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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? 

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.

 Click on the infographic for a PDF version. 

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.

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.

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. 

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.

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:

1. 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. 

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.

“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.

 

Click on the infographic for a PDF version. 

Author: Jack Jager

While there are three main reasons organizations typically perform Root Cause Analysis (RCA) following an issue with their asset or equipment, there are a whole host of other indicators that RCA should be performed. 

Odds are, you’re recording a lot of valuable information about the performance of your equipment - information that could reveal opportunities to perform root cause analysis, find causes, and implement solutions that will solve recurring problems and improve operations. But are you using your recorded information to this extent?

First, let’s quickly talk about three reasons why root cause analysis is typically performed. 

1. Because you have to

There may be a regulatory requirement to demonstrate that you are doing something about a problem that’s occurred.                                    

2. You have breached a trigger point

Your own company has identified the triggers for significant incidents that warrant root cause analysis. 

3. Because you want to

An opportunity has presented itself to make changes for the better. Or perhaps you’ve decided you simply don’t want to lose so much money all the time.

At the core of all industry is the desire to make money. Anything that negatively impacts this goal is usually attacked by performing root cause analysis.

I was having a conversation with a reliability engineer at an oil and gas site, and I asked him what lost opportunity or downtime might cost that company over the course of a year. He said it was in the vicinity of three quarters of a billion dollars. $750,000,000. Is this a good enough reason to perform root cause analysis? Even a 10% change would have a huge impact on bottom line figures.

The monetary impact to the business was of course not due to any single event, but to a multitude of events both large and small.

Each event presents itself as an opportunity to learn and to make any changes necessary to prevent its reoccurrence. Once can be written off as happenstance… things happen, serious or minor, and that’s life. But to let it happen continuously means that something is seriously wrong.

While these are all valid reasons to perform root cause analysis, there are at least ten more tell-tale equipment-related clues that an RCA needs to happen – most of which can be identified through the information you’re probably already recording.

Here are ten tell-tale signs that your organization needs to perform Root Cause Analysis:

1. Increased downtime to plant, equipment or process.
2. Increase in recurring failures.
3. Increase in overtime due to unplanned failures.
4. Increase in the number of trigger events.
5. Less availability of equipment.
6. High level of reactive maintenance.
7. Lack of time… simply can’t do everything that needs doing.
8. Increase in the number of serious events… nearing the top of the pyramid.
9. Longer planned “shut” durations.
10. More frequent “shut” requirement.

These indicators imply that we need to be doing more in the realm of root cause analysis before these issues snowball.

If you can identify with some of these pain points, download our eBook “11 Problems With Your RCA Process and How to Fix Them” in which we provide best practice advice on using RCA to help eliminate some of these problems.

Author: Kevin Stewart

Audit is defined in the Merriam-Webster dictionary as:  “a methodical examination and review.” When we talk about auditing your Root Cause Analysis (RCA) investigations, we mean just that -- a methodical examination and review. This is easier said than done, especially without some sort of standard to gauge against. If we establish a standard by which we gauge the quality of an RCA, the audit then becomes a simple matter of checking the RCA against the accepted standard and then determining how well it meets that standard. This post is all about helping you establish a standard, and we’ll even give you a free score sheet template to get you started.

Could you have the worst-looking RCA in the world and meet none of the criteria, but have an effective solution that: 

• prevents reoccurrence,
• meets our goals and objectives,
• is within our control, and
• doesn’t cause other problems?

Sure, and it is hard to argue with success. I doubt anyone would say: “Even though this solution will prevent the problem from recurring, it comes from an RCA that doesn’t meet our stringent, high-quality metrics so we can’t use it.” This scenario is entirely possible, though the odds of it are unlikely. If we have a set of measures to check an RCA against to ensure it meets some quality standards, the probability of an effective solution coming from that RCA is greatly increased. 

So what characteristics of an RCA are important?

Here are some questions to consider: 

(If you need a refresher on some of these points, I’ve included the relevant page numbers from the eBook “RealityCharting™: Seven Steps to Effective Problem-Solving and Strategies for Personal Success” by Dean L. Gano.)

