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By Kevin Stewart

A facilitator conducting a Root Cause Analysis using the Apollo method performs a crucial role throughout an investigation. Here are some tips and steps to keep in mind when facilitating:

Over many years, I repeatedly hear that the ‘Apollo Root Cause Analysis methodology is only used for big, serious investigations.’ This statement always makes me smile – because it is completely untrue. 

An RCA using the Apollo Root Cause Analysis methodology can be performed on any problem, large or small, as long as the right facilitator is on board. This article, part 1 of 2, explores the strategies and processes a facilitator should keep in mind when an investigation proceeds.

ANYONE CAN FACILITATE

In my Apollo Root Cause Analysis methodology training classes, I always ask whether anyone is a certified facilitator. I’ve only received one ‘yes’ from the 2,000 or so students that have attended my courses. This sole person will have been trained in how to manage a group of different personalities; how to progress a group towards its goal; how to be firm and fair; and so on.

Yes, these are valuable skills to learn. And, in an ideal world, every facilitator would have the time and resources to complete the training. But you can facilitate a Root Cause Analysis using the Apollo Root Cause Analysis methodology without this certification.

Facilitating RCAs requires flexibility – yet it also requires that you follow a standard outline. While every RCA has its own path, it will generally adhere to these main steps:

1. Gather information
2. Define the problem
3. Create a Realitychart
      a. Phase one: Create the draft RealityChart™
      b. Phase two: finish and formalise the RealityChart™
4. Identify solutions
5. Finalise the report

The process – as laid out above in its basic format – may look a little daunting to someone who has never facilitated an RCA before. Particularly, if you are contending with other feelings – like being anxious in front of a crowd, or feeling responsible for the outcome. You will need to deal with these latter issues in your own way.

What you can take charge of is finding a way to shape a group of disparate people into a highly functioning team, who share the common goal of reaching a solution. By following the steps below, you can prepare for a smooth facilitation process.

PREPARING FOR A FACILITATION

Step 1. Familiarise yourself with the Apollo Root Cause Analysis methodology.

First, ensure you are familiar with the Apollo Root Cause Analysis methodology – after all, it’s what you’re trying to facilitate. If you need a review, the RealityCharting™ learning centre is a great place to visit to recap on the basics. Here, you can complete a simulated scenario to really fine-tune your understanding of the process.  It would also be a good idea to review the facilitation guidelines in the manual that you received with your original training.  It gives an excellent overview of the entire process.

Step 2. Gather your supplies.

Stock up on post-it notes – and get the good, super-sticky ones that will stay on the wall.

We suggest that you use post-it notes instead of a computer to perform the analysis, as these help to enhance the common reality.  With post-it notes, all participants can see what’s happening.

If you think the analysis will take a few days, get multiple colours of post-it notes so you can easily distinguish between the changes to the chart created on different days or at different times.

Ensure the room you’re working in has plenty of wall space. And, if the walls are unsuitable for post-it notes, tape poster paper to the wall first and then adhere your post-its. Using paper can provide the extra advantage of making the chart easy to remove and take with you.  If it’s sensitive subject matter, you can roll it up and take it with you at the end of the day.

Step 3. Prepare the participants.

Ensure that all participants know what to expect before beginning an RCA. An RCA can require a significant time commitment, so make it clear from the outset how much time is needed from them. 

Step 4. Gather information.

The more information you have at the outset, the smoother the journey.

You may already have information at hand in the form of pictures, emails, reports, write-ups, witness statements, and so on.  There may be some useful physical evidence. Request evidence from the right people, collect it and store in the one file.

You may also choose to take the entire team to see the area under investigation, so that everyone has a clear picture in mind about what you’re discussing.

Be aware that, no matter how hard you try, there will always be some missing information.  This is not a problem. You can call someone, look it up at the time, or make an action item for someone to gather the evidence later. 

Read Honing your Facilitation Skills: Part 2

By Kevin Stewart

One definition of Root Cause Analysis  is:
Root Cause Analysis is any structured process used to understand the causes of past events for the purpose of preventing recurrence.

This basic premise is the reason that the RCA is done.

On the surface, it always appears to be a simple matter, however there are always pitfalls and nuances.

One such pitfall that RCA investigators or facilitators face is something I call the “problem is fixed” syndrome. In my work at plants I would run across situations where a problem occurred and a solution was implemented. The particular solution used may or may not have been arrived at by using RCA. In either case the solution is implemented and the “problem is fixed."

