is the only way to ensure the improvement is continuous. Even a site with an almost blemish-free record needs to be totally vigilant about the changes that are being undertaken there. Change is the only constant and, regretfully, is also an opportunity for hazards and harm to arise. The fresh targets ought to be reflected in the key performance indicators (KPIs) applicable to the respective safety roles for your enterprise.

6. Are there any unidentified hazards facing the personnel? 

Only systematic inspection and auditing processes will reveal previously unrecognized hazards. The certainty that you have minimized risks and hazards will grow proportionally as the employees who encounter the hazards demonstrate their ownership of the safety program. They have the ultimate control of the likely causes of their own potential harm. But whether the personnel have accepted ownership of the program or not, it is incumbent on the responsible officer to implement the specific hazard identification process. This will necessitate close engagement with the plant or equipment operators, technicians, or any person with an exposure to their work environment. Yes, that’s everybody.

There are also hazards of the interpersonal type that may never be apparent to the observer; bullying and stress are increasingly the causes of substantial claims for compensation and can only be detected by building a trusting relationship with the personnel and developing confidentiality protocols.

 7. How effectively are you learning the lessons from each “accident”? 

The parlance “lessons learned” is commonplace but not consistently applied. These are words that express an intention to make improvements in the organization but all too often focus on the actors in the event rather than the systems and processes that are central to the business.

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“Human error” is the categorical expression most commonly heard when blame is being attached and represents a plethora of mistakes that humans make. Discovering that precise error in this unique event and the reason(s) for it can add value and lead to preventive measures being implemented -- but not in isolation, not as the so-called “root” cause.

Perfect knowledge, perfect understanding, and perfect operation by all humans in the enterprise are a fantasy. Humans are fallible and accidents will happen if the situation exists.

 

8. Which causes are “evitable”? 

The “evitable” causes are simply the known, designed, or planned components of the situation – the hardware, equipment, systems, and processes that are used in the production of the goods or service in question. These are all possible causes which, with a human interface, can create hazards with potential negative safety consequences. They are the opportunities for establishing controls or installing barriers that prevent harm.

The safety program needs to identify improvements to the systems or equipment, which would at least minimize the likelihood of a repeat occurrence given the fallibility of the human factor. What are the possible failure modes or the mis-operations that could occur?    

9. Can you demonstrate that you have thoroughly and methodically analyzed every event in order to prevent recurrence?

A thorough and methodical causal analysis is not possible without the creation of a cause map. This is best achieved through a mediated process involving the pertinent stakeholders and subject matter experts and identifying and arranging the proven causes in a logical manner. It needs to be both comprehensive and comprehensible to win the confidence of the decision makers who are looking for recommendations that will effectively modify, substitute, or eliminate the causes.

There are regulatory authorities that have expectations in this sphere and will want to see the assiduous application of a method that has proven to be effective regardless of the industry or problem-type.   

[1] http://www.businessdictionary.com/definition/accident.html#ixzz3QpGESuXU

 ARMS Reliability is here to help you answer these questions. Our free eBook "11 Problems With Your RCA Program And How To Fix Them" is a great first step to figuring out “How can we do better?” Download it here.

 

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8 Tips to Overcome Barriers & Implement Lasting Solutions in Your RCA Program

Posted by Jessica Peel on Tue, Jul 21, 2015 @ 01:07 AM

Click on the infographic for a PDF version. 

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What is the Value in Identifying Root Cause?

Posted by Jessica Peel on Tue, Jul 09, 2013 @ 10:07 AM

 

By Jack Jager

Understanding the root cause of a problem is the purpose of many or all investigations. However, the concept of “root cause” suggests that there is only one, singular cause that is at the “root” of any problem.

 

Searching for Root Cause

The root cause concept and how it is applied often leads to this perception of a singular cause. For example, the statement “What is the root cause of the problem?”