• Do the causes pass the noun-verb test? (page 83)

• Do the causes have a lot of unnecessary words or descriptors?
• Do the causal elements pass all logic tests? (page 108)
  • Space-Time Logic Check 
    • Do the causes of this effect exist at the same time? 
    • Do the causes of this effect exist in the same place?
  • Causal Logic Check
    • If you remove this cause, will the effect still exist?
      If the answer to this question is no, then the cause is necessary for the causal relationship and should stay on the chart. If the answer is yes, it should be removed or repositioned.
• Are there any rule violations? If so, what are they and do they pass the minimum standards? Rules to be included are:
  • Are any of the cause boxes empty?
  • Are there any unconnected causes floating around in the chart?
  • Has each cause been identified as an action or condition?
  • Does each effect meet the 2nd principle (causes exist in an infinite continuum – there is an action and a condition for each effect)?
  • Have all conjunctions been eliminated? Remember that “and” is often interpreted to mean “caused,” which can leave too much room for misunderstanding and error. (pages 67-68)
  • Does each cause have the appropriate supporting evidence to justify its inclusion in the chart?
  • Does each branch have some type of stop identified for it? Below are the five potential stops: (pages 88-89)
    • Question Mark – more information needed; an Action Item is created.
    • Desired Condition – there is no need to keep asking why.
    • Lack of Control – something over which you or your organization have no control, for example “laws of physics.”
    • New Primary Effect – a separate analysis is required.
    • Other Cause Paths More Productive – continuing down this path would be a waste of time.
• Does the solution matrix fall into a typical mix such as:

• Have the solutions been judged against a standardized set of criteria with standard ranges to minimize the possibility of favorite solutions being chosen? (page 118-120)
• Has each solution been assigned to a team member and given a due date?
• Does the chart meet all of the four principles of causation? (page 36)
  • Causes and effects are the same thing.
  • Causes exist in an infinite continuum.
  • Each effect has at least two causes in the form of actions and conditions.
  • An effect exists only if its causes exist in the same space and time frame.
• Does the problem definition establish a clear dollar value significance that will let management make informed choices and approvals?
  • If a dollar value is not appropriate (safety near miss or potential fatality) does the problem definition establish a significant value?
• Have all of the action items been resolved? (Action items can include areas where more information is needed, there are evidence issues, or any manually entered items need to be resolved and deleted.)

The next step in developing an audit is to generate a checklist that your RCA 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 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.

Develop a score sheet with each item listed and a place to put a score for each one. Don’t forget to leave a space for notes from the reviewer to explain the reasons for partial credit. It’s handy to add some guidelines with each item to give the reviewer a gauge to score the item against. 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

With guidelines like these easily available as a reference on your score sheet, it helps ensure consistency in the scoring, especially if multiple people will be scoring an RCA.

Now all you have to do is review an RCA against your list, score it, and have some sort of minimum for passing.

This will ensure that each RCA is measured against a consistent standard that can be repeated by multiple people, though there will always be differences if multiple people are auditing RCAs. Differences can be minimized by either having only one person doing the audit or calibrating the audit, or by bringing all personnel together and scoring several as group so that all auditors understand the scoring nuances.

While I’ve provided a pretty thorough list of what to check for when auditing an RCA, my experience is that an RCA can meet all of the requirements above and still have some issues. The biggest one is that the logic may be correct but the causes may not, so the RCA can pass the tests but it won’t actually fix the issue. The fact is, humans are involved and we make mistakes. Sometimes the errors can be caused by inexperienced investigators that need more practice. Other reasons for error are some of the filters that we talk about, such as time constraints, preconceived notions or biases, language issues, etc. This means that there is still a component that needs to be reviewed by someone for general integrity and for things that a computer just can’t look for. This person can be an external corporate person, a contractor, or an internal resource.

RealityCharting™ has tools that are available to the reviewer to assist them in critiquing the analysis such as rules check, action item report, causal element view, and most importantly there is a dashboard.

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To assist you in creating your RCA score sheet, we’re offering a free template.

Author: Kevin Stewart

Oftentimes our differences can be a source of conflict and confusion, but in this article I’d like to explore how they can be harnessed to solve problems rather than create them.

“Everything will be fine if you’ll just do it my way.” At some point we have all probably said or thought something like this. Or maybe you’ve heard it from someone else (quite possibly your significant other). What is the underlying feeling or issue here? What we’re really saying is: “If everyone was just like me and thought the way I did, everything would be fine.” Of course, this is impossible. Neuroscience research tells us that no two brains are exactly alike, and to quote an article from Scientific American on this topic, “…if the apparatus that senses the world differs between two individuals, then the conscious experience of the brains wired to these sensors cannot be the same either.”[1] 

Good problem solvers need to be aware of this so they don’t fall into the trap of assuming that everyone knows what everyone else knows, or that everyone interprets information in the same way. I was channel surfing one day and spotted an interesting show about conjoined twins who share one body and most organs, but have completely separate heads (and therefore brains). When the interviewer posed a question, each twin responded in turn with different answers. This caused an ensuing disagreement between them.