How is this statement validated as being true? Those involved will justify the solution by the simple fact that the problem hasn’t recurred, at least not in the immediate future, which unfortunately is sometimes the focus of plant management due to pressures, career goals or other reasons. On the surface this may seem to be difficult to argue – after all the problem is fixed – or is it?

In the cases I have been involved with, what has really happened is that the MTBF (Mean Time Between Failure) of the problem is actually a long time, say 5 years or greater. I was involved in two investigations where the incident hadn’t happened in the previous 5 years and most likely wouldn’t happen for another 5 years. Investigations had been performed and solutions were offered and implemented.

When asked about the effectiveness of the solutions the evidence given was that the incident hadn’t recurred so the solution must have been effective. On the surface this may appear to be difficult to argue back, since it is true that the problem hasn’t recurred. However by looking at the MTBF of the incident, you can point out that since the MTBF is long the effectiveness of the solution put in place will not be known until the problem recurs at some time in future. So at this particular time no solution, or any other proffered solution would be just as effective since the problem won’t recur anyway. You can easily see where if a facility is not careful they could be “fixing problems” with long MTBF’s claiming success and in reality not have actually provided effective solutions. This argument supports a thorough and complete RCA that is based on the cause and effect principle and are supported by evidence to insure an effective solution is implemented.

In one of the cases above the solution was to do more frequent maintenance to insure the problem was identified. While this would have worked for anything that had a MTBF longer than the frequency chosen it would not have worked for something that had a MTBF less than the frequency chosen. In addition to a solution that would not work in all cases it would have increased the cost of maintenance significantly. In this particular case a little more investigation and adding some additional causes to the chart identified that some external damage had been done and not reported, which caused the issue. If they could fix the unreported damage issue then an effective solution would be found that covered the situation that brought this incident on, it also would most likely fix other incidents that hadn’t even happened yet.

In this case you can see that the offered solution would have appeared to work just fine and since they did “something” everyone feels good about the work and “effective” solution.

The other incident was caused by someone who had recently returned to work after an extended leave. During an operating situation this employee correctly followed the incorrect procedure that was posted at the unit. The solution was to replace the incorrect posted procedure that was found to be incorrect at an operating unit. While replacing the procedure was necessary, they would not know if it is effective for quite a while. Again a little more investigation and a few more causes identified that there was no process to replace modified procedures around the plant. If this was fixed then an effective solution would be identified. You can see that here also the plant management would be thrilled because and investigation was done, something was put in place and the problem hasn’t happened again. I’m sure you can see that this situation very well could happen again either at this unit or other similar pieces of equipment.

Both of these examples also point out that a good RCA must be done using valid principles and evidence for the causes and you must not stop too soon! Stopping too soon is another common mistake in RCA – but that is another tip.

In the meantime be aware of incidents with long MTBF and offered solutions that are not based on good analysis or inappropriate causes.

RCA DISCUSSION

What are your thoughts on conducting an RCA facilitation / Investigation and how much time have you spent preparing the analysis and implementing solutions?  Do you have a successful tip worth sharing or discussing? We look forward to reading your feedback and perspective via comments below or let’s connect on our LinkedIn Group – ARMS Reliability - Reliability & RCA for further discussion.

By Jack Jager

How often have you looked at corrective actions and thought that they would have little, if any impact in preventing the problem from reoccurring? It wasn’t just once…. and it continues to happen.

The Question is Why?

Yet the answer is not a simple or straight forward one.  Do we believe that the person(s) creating these corrective actions aren't trying to do their best? No, I don’t think so. I firmly believe that almost all people are trying to do their best. So where does that leave us?

I think that we are caught up in a system where the reactive, quick fixes are the goal, the way of dealing with incidents on a day to day basis. If you were to have a downtime incident and you were  to bring the  power  back on quickly after an outage, or the machine is back in operation after a short space of time, then the reaction from the management group and from all of your peers is typically….”Well done! Great job!”  A pat on the back for those who have performed the job well.  In other words we give respect and accolades to those who can fix it quickly.  Conversely there is often little reward or acknowledgement for hours of diligent work in the pursuit of actions that will resolve the issue once and for all. We reinforce the quick fixes.
Now don’t get me wrong here because the ability to do the quick fix is and always will be a valuable skill, but the real challenge is to understand whether we have prevented the problem form reoccurring?

What happens after the initial fix is put into place? Where do you go to from there? In the completely reactive model, the fire-fighting model,  where breakdown maintenance often takes precedence over planned maintenance (which then sets you up for the next round of failures), there is always a fire that needs tending, so we will typically tend to jump to that fire, to the next problem on the list. “I have dealt with that one, what’s next?”

