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By Jack Jager

Giving the right name to your problem – in other words, defining it clearly – is the first step towards fixing it.

The naming of a problem before you actually start investigating it is a critical first step. It gives the investigation a clear purpose, a clear starting point and a clear direction.

Think about it. If you can’t define your problem clearly, then how do you know if the solutions proposed in the investigation will actually prevent its reoccurrence? How will you know if you have achieved what you set out to do?

Not only that, but a clearly defined problem is essential for when you present your initial report on the investigation. You need a strong name for the problem to catch the reader’s attention and make it very clear what the report is setting out to solve. You need management to buy-in into your problem to secure the time and resources needed to conduct a more comprehensive analysis. A strong title is always the first step.

What makes a good name?

The name of the problem needs to be short and concise. It should have impact. It should avoid the use of generic or ambiguous language.

For example, a “Failed bearing” is generic in its description. The title is vague – I know I have a problem with the bearing, but I don’t really know what sort of problem it is. A generic heading opens the door to many different possibilities. If you ask yourself why you have a “failed” bearing, many new questions and options arise resulting from the many different failure modes that are possible. This is not really what you want.

Rather, you should convey the understanding that the particular failure of the bearing is a unique, single incident in its own right. It has specific causes. And it needs a specific name.

Root cause analysis vs failure modes effects analysis

What are you trying to do with your investigation? Are you performing a “failure modes effects” analysis, or a “root cause analysis” on a very specific issue? If it is the latter, then the language you use needs to reflect this. It needs to be specific.

If the problem’s causes are unknown when you first start an investigation, then an understanding of all possible failure modes has some merit. It’s a good place to start, as it will help to point you in the right direction. However, keep in mind that it’s a starting point only. Once you have found the evidence to determine which cause path needs to be pursued, your investigation should become very specific, with all alternative pathways eliminated.

Think about a generic problem title: “person injured”. To make it more specific, we ask “What is the injury?” The response tells us that the person received “second degree burns to left forearm”. This more specific title immediately conveys how serious the problem is, and also generates far more specific questions in the analysis of the incident. In turn, this leads to more precise responses and a better understanding of the issue.

Streamlining your cause and effect chart

A more specific and clear problem name will also make your cause and effect chart more specific. It will become more streamlined, with fewer possible cause path options and “OR” scenarios.

Going back to the earlier example, if you say that the problem is a “Failed bearing”, you will likely get responses like “That’s normal. It happens all the time.”

But if you call the problem: “Conveyor offline” (because of a failed bearing) then what sort of response do you get?

Or if you were to describe the problem as: “Can’t load the train” (because the conveyor is offline) what reaction would you get? Again, the response is likely to be ramped up even further.

The fundamental problem – a failed bearing – is still the same. The three ways to name the problem show how the events are connected, yet sit in different positions on the time continuum. Each is a possible starting point, but which one will give you the biggest buy-in factor?

You may want to choose the most significant event as your starting point, as this will surely obtain greater buy-in.

If unsure of where to start, try using a “so what” question to guide you – “So what if the bearing fails? What’s the impact?”

This may tell you: “Conveyor is stopped.” So what?  What’s the impact of the conveyor stopping?

“Cant load the train.”

In this scenario, this last issue – an inability to load the train – is arguably the best starting point as it will gain far more buy-in from people further up the chain of command, and hence be more likely to secure funding and resources.

All because of a name

When choosing an appropriate starting point for your investigation, consider your options carefully and then assign a name that will clearly articulate the problem you intend to solve – one that also echoes the significance of the problem itself.

Further food for thought

Remember:  You are never wrong when choosing a starting point as all causes are related. They are simply at different points in the timeline. Your choice may reflect your role or responsibility within the company.

 By Jack Jager

The ability to demonstrate the success or failure of Root Cause Analysis (RCA) is a crucial stage of incident investigation that is often missed. After all, if you don’t measure, how do you (and others) know if your program is working and whether it’s worth the effort?