So what is “root cause” and how is it defined? It can be difficult to find a clear and precise definition. The following  well-defined description reveals something very simplistic;  “Root Cause can be described as that cause, which if it were controlled or eliminated would make the problem go away. Therefore it may be considered a root cause”.

This is an interesting concept as it can be applied to a number of causes within a cause and effect chart, therefore, it can be said that there are many “root causes”.

Cause and Effect analysis and Reality charting indicates that a problem doesn’t occur from a single cause, but for any problem there can be many cause and effect relationships that can trigger a problem. Therefore how do we know which of these causes is the root cause?

If you were to ask this question to various people, there may be a number of different answers.  One person may think the root cause is one thing, while another would consider the root cause to be something else. Each party may in fact be right. So how can a “root cause” be assigned unless we are certain that a solution will prevent the problem from recurring?

Let’s look at the example below:

What are the causes of a fire? For a fire to occur there must be certain conditions present. Each of these conditions are a contributing cause of the fire.

  • There must be oxygen present (a conditional cause)
  • Fuel to burn (a conditional cause)
  • An ignition source, such as a match or lighter (also a conditional cause)

All of these causes can exist in harmony with each other and can do so for some time.

It is only when an “action” cause occurs, such as the lighting of a match that the fire will actually occur.

So what is the “root cause” here?

If we apply the definition provided above for “root cause” here, then by eliminating the oxygen, there would be no fire. Therefore “oxygen” is a root cause of the fire.

If you were to remove the combustible material, fuel, then this too will satisfy the definition requirement. The problem would not reoccur. Therefore “fuel” is also the root cause of the fire.

If you were to also remove all of the ignition sources, then there would be no possibility of a fire. This too satisfies the definition requirements. Therefore the “ignition source” is the root cause of the fire.

If no match was to be lit, then there would be no fire. Therefore “the lighting of the match” must be the root cause of the fire as well.

Based on this example, there are potentially four root causes and each of them satisfies the root cause definition. This can be quite confronting in a sense to recognise that there are many potential root causes for a problem. It is, however, liberating too because now you have many potential corrective actions rather than just one.

How often have you heard someone ask “What is the root cause of the problem?” and “you can’t control the problem until you have identified what the root cause is”.

How do we determine which causes to control? In the fire example, who will determine the control or controls to put into place? It’s unlikely that oxygen will be eliminated, as this can be a very costly and difficult process (although we do use this concept in confined spaces).

Can we control the combustible material? If we were to eliminate the fuel then would we have an effective control? This is possible in some cases but not in others.

What about the ignition sources? If there were no lighters or matches present or available, then there would be no fire. Do we have the ability to remove these?

If we could stop the persons action from occurring then we would also have controlled the possibility of a fire happening.

Based on these rationales, which of these controls should be implemented? Is this decision governed by certain criteria? And then the question about what we can control also comes into play.

So what criteria can we use to determine our choices?

  • Money - it needs to be cost effective
  • Safety - it needs to be safe
  • Easy - if possible it should be easy to do
  • Quick - being able to do it quickly has merit
  • Doesn’t cause other problems – at least not unacceptable problems
  • Is an ongoing fix – and is not a band-aid. The solution will fix the problem for today and tomorrow, as well as next week and next year.

and other criteria may also be considered.

The above criteria are taken into consideration when making the decision about which solutions to implement. At the end of the day, it is important to have an understanding of the problem and how many of the causes you need to control to prevent recurrence.

Did the notion or understanding of what the “root cause” is come into consideration when making the decision about which solutions to implement?  No, therefore what is the value of identifying “root cause”?

In my mind, it is the concept of “root cause” that is important. Applying this concept requires us to understand the problem as completely as possible, before we make decisions about corrective actions. If we do this, then we are in the best possible position to make good decisions about which corrective actions to implement. 

The decision of which solutions to implement is a choice. It is a choice we make according to a set of criteria. It is based on the answers you acquire when applying the criteria questions that allow you to be objective in your decision making process to find the best solution.