The Blame Game

From my conversations with people who attend the courses that I present covering the Apollo Root Cause Analysis methodology, something else becomes blatantly clear. We still seem, on many different levels, to be playing the “blame game”.  The question of “who” still seems to be of paramount importance to some, perhaps many people.  The question I would put forward to these people is “Will knowing who did it, stop it from happening again?” Now to my way of thinking by far the most common answer to this question will be “No”(although there are exceptions). So why do we feel that we need to focus on the “who”? If the goal of doing Root Cause Analysis is to prevent recurrence of the problem the challenge lies not so much in who was involved but rather emphasising, or focusing, on what you can do to stop it from happening again. This focus will lead to gathering more factual information which is the essence of understanding the problem first and foremost.

The “who” side of the question is pretty easy to determine, but if that is what we focus on then it is likely to limit thorough questioning,  and leads quickly and easily down a blame path. Sanctions are given or jobs lost, all based on the knowledge of “who” was at fault. But where does this lead? Wouldn’t this lead to a lack of reporting mistakes or faults as there will be unwanted consequences because of the report? Doesn’t it elevate risk as there would now be a culture of hiding or covering up mistakes? When you ask questions, what are likely to get? The truth?

Something else to consider is whether people intend to cause damage, create failures, injure themselves or hurt others? Again the overwhelming answer is still “NO”.  That people are often involved in many incidents, and make mistakes, is seemingly the constant part of the equation. But that is the nature of the beast. People are fallible, they do make mistakes and no matter how hard we try to control this aspect, the “human error” side of causes, it is forever doomed to failure. If we rely on trying to control people then our solutions will have no certainty in their outcome. Going down this path is simply not reliable.

Hierarchy of Control

This is echoed in the concept of the “Hierarchy of control” where corrective actions are placed within the Hierarchy, as being either a form of Elimination, Substitution, Engineering,  Administrative or P.P.E.  controls.

The first three of these are perceived to be very strong controls, or hard controls, with almost guaranteed, reliable, consistent results. They are however more time consuming and typically involve spending money to achieve your desired outcome. Administrative controls or the use of PPE as a form of control are perceived to be soft controls. They are relatively quick to implement and don’t cost too much and yet if you were to ask the question “will they prevent recurrence”, almost universally the response will be “NO”!

They may however satisfy the need to report.  I have “ticked the box” and created a perception of having done something about the incident. To take this a step further these “soft options”, now get signed off by management who are fully cognisant of the “Hierarchy of control”. If we keep taking the soft options however is it any wonder that we are still “fire fighting”. If we don’t fundamentally change or control causes that create the  problem then the problem still has an ability to happen again, regardless of the “who”, the person involved. This could be anyone.

Creating another Procedure

How often have you heard or seen, as a response to a problem …….”create another procedure”? Would you be certain that this will prevent recurrence of the problem? It could be said that you have tried to control the problem. You can certainly show that you have done something. Would it however be defensible in a court of law if someone were to subsequently get hurt? If you expect someone to remember every single procedure, of every single task, of the many tasks that they need to perform in every single day, is this feasible? And we all know it is a soft control! An administrative one. So do the courts.

The Argument about Sanctions…

Who learns the most from the mistakes that are made? Isn’t it the person or the people involved? This was put into perspective for me by another Apollo instructor at a conference in Indianapolis. He said to me “if someone makes a mistake for instance and the cost of that mistake might be say $500,000, and you are so angered by this that you then sack the person who made the mistake (quite possible, even probable)……it is like sending someone on a $500,000 training course and then sacking them the next day”.

Does this make any sense?

RCA DISCUSSION

What have you learned from conducting an RCA? Do you have any successful tips or feedback woth sharing or discussing? We look forward to reading your feedback via comments below or let’s connect on our LinkedIn Group – ARMS Reliability - Apollo Root Cause Analysis for further discussion.

When an incident or accident occurs at your workplace, what do you do to fix the problem?

In many cases, the "5 Whys process" is a proven and accepted means to get to the root cause of the incident. But what do you do if this technique doesn't dive deep enough - and only presents further symptoms rather than the real cause or, indeed, causes?

Ths eBook reveals the benefits and limitations of the 5 Whys process; and then presents a useful method for taking the analysis further.

By Ned Callahan

Everybody agrees, don’t they, that the whole point of the investigation of safety incidents, whether injuries have actually been suffered or the potential for them was high is to prevent their recurrence? Regrettably, the tendency to blame is more apparent in these cases than in mechanical failures or supply chain deviations, for example, presumably because of the deeper emotional responses from the affected parties.