Measuring the success of an RCA program is important both for the short-term and the long-term. In the short term, you need to know if the changes implemented as a result of the RCA findings are effective. Longer term, you need the proof that your RCA program works – so that you gain ongoing support from management for this important tool.

Yet some companies fail to measure the success of their RCA programs. Here, we look at what’s stopping them, and how to overcome it.

First, why is measurement so important?

The goal of RCA is to improve processes or reduce the severity or impact of incidences. In RCA, you typically generate a raft of possible solutions and only implement some of them.

Implementing RCA solutions without measuring their effectiveness is akin to trial and error.

Measuring the changes caused by RCA solutions – good and bad – is critical to knowing whether your RCA efforts were successful. You need to know the “before” and “after” states of whatever the RCA is trying to improve, and assess how effective the solution is.

Measurement is probably more important for the “bad” results. You need to know if a solution isn’t working. A negative result will show you that the problem was not understood well enough (in which case you can go back to your cause and effect chart) or that poor choices were made in terms of which solutions to implement.

In this way, a “bad” measure still leads to a positive outcome. It allows positive decisions to be made to revisit the issue. After all, if the problem was significant enough to warrant an investigation in the first place, you need to know whether to revisit it or not.
 

What’s stopping you from measuring RCA success?

In some cases, the lack of measurement boils down to the fact that the RCA process is still relatively immature, and has not yet evolved into a complete process. In these instances, you need to deepen your commitment to grow your RCA program so that it captures this crucial step.

In other cases, unfortunately, measurement is simply shelved in the “too hard” basket.

Yet it doesn’t have to be hard. To measure the success of RCA, you simply need to set some parameters or criteria. Identify what you are trying to achieve – both the “big picture” goals and those relating to the RCA program itself.
 

What measures would indicate success of your RCA process?

The big picture will show:

• Improved availability of plant (less downtime) – either mobile plant or fixed plant (production infrastructure)
• Improved production data – weekly, monthly, per quarter, biannual and annual
• Less downtime when things go wrong
• Lower frequency of problem occurrence or similar types of problems
• Less impact of problems – problems are less severe or the ramification of these problems are less severe
• Less time spent reacting to problems and more time available for planning and making improvements

At a more local level, RCA program measures will show things like:

• Ratio of total number of incidents which should trigger an RCA against how many RCAs were performed
• Percentage of solutions generated against how many were implemented
• Percentage of people who have been trained in the process against those who have actually conducted RCAs or are using the process informally
• Indication of the timeframe needed to begin investigations (shorter is better)
• Indication of the timeframe required to implement solutions

By collecting information of this nature, you will be able to demonstrate how successful the RCA program is. In doing so, you will gain valuable support from management and co-workers.

Remember, you can easily tell someone a story of how good the RCA process is – but if you can’t show them the actual benefits in terms of production, availability or dollars, then the story counts for nothing. You have no evidence to prove it.

Instead, let the data from your measurement tell its own story. 

By Jack Jager

An incident has occurred, and a Root Cause Analysis (RCA) is needed to find an effective solution. How do you ensure that the RCA delivers the best results – that is to say arriving quickly and accurately at the cause or causes of the problem?

At the start of any analysis, there are a number of simple things you can do to boost the likelihood of a successful outcome. These tips are not rocket science; yet they are important to get right.

Be prepared.

Make sure you do your homework before you start, and have everything ready. This includes:

• The workspace – have large white boards and lots of them. In the absence of whiteboards, use walls or windows with butchers paper. Stock up on markers and post-in notes. In other words, make sure you’ve got plenty of room – and the tools – to write down all ideas coming from the group.
   
• The information – collect all of the information available, and have someone assigned as custodian so you can call on it and don’t have to go looking for it.  Depending on the incident you are investigating, you should collect things like the maintenance history, reports, photos, design specs, eye witness statements and OEM recommendations.
   
• The timeframe – stipulate clear timeframes for the RCA, including the start time, breaks and finish time.
   