These two people had as identical an upbringing and exposure to life and environmental factors as is humanly possible and yet they still thought differently.  If that doesn’t convince you that it’s impossible for two different brains to share the same perspective, I’m not sure what will!

Here’s an example of how two people can be having a conversation about the same thing and yet not be talking about the same thing at all. During a common exercise in one of my classes, a rousing discussion started about cleaning fish. Everyone except one bright student seemed to be on the same page. Everyone else got the feeling that this person was just being difficult, but something inside reminded me to get more information. After a few probing questions we discovered that we did not have the same perspective on the issue. This person had never been fishing and did not understand that “cleaning fish” implied gutting and preparing it for consumption. She couldn’t understand the exercise because her perspective of cleaning was to wash and in general clean the outside, so what did a knife have to do with it!

One more personal observation to cement this issue is a discussion I had with colleagues about the “Hierarchy of Controls” (pictured below for reference). 

One colleague stated that another must understand this concept since he has an engineering background, and all engineers would know this. I had to inform them that I also have a 30-year background in engineering, maintenance, and reliability but actually had never been exposed to the term either. So once again, the impossible situation of everyone’s perspective being identical rears its head.

While doing your root cause analysis, keep the perspective issue in mind. Ensure that you formulate the problem definition so that each perspective has a chance to be heard, and that the problem is a reflection of all of the perspectives of the team. While doing the root cause analysis, some may not speak up in the meeting but will have a different perspective, so as a facilitator it is your job to draw it out and ensure it gets voiced.

In my experience it can have a significant impact on a team’s understanding of a particular cause. Though sometimes we might wish everyone saw things exactly as we do, allowing for others’ alternate realities is actually key to building a more complete picture of your problem, thereby allowing you to find the best solution.

[1] http://www.scientificamerican.com/article/think-different-jan-11/

The lion and gazelle have to be at the top of their game each and every day. If they get lazy, they lose.

The Apollo Root Cause Analysis methodology can help you maintain a competitive advantage, but only if you use it completely and consistently.

How are you ensuring that you maintain and improve your lead?

Can you measure what you have achieved since your Apollo Root Cause Analysis methodology training, or has it become just another initiative that didn’t work?

You spent the time and effort learning a proven methodology that solves event-based problems every time, and perhaps it has become a company standard tool. But the creation of the reality chart and incident report are only steps on the journey. We also need to focus on creating an effective problem-solving culture (for alumni: page 109 in your manual). The culture part of the equation can be easy to overlook, but it is this holistic approach that will help you get the most out of the Apollo Root Cause Analysis^TM method.

If we do nothing after the initial implementation of the Apollo Root Cause Analysis methodology, entropy kicks in and the system begins to unravel. Any shortfall from the potential gain becomes considered “normal” and root cause analysis just gets accepted as another initiative that didn’t work.

With this in the back of our minds, we have to put supports in place to develop a solid platform on which incremental change can be applied to achieve ever greater gains.

To help enhance your company’s problem-solving culture and get maximum benefit from your Apollo Root Cause Analysis program:

1) Ensure your senior leadership team is fully aware of your efforts.

Try to get an influential sponsor to regularly mention root cause analysis in group communications. Remember that everyone’s reality is different, so time and energy spent with this team creating that common reality is going to pay dividends.

2) Implement Leader Standard Work.

(See chart below for an example) This ensures the ball is kept rolling from leadership down the chain. Developing formal, measured business processes can really help with this, along with good visual management tools.

*HOD = Head of Department

3) Increase awareness of the benefits and gains brought about by your successes.

Celebrate the gains!

4) Involve union and safety reps.

If this is done correctly, these folks can be your biggest evangelists. You can then use them as a resource. The “No Blame” approach of the Apollo Root Cause Analysis methodology should make it easier to sell.

5) Create a robust, visible, and measured action tracking system.

Unlike work orders that are in a CMMS, these actions have a tendency to fade away. Ideally you would create one place for all actions, making them easy to prioritize. 

Ultimately, you have to use it or lose it and these five tactics have the potential to help a great deal towards establishing a problem-solving culture and embedding it into an organization.