The significance of the particular event can then be intensified because the variety and depth of the participants’ emotional responses are undeniably “real” and can, if not appropriately accommodated in the total incident management process, cloud the judgement of the investigator/s and even complicate the task for the team of analysts assembled for the RCA.  Minimising the risk of friction, avoiding undue “heat” being generated by the harm (nearly) caused, can be achieved by the prompt application of an investigation process which both encourages and relies upon the frank sharing of information in order to achieve the agreed objective.

A mature business will have a risk matrix which pre-determines the level at which the investigation is undertaken and therefore, which “tool” or methodology may be prescribed for the particular event. The previous deliberations about which method to use for what level/type of event will have been influenced by the organisation’s previous analysis history, incorporating the relative success or otherwise of previous investigations. These results will have been generated by multiple factors such as the quality of evidence, determined by the care taken in its collection and preservation, the rigour of the facilitation process, the relative “influence” of stakeholders and significantly, the co-operation of the incident actors, being the victim/s and witness/es.

An event, being the first of its type in the organisation, with a very minor injury and no time lost may only require a “trouble-shooting” type approach. The expectations of regulatory authorities in hazardous industries can be another influence on the choice.
But then all that experience, positive, negative or mixed can be neutralised by the emergence of a different principal with responsibility for the RCA process who has experience of another method or specific training and expertise and has the clout to sway the choice. It may well be simply based on a personal preference arising from familiarity rather than an objective assessment of alternatives.

Regardless of the methodology selected, the purpose must be to prevent recurrence and not to blame. If the investigation focuses primarily on “who” did or did not do something or other, the tenor of the subsequent analysis may become negative and the opportunity to really learn from the experience will be subordinate to the search for a culprit. By the way, this “no blame” attitude does not exempt personnel who are repeatedly and wilfully negligent in the performance of their duties or associated activities in the workplace. The owners have a duty of care to provide a workplace for all and if misbehaviours increase the probability of increased risk of harm they are obliged to respond. Reprimand is a reasonable sanction. Or, in the most severe but rare cases, dismissal might be reasonably justified. The justification would be the thorough, objective analysis. Otherwise the organisation could find itself liable to unfair dismissal or similar charges.

The need for objectivity cannot be over-stated and explains why best practice for significant events is to engage a third party facilitator who has no “skin in the game”. If the broad business context for deep analysis is Continuous Improvement, the enhanced safety of the workplace and all processes and equipment operations used by its employees must be the outcome.

Keeping in mind that every event is unique in some respects – the most obvious being that it happened at a different time to every other one (you know of) – the purpose of the RCA is to discover what is different or distinctive about this event. What are the other unique causes which might be effectively controlled or negated in order to significantly reduce the likelihood of a repetition or similar occurrence?

So, after the exhaustive process has been followed, with the facts associated with the incident having been recorded, the consequences measured and documented, the timeline and sequence of events mapped, any cans of worms expertly opened and explored, you have discovered a number of causes. Typically and ideally, you will have discovered causes of which you were ignorant at the beginning of the analysis. And these will only be discovered if the event is sliced thinly, if every phase is considered very carefully. These ought to be documented in some graphical form so that the team’s understanding of the event can be shared and agreed as complete. The cause and effect chart or tree is the most common display form employed and there needs to be provision for the display of the pertinent evidence for each cause.

It is imperative that all of the causes are revealed before you can be confident that prevention is assured. Being persistent in the quest for causes is a very desirable trait. Don’t stop too soon. Then, the existence of clearly defined relationships between the causes and their effects will provide the clarity necessary to instil confidence that the consequent solutions will be effective. It is the solutions, targeting specific causes, which combine to assure prevention, or at least, serious mitigation of the consequences.

But the job is incomplete. The solutions need to be implemented in a timely fashion to have an effect on the probability of recurrence. If, for example, one of the causes is the failure of some mechanism then identifying a solution for that may also entail deeper investigation to determine other failure modes which could have similar, potentially harmful effects. Note however that the investigation is not per se a solution even though it may provide data which leads one to alternative or complementary solutions.

Establishing the priorities for that implementation, giving ownership and due dates for completion are the closure everybody needs. It will be a learning experience for all intimately concerned but can and should be shared more widely in a large organisation. Nobody disagrees with a safe workplace and that attitude will reflect well on the organisation and community regard may well be heightened.  A safe workplace also reduces the likelihood of interruptions to business and therefore this increased reliability will strengthen relationships with customers and suppliers alike long-term. 

By Ned Callahan

“How long should an RCA take?”

This question is similar to how long is a piece of string?