• The rules – set expectations around usage of mobile phones and email. It is also important to have rules around the discussion itself – such as “no put-downs”. In short, the less interruptions, the better. Encourage an “open” discussion and allow all information to be brought forward. Don’t argue about ownership of information – what matters is that it was brought to light. Focus on “why”, not “who”. This reduces the emotion in the room and minimises conflict or argument. If blame becomes a part of the RCA process then defensive attitudes will start to appear, and people get too afraid of the consequences to speak up and say what really happened.

Form your group.

For an RCA to be successful, you need the right people to be present for the investigation. In other words, people who have access to or knowledge of information relating to the problem. You may need to invite an independent “expert” to assist with your RCA.
Sometimes the people directly involved in an incident or accident may  be the “right” people to have in the room.  But if there are other agendas or emotions at play, then leave them out. The RCA team should be genuine seekers of effective solutions, who share a goal of preventing similar events happening again.

Be wary of inviting senior managers into the group – they could hinder open and truthful dialogue. It may be better to give senior managers a separate review and opportunity to challenge so that they stay engaged in the process and buy-in to the solution.
It’s also important to have the right number of people in the room. The “right” number is dependent upon the significance of the problem, but also upon the ability of the facilitator to handle the group. As a general rule, it is difficult to facilitate groups greater than 10. If the group size becomes too large, consider splitting the group and having two sessions.

Control the group.

This may prove difficult, yet the ability to control a group is an important skill to have. You should value all contributions from all group members. While people don’t necessarily have to agree with each other, it’s important to acknowledge that everyone is entitled to their opinion.
If there is any confusion about a person’s comment, ask them to explain it again. If there is still no agreement, then capture both sides of the story and let the evidence prove one or the other. Don’t tolerate an argument or a contest of wills – let the evidence determine the merit of following a particular cause path.

Use all of your non-verbal skills to assist you in controlling the group. Use direct eye contact and a hand gesture to indicate whom you wish to speak next. This lets everyone know who has the floor. When you shift your focus to someone else, in conjunction with the arm movement, you pass ownership of the right to speak to the new person.
Be the traffic cop. With a simple hand signal, you can control the person who is impatiently wanting to say something, by showing them an open palm that says “stop”. This will let the other person finish what they were saying.

Respect everyone’s right to be heard, and remember that everyone in the room has a reason for being there. Ensure they all have the opportunity to speak.
Use your body as a means of directing the flow of traffic. Turn your body to face someone in the group whom you wish to speak. When you couple this with strong eye contact and a hand signal toward them you are effectively giving control of the floor to them. The key here is that everyone else in the group sees these silent signals too. Don't think you’re being rude – rather, you are showing control. And the better you can control the group, the more effective your investigation will be.

Keep the group on-task.
The facilitator’s job is to be direct and to ask specific questions to keep people focussed. If the focus strays, then it’s a good idea to go back through the chart – starting at the beginning – to get everyone back on track.

The facilitator should be the prime-mover during the RCA, constantly asking questions –  along the “caused by” or “why” lines – to maintain focus. These questions demand responses and keep everyone engaged, involved and on-task. Your questions will also prevent the group going off on tangents, which lead to almost anything being added to your cause and effect chart.
If someone is having a side conversation, then pose the next question to them. Put them in the hot-seat. If you do this consistently, you will demand their attention and also the group’s attention.

Being animated or dynamic when you facilitate is also a great way to maintain focus. Modulate your voice to keep people’s attention. Avoid a boring monotone. Remember, if the facilitator is quiet then it follows that the group is also quiet. This is not what you want.

Schedule regular breaks – a few minutes on the hour and 10 -15 mins after 2 hours. This will help to ensure that the energy levels in the room remain high and also allows people to check emails and phone messages. This is important in maintaining the focus of the group.

Follow the process.

Some people seem to have a natural affinity for facilitating investigations, but anyone can become adept and successful at it. The art of facilitation is a skill that can be learned through practice and reflection. A good facilitator knows he can walk into any situation and find a solution. This is a very powerful and rewarding skill for both the individual and the organisation.

As a facilitator, if you can follow these suggestions then the likelihood of a successful outcome from your investigations will increase.

Learn about five critical skills that an RCA facilitator should possess.