In Summary

In many ways the concept of “root cause”, whilst being important in the broader application, is often a misnomer when used to describe the critical cause for a unique incident. It is not the only cause. Other causes must also exist.  

At the end of the day it is your choice about which causes you wish to control. Therefore it is important to remain objective in this decision making process, via utilising a set of criteria, and applying them to all possible solutions. Let the answers to the criteria questions determine what the best solutions are, and that will determine what you consider to be the “root cause” of the problem.

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Topics: root cause analysis, rca skills, root cause analysis skills, rca facilitation, root cause investigation, critical rca skills, root cause analysis program, root cause facilitation

I Wonder Why – 5 Whys

Posted by Jessica Peel on Fri, Jul 05, 2013 @ 09:07 AM

By Kevin Stewart

As is so often the case, sometimes we simply forget to wonder why

 

5 whys and Root Cause AnalysisHave you heard the one about the daughter that saw her mother cut the ham in half before cooking it at the Christmas gathering and asked why?  “Well mom said we’ve always done it that way, but Grandma is here and I learned from her, so she can tell you why!”  So the daughter asks Grandma, “Why does mom cut the ham in half before cooking it?”  Grandma says, “Well Dear, I’ve always done it that way and I suppose your mother is just following suit. We’re in luck though, Great Granny is here and I learned from her, so why don’t you see if she knows.”  So she goes to Great Granny and asks, “Why does mom cut the ham in half before cooking it?”  “Oh dear!” says Great Granny.  “That is simple. When I was cooking Christmas dinner I didn’t have a pan big enough so I cut it in half and put it into two pans!!”

Perhaps we have forgotten to wonder why about 5 Whys?  I’m all for using the right tool for the right job, but what job was 5 Whys designed for? 

According to Wikipedia, it was developed by Sakichi Toyoda  and was adapted for the Toyota Production System (TPS) by Taiichi Ohno.  While not an expert on 5 Whys by any stretch, I do know the premise of TPS was to eliminate waste.  Everything was predicated on that simple notion, and all of the other tools were built to help them achieve that goal.  So I don’t think it is a giant leap to make the assumption that the 5 Whys was part of that.   I’m always interested in others thoughts, so I offer up that the 5 Whys was not designed as a tool to solve complicated problems that have many twists and turns to root cause, but rather as a simple tool that was supposed to help the operator on the floor become engaged in the problem solving methodology, and in the process, eliminate waste. 

If this is truly the case, then one can make the assertion that just because you have a hammer – everything isn’t a nail.

By this I mean that the 5 Whys can be used successfully in a simplified manner where the consequences are low, the time is short, and the tool is used close to the time of the incident.  This would mean that there would not be a lot of evidence or verification necessary because the consequences are low. In addition, suggested changes could be reviewed by supervisors and operators for validity before being put in place without a fear of major consequences.

So that leads us to the question – is the biggest problem with 5 Whys that in many cases we may be attempting to solve problems the tool wasn’t designed for? 

If it truly was designed for an operator to fix small problems that he recognized at the time they happened, then he wouldn’t have a lot of time. The problems wouldn’t be big and complicated, and the consequences were only that he would continue to waste time and money until the problem got fixed.  

In summary:

Let the consequence determine the need for validation. The 5 Whys are just “caused by…” statements that we don’t need to delve into when using the method for its intended purpose - analyzing a simple problem.

 

RC Simplified™ is the perfect tool to conduct 5 why investigations. It is free, readily available and simple to use. If the investigation requires a report or follow up, simply convert RC Simplified™ to an Apollo investigation in RealityCharting®. This provides for reporting, documenting actions and finding solutions. They are the perfect combo - 5 whys + RC Simplified™

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Topics: root cause analysis, root cause analysis skills, root cause investigation, 5 Whys

When is the Time Ripe for Root Cause Analysis?

Posted by Jessica Peel on Wed, Jun 12, 2013 @ 08:06 AM

 

By Ned Callahan

When is the right time for Root Cause AnalysisEvery organisation has unresolved problems. Some are greater than others.