I have heard one manager in a plant that has stipulated a maximum of two hours for an RCA to be conducted in his organisation. Another expects at least “brainstormed” solutions before the conclusion of day one – within 6 or 7 hours.  It is not uncommon for a draft report to be required within 48 hours of the RCA.

The following three tips may assist to meet tight deadlines and when time expectations are short. One advantage of the Apollo Root Cause Analysis method is that it is a fast process but the “driver” has to be on the ball to achieve the desired outcomes – effective solutions.

1. YOU DEFINE THE PROBLEM

Imagine the RCA has been triggered by an unplanned incident or event which falls into any of the safety, environment, production, quality, equipment failure or similar categories. You have been appointed as the facilitator by a superior/manager who is responding to the particular event. Your superior/manager may understand the trigger mechanism and may well nominate the problem title.

For example, “upper arm laceration”, “ammonia spill”, “production delay” and so forth could be the offering you make to the team as the starting point for the analysis. Typically, as facilitator you will have gathered some of the “facts” from first responder reports, interviews, data sheets, photographs and so on.  So a good first step is to draft a problem definition statement, including the significance reflected by the consequences or impacts. The team then has a starting point to commence the analysis, albeit the problem statement may change as more detail is provided.

Ideally, you will have already created a file in RealityCharting™ and the Problem Definition table can be projected onto a screen or even onto the clear wall where your charting will be done with the Post-It™ notes. The team members’ information ought to have been entered and can be confirmed quickly in this display. You might even show the Incident Report format and focus on the disclaimer option you have selected deliberately: Purpose: To prevent recurrence, not place blame.

This preparatory work could save at least 20 minutes of the team members’ time and enable an immediate launch into the analysis phase.

NB: 
Save yourself hours of re-work and potential embarrassment by saving the file as soon as this first process is complete, if you haven’t already done so, and thereafter on a regular basis. Maintain some form of version control so that the evolution of the chart in the following day/s can be tracked if necessary.

If you are particularly well-resourced the chart development might be recorded on the software simultaneously as the hard copy is created on the wall space. A small team might choose to create the chart directly via the software and a decent projection medium.

2.    DIRECT THE ANALYSIS

It is critical that your initiative in preparing the problem definition is not considered by the team members as disenfranchising them. The analysis step whereby all have an opportunity to contribute should ensure that they feel they have “ownership” of the problem.

To reinforce this, it is advisable to choose a sequence of addressing each member, typically from left to right or vice-versa depending on the seating arrangements. This establishes the requirement that one person is speaking at a time, secondly, that each and every statement will be documented and thirdly, that every person has equal opportunity. Your prompt and verbatim recording of each piece of information will provide the discipline required to minimise idle chatter which can waste time because it distracts focus. When you have a series of “pass” comments from team members because the process has exhausted their immediate knowledge of events, launch the chart creation. 

It is worthwhile reminding the team that each information item that has been recorded and posted in the parking area, may not appear in their original form on the chart or at all, in some cases. Because the information gathering is a widespread net to capture as much knowledge regarding what happened, when and why, there will be no particular focus. But because they are coming from people with experience and expertise or initimate knowledge of events and
circumstances, they have some value. The precise value will be determined by where the information sits in the cause and effect logic that starts at the problem and is connected by “caused by” relationships. 

NB. Cause text should be written in CAPITAL LETTERS. It will be easier to read/decipher for the team at the time and perhaps from photographs of the chart later. Similarly using caps in the software itself means that projection of the chart is more effective and the printing of various views is enhanced.

3.    THE “HOW AND IF”  OF  CREATING A REALITYCHART™

Many proponents tap the existing understanding of the event by capturing as many of the action causes as possible. These may arrive via a 5 WHYS process, for example, which starts at the Primary Effect.

            Plant Stopped (Problem or Primary Effect)

            Why? Feed pump not pumping

            Why? Broken Coupling

            Why? Motor Bearing Seized

            Why? Bearing race Collapsed

            Why? Fatigue

The Apollo Root Cause Analysis methodology requires use of the expression “caused by?” to connect cause and effect relationships. Understanding that there must be at least one action and one condition helps  reveal the “hidden” causes and especially the condition causes which do not come to mind initially.

To support this expression and the essential “why”, consider asking “how”. This may be  employed initially by the most impartial member of your team who has been engaged specifically because of his/her lack of association with the problem and can sincerely ask the
supposedly “dumb” questions. Invariably these questions generate more causes or a more precise arrangement of the existing causes. A “How does that happen exactly?” question can drive the team to take the requisite “baby steps”.  This also often exposes differences between “experts” and the resolution of these differences is always illuminating.

The facilitator needs to be aware of the need to softly “challenge” the team’s understanding while ensuring the application of sufficient rigour to generate the best representation of causal relationships. This can be done in a neutral manner by using the “IF” proposition.

Given that every effect requires at least two causes, you can then address the team with the proposition: “If ‘one exists’ and ‘three exists’ (two conditions) then with ‘four added’ (the action) will the effect be “eight” every time?”. Using this technique on each causal element will generate the clarity and certainty being sought to understand the causes of the problem. If every “equation” (causal element) in the chart is “real” and the causes themselves are “real”
(substantiated by evidence) then the team is well-placed to consider the types of controls it could implement to prevent recurrence of the problem.

The more causes which are revealed the more opportunities the team has to identify possible solutions.

SUMMARY

To speed up the RCA process,

Step 1 Facilitator gathers event information and fills out Problem Definition Statement.

Step 2 Facilitator directs the Information gathering casting a wide net and systematically requests information from participants.

Step 3 Use information gathered to build a RealityChart™ with actions based on what happened then looking for other causes such as conditions which may initially be hidden. Use how and If to help validate that causal relationships are logical.

With a completed chart the solution finding step can begin.

RCA DISCUSSION

What are your thoughts on conducting an RCA facilitation and how much time have you spent preparing the analysis?  Do you have a successful tip worth sharing or discussing? We look forward to reading your feedback and perspective via comments below or let’s connect on our LinkedIn Group – ARMS Reliability - Apollo Root Cause Analysis for further discussion.

Incident Investigation is an improvement process. It's about continually working on your weaknesses to realize marginal gains - a number of small improvements that result in a better program overall. 

This eBook breaks down the 5 critical components you should consider when establishing your RCA program – or just as important, when striving to improve your RCA program. You’ll also get practical tips and tactics to get the most value out of each element of your program.

By Ned Callahan

1. Identify training which will attract maximum participation for maximum benefit.

The one single thing which affects everybody is change, planned or unplanned.

In the realm of Continuous Improvement, which is about implementing planned changes for efficiency, safety, quantity or quality benefits, the capacity to adapt to change is particularly valuable.

Even planned changes can cause problems which have not been anticipated. Sometimes execution is imperfect. Risk assessment is a particular discipline which aims to identify then minimise possible negative consequences. Expressing these possible negative scenarios as potential problems is a starting point for assessment and the identification of possible controls.

But it is the unplanned changes which are the greatest cost to business. The most adaptable personnel are typically the best learners and effective learning requires acknowledging the past. The adage that “learning from history means not repeating the mistakes of the past…” is often quoted.

In a commercial or industrial sense, past events, past failures, past incidents need to be mined thoroughly to derive the benefits of the experience if they are to be avoided in the future; hence    the “lessons learned” expression is widely applied in business analysis nowadays. 

There is little doubt that everybody can benefit from the ability to thoroughly and methodically analyse those “mistakes” therefore a targeted problem-solving course ought to be a priority.

2. Provide short, practical courses which challenge conventional thinking.

Any training course exceeding three days is going to test the endurance, not to mention the enthusiasm, of participants. Individuals learn at their own pace and need to feel challenged in order to maintain their concentration and to realise the potential benefits of the course content. One day is barely enough in many cases, two allows for the new learning to settle overnight - the learner will have “absorbed” some key concepts (new neural paths created) and have developed a more critical approach.  The third day, if structured appropriately, or even customised to suit the specific needs of the student/client, will ensure that the expected benefits are actually produced in the classroom.

The course itself needs to have sufficient clout – in other words, its impact will far outweigh the “time lost” attitude that often prevails. The students have their other work to do still.

Finding a course that makes them more efficient at solving their current problems would be most appropriate.

3. Utilize a course which encourages cross-discipline co-operation via collaborative exercises.

Most training courses are directed at specialists in particular fields with rich content and “sophisticated” methods. Typically, there is a modicum of small team exercises complementing a lecture type presentation and a plenary session for answers and questions. 

Consider a course which benefits the students precisely because they do have different
professional skills, experience and ways of thinking about the world around them. Staged exercises of varying length ensure the students have the opportunity to challenge one another continually in an open, respectful manner while focused on an agreed problem for analysis. The egos and preponderance of “rules” required by the method which makes so much problem-solving activity inefficient, stressful and ultimately unproductive can be neutralised.  

4. Require continuing support via web-based resources and specialist advice.

The era of e-learning is well-advanced and having access to a website containing substantial  pertinent printable material, multiple video clips as well as interactive simulation exercises to reinforce the student’s understanding is  most valuable. All the better if this is provided gratis after the completion of the course.