The prospect of undertaking an RCA usually arises because there has been a persistent problem, a repetition of a failure or other “significant” event.

A problem which has never been “solved” will continue to cause headaches within the organisation and may well have very significant financial consequences. The question arises, why has it never been resolved?

  • Is it a matter of scarce resources?
  • A lack of expertise?
  • or, fear of the unknown?

More pressing priorities often take the lion’s share of available resources and this particular problem continually falls down the list. Those ‘other’ problems are more important because, generally, they have greater or more immediate impacts.

Recognition that there is a lack of expertise in the organisation to properly tackle the problem is not uncommon. This leads to a lack of confidence that an analysis will be productive or “successful” so why allocate already scarce resources? Will it just amplify the frustration? If it requires the engagement of external investigators, the whole gamut of decision-making about “who?” and “which method?” and “who’s paying?” confronts the organisation.

Work-around’s for managed problems

Perhaps the problem has actually become manageable. The consequences or impacts may already have been limited by some measures which contain or control the problem. Typically, this method of limiting the impacts becomes the norm and in no time at all the expression: “it’s always been like that” will be the standard response to queries about the persistent fault. This is the signal that we are coping in spite of the problem – a “work-around” is feasible.

Kick starting the process

These scenarios can be resolved quite simply. A single person can begin to determine whether an RCA is warranted by actually beginning the process. That requires the problem to be simply stated as the name or title of the ‘supposed’ problem. For example, two or three word expressions such as “broken pump shaft” or “repeated reportable emissions” or “declining customer satisfaction”. This simple focal point can generate a useful discussion about the “real” problem and that discussion can either begin to narrow towards causes or broaden towards the “big picture”.

But it’s best to first identify the simple facts about the location and time of the problem or incident and then to thoroughly quantify the impacts or consequences. Remember that this person is trying to determine whether an RCA is warranted and that necessitates measurement. Typical types of impacts; are Reputation, Financial, Safety, Legal, and Shareholder Confidence.  In fact, the initial problem may well be replaced by one of the negative impacts as the “real” problem of which it becomes a cause.

Once these have been calculated (or estimated) and the problem quantified, you can then justify a recommendation for the analysis to continue and be formalised by the establishment of a team, a facilitator and a timetable or to suspend the analysis on the grounds that it hasn’t (yet) replaced other “issues” on the list.

Activation of Triggers

In a mature organisation, the decision whether or not to conduct a “formal” RCA is determined by the activation of triggers which are particular to that enterprise or organisation. In other words, the impacts such as Reputation, Financial, Safety, Legal and Shareholder Confidence are being felt and are more or less measurable.

For Reputation, the trigger might be more than five negative media references in the preceding twelve months. For Safety it may be any “Lost Time Injury” or “First Aid Event” and/or “Near Miss’’. For Legal, it might a predetermined number or value of litigations and fines incurred.

There is no definitive level or standard. The definition of triggers for an organisation is the recognition of its own threshold or degree of tolerance for negative consequences, its own “lines in the sand”.

In summary

The question of when to do an RCA is most easily answered by the response:

“when you will no longer tolerate the consequences of the problem and are therefore determined to prevent its recurrence or, at the very least to minimise any negative consequences”.

And that will only happen if a thorough and methodical process is undertaken to discover all the causes of the problem and to clearly illustrate the relationships between them. Clearly, there are causes you have not identified yet. There is something you don’t understand about the problem. Otherwise you’d have already identified effective solutions.

Keep in mind that sometimes the cost of prevention outweighs the cumulative total of historical and anticipated losses and a business case for the implementation of a particular solution doesn’t pass the ROI test. In other words, after the implementation of what are considered to be “reasonable” corrective actions and controls, management will be prepared to “self-insure”, to tolerate the risk of recurrence. 

This can be done confidently after the RCA has revealed all the causes and all the possible solutions have been evaluated but not before.


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Topics: root cause analysis, root cause investigation, root cause analysis program