Furthermore, the trainer will be available for individual facilitation sessions at the organisation, will gladly take back-up calls post-training and will be delighted to cast a critical eye over submitted charts should the student require another objective opinion.  This needs to be done in strict confidence.

5. Expect useful software with a perpetual licence.

Software which enables the development of charts, tables and reports in order to concisely communicate the detail of the analysis and its recommendations is almost obligatory.

A digital format of the course may be preferred. This could entail the use of a computer lab or alternatively, students with the licensed, registered copies of the software receive guidance and growing confidence during class exercises. By the conclusion of the course they should be able to produce professional problem reports with effective solutions identified.

By Kevin Stewart

Over the years of using the Apollo Root Cause Analysis methodology in the field, I’ve achieved a “normalization of deviance” when it comes to generating a common reality.  In general, it means that I don’t always think about it or discuss it much because it is just the way things are and have been for me.  So I thought I would reflect on this to remind myself how powerful a tool the Apollo Root Cause Analysis methodology is.

Unfortunately I can’t speak for other processes since the company I worked for standardized on the Apollo Root Cause Analysis methodology early on.  Since it worked for us we decided to spend our time using it instead of looking for the best process.  (I would be interested in others’ comments about generating a common reality utilizing other processes.)  So, my comments are from a single perspective but to use an old phrase – don’t tell me it can’t work – when others are doing it!  Hopefully other processes have equal success in this important aspect of RCA work.

In my corporate life we used to always be concerned with people who would nod their head yes to your face but internally were thinking – “it isn’t going to happen buddy”.  Many times this was associated with the first line supervision since they had the direct contact with the work force and could make or break any initiative regardless of whether it came from the highest levels or not.  It was very clear to me that if they saw the “WIIFM” (What’s in it for me), and agreed with it, that they could also be the biggest ally. 

After many tough lessons and some personal experience, this fact became painfully obvious to me - If the supervisor recognized the value to him by believing that something would actually solve a problem that caused him pain and anguish, he was more likely to support it and even take the lead in implementing the solution.  So how do we make this happen?

Most of us have heard the saying that “You support what you help to create”.  Well, the Apollo Root Cause Analysis methodology helps insure this happens by creating a common reality where everyone who participates in the team truly understands:

• The value of the problem
• What the solutions are

And more importantly –

• How they will affect the problem

If they can see the causal connections and understand them, it is not a big stretch to see why chosen solutions will actually fix a particular problem, or “Primary Effect”, as we like to call it.

I have participated and facilitated in many RCA’s and have yet to leave one where everyone isn’t on board. I don’t think about this much, but that is the normalization of deviance. 

Why does it work?

My thoughts are that if you come out with an initiative and tell everyone that they will do it.  They have little choice in many cases, but they can dig in their heels and wait out the management change – then they don’t have to do it.  Why is this? 

My opinion is that everyone can either see or know that the initiative won’t fix the problem, or won’t work, or has been tried before, etc.  So why bother. 

I myself remember saying “How could that possibly solve the problem!?”  Or if it was some off-the-cuff initiative – perhaps my thoughts were “What problem are they trying to fix?”.  In either case, I saw no value in pursuing the initiative or helping since the work I was doing was helping to make my life or my corporation’s life easier or more efficient (and besides I can always wait out the 3-4 year management exchange period and not have to deal with it). 

The problem here is that they didn’t ask me what I thought, or they didn’t make the connection for me by telling me “WIIFM”.  Now if I had been part of the team, or could see the connection, that would be a horse of a different color.  This is why I believe the Apollo Root Cause Analysis methodology is so good at generating a common reality. People responsible for the solutions are usually part of the team, and if they are not, they can look at the chart and see the causal paths and everyone inherently knows that if you block off a street a car can’t go down that path (in other words, eliminate a cause path and the effect won’t happen).

So when you complete the analysis and ask around, everyone is in agreement because they all have participated, their input is on the chart, and they understand the flow and can speak about it. They also understand why implementing their solutions will be effective.  This, in a nutshell, is the common reality we need to insure the team is all rowing in the same direction.

By Jack Jager

We are all problem solvers. Each and every one of us actively deals with problems on a regular, if not a daily basis. However, the crucial question is “Is everyone actually good at problem solving?”

Quality of investigations vary and the trend appears to be a practical application of the normal curve. There are some fantastic results from investigations and also some poor results. But, if your organisation is seeing  a whole pile of average investigations and average reports that result from them, then the effectiveness of your Investigation program can be improved.

Mediocrity occurs for a number of reasons. This article focuses on four aspects of your RCA program which, if not set up correctly, could be catalysts behind a consistent flow of mediocre root cause analysis investigations within your organization.

1)     A structure to support training

So, you’ve trained your employees in root cause analysis and you’re expecting to see some fantastic RCA results coming through. Right?

…Not so fast.

If there is little structure to support the training in terms of:

• a requirement to use the process,
• mentoring and feedback provided to trainees,
• or quality audits on their efforts,

Then you can expect to see a whole range in terms of the quality of investigations being submitted. If the majority of the investigations are average then the value of the training comes into question.

This has often been the stimulus to look for different training in an alternative methodology because the perception is that the process selected for use by the company is not meeting expectations, it’s not working, people are not using it, and people don’t like it, or it’s not getting the results…..and so on.

If any training is unsupported, the same outcome could occur. So is this a problem with the training or a problem with the structure that supports the training?

Two days of training or a week of training doesn’t make anyone an expert in anything. Each trainee sits somewhere along the learning curve at the start of the training and hopefully, if they have been paying attention, they move along the curve to a better place after the training. The purpose of the training is to skew the curve – to move the curve to the right so you have more investigations being completed to a higher standard.

The challenge for all companies is to work out how to move trainees from where each
individual sits on that learning curve after the training, to application of excellence within the discipline at which the training was directed.  Isn’t this what was originally intended?

For many individuals, this transition along the learning curve lacks clear structure and in many cases this structure simply does not exist. We train our people and then, figuratively speaking, throw them to the wolves expecting them to be the evangelists for the learning and the cure to all of our problems.

So what happens when we then get an average outcome? We don’t see the value in training more staff. And in this instance of problem solving, we will see a greater acceptance of mediocrity and of our inability to change this. It is essential that there is a feedback loop, whereby mediocre investigation reports are not accepted, or signed off.

Underpinning an effective investigation program requires managerial overview, whereby
managers are skilled in the RCA methodology and can challenge the outcome, provide positive recognition or insist on rework. If managers are not trained in the RCA method, then they are in the hands of the people who have been trained, and the danger is that mediocrity becomes the norm.

2)     Amount of time dedicated to investigations

How long does an investigation take? Should it be one hour?  Four hours? One day? One week?

There is no right answer.

If an investigation is warranted then it should be resourced to a point where an excellent result is possible. If that means you have 5 people in a room all day then so be it. The significance of the problem must warrant that level of support.  

Conducting a root cause analysis requires a dedication of time and resources to achieve a
desirable outcome. How much do your problems cost you after all? If you want your investigations to be effective, then you will need to support them to the level needed. A clear understanding of the organisation’s threshold limits that determine the level of response, is essential to ensure appropriate allocation of resources and time to attend or complete an investigation.

When you find yourself in a rush, ask yourself if you are simply satisfying the need to report, completing obligatory requirements, just meeting deadlines or is there a genuine opportunity to improve the business and make a difference.

3)     Involving the “right” people

If you don’t have the “right” people in the room – those with intimate knowledge or experience with the problem, then how good will the investigation will be?

Information is a key ingredient in all investigations and successful investigations require
that you have that information in the room in the form of the people who have the knowledge, data, evidence and reports.

Positive support and approval from management are necessary for people to be given the
time to attend the investigation.

4)     Having the “right” facilitator

Do you have the “right” person facilitating?

Good communication skills are important, both verbal and non-verbal. A willingness to be the facilitator should also be considered…someone who has the desire to do this job.

A good facilitator should be impartial, unbiased, willing to ask the dumb question, and arguably should not be the subject matter expert. A great facilitator recognises that the credit for a good investigation outcome belongs to the team, and he works deliberately to facilitate that outcome.

In summary

The cost of significant incidents has a direct impact on the bottom line. Incidents can cost a company hundreds-of-thousands or even multi-million dollars. Every incident or accident that occurs is an opportunity to learn. If we can learn effectively by doing a high quality RCA, then the goal of trying to prevent their reoccurrence is far more likely to be achieved.

The best results occur from investigations that are well supported, have the right facilitator, and have the right people involved who have been given sufficient time to understand the event so they can present the best report possible.

Getting these elements right will go a long way towards moving the quality of your RCA investigations away from mediocrity and towards excellence.

A key factor in establishing the framework for an effective RCA program is a common application standard, and easy to use reporting, and charting tools. The Apollo Root Cause Analysis methodology has been used for over 20 years to support effective Problem Solving. RealityCharting™ software has been developed to provide standardisation, as well as quality checks and help. RC Coach is an online support tool with easy to access refresher training to help individuals to keep learning beyond the classroom.