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Author: Jack Jager

Here are the top 6 sure-fire ways to kill off a Root Cause Analysis program

1. Don’t use it.

The company commits to the training, creates an expectation of use and then doesn’t follow through with commitment, process and resources! Now come on, how easy is it to devalue the training and deliver a message that the training was just to tick someone’s KPI box and that the process doesn't really need to be used.

2. Don’t support it.

Success in Root Cause Analysis would be the ultimate goal of each and every defect elimination program. To achieve success however, requires a bit more than just training people in how to do it. It requires structures that initially support the training, that mentor and provide feedback on the journey towards application of excellence and thereafter have structures that delineate exactly when an investigation needs to take place and that delivers clear support in terms of time and people to achieve the desired outcome. Without support for the chosen process the expected outcomes are rarely delivered.  

3. Don’t implement solutions.

To do all of the work involved in an investigation and then notice that there have been no corrective actions implemented, that the problem has recurred because nothing has changed, has got to be one of the easiest ways to kill off a Root Cause Analysis process. What happens when people get asked to get involved in RCAs or to facilitate them when the history indicates that nothing happens from the efforts expended in this pursuit? “I’m too busy to waste my time on that stuff!”  

4. Take the easy option and implement soft solutions.

Why are the soft controls implemented instead of the hard controls? Because they are easy and they don’t cost much and we are seen to be doing something about the problem. We have ticked all the boxes. But will this prevent recurrence of the problem? There is certainly no guarantee of this if it is only the soft controls that we implement. We aren’t really serious about problem solving are we, if this is what we continue to do?   

5. Continue to blame people.

The easy way out! Find a scapegoat for any problem that you don’t have time to investigate or that you simply can’t be bothered to investigate properly. But will knowing who did it, actually prevent recurrence of the problem?

Ask a different question! How do you control what people do? You control them or more correctly their actions by training them, by putting in the right procedures and protocols, by providing clear guidelines into what they can or can’t do, by creating standard work    instructions for everyone to follow and by clearly establishing what the rules are in the work place that must be adhered to.

What sort of controls are these if we measure them against the hierarchy of controls? They are all administrative controls, deemed to be soft controls that will give you no certainty that the problem will not happen again. We know this! So why do we implement these so readily? Because it is the easy way out! It ticks all the boxes, except the one that says “will these corrective actions prevent recurrence of the problem?”

We all understand the hierarchy of controls but do we actually use it to the extent that we should?  

6. We don’t know if we are succeeding because we don’t measure anything.

You get what you measure! When management don't implement or audit a process for completed RCAs it sends a strong message that there is no interest, or little, in the work that is being done to complete the analysis.

Tracking KPIs like, how many RCAs have been raised against the triggers set? How many actions have been raised in the month as a result and, of those actions raised, how many have been completed? If management is not interested in reviewing these things regularly along with the number of RCAs subsequently closed off in a relevant period, then it won't be long before people notice that no one is interested in the good work being done.

The additional work done to complete RCAs will not be seen as necessary, as it's not important enough to review and the work or the effort in doing this will then drop away until it's no longer done at all.

Another interesting point is that if only the number of investigations is reported, and there is no check on the quality of the analysis being completed, then anything can be whipped up as no one is looking! If a random audit is completed on just one of the analyses completed in a month then this implies that the quality of the analysis is important to the organisation. 

What message do we send if we don’t measure anything?

In closing, the first step on the road to implementing an effective and sustainable Root Cause Analysis program is to pinpoint what's holding it back. These Top 6 sure-fire ways to kill off a Root Cause Analysis program will help you identify your obstacles, and allow you to develop a plan to overcome them. 

Author: Kevin Stewart

 
This question was posed to a discussion group and it got me thinking how do you grade an investigation?

The overall success will be whether the solution actually prevents recurrence of the problem.  One definition of Root Cause Analysis is: “A structured process used to understand the causes of past events for the purpose of preventing recurrence.” So a reasonable assessment of the quality of the analysis would be to determine whether the RCA addressed the problem it set out to fix by ensuring that it never happens again (this may be a lengthy process to prove if the MTBF of the problem is 5 years, or has only happened once). 


Are there some other tangibles that can help you assess the quality of an RCA?  RCAs use some sort of process to accomplish their task. If this is the case then it would stand to reason that there will be some things you can look for in order to gauge the quality of the process followed. While this is no guarantee of a correct analysis, ensuring that due diligence was followed in the process  would lend more credibility to the solutions.


What are some of these criteria by which you can judge an analysis?

• Are the cause statements ‘binary’? By this we mean unambiguous or explicit. A few words only and precise language use without vague adjectives like “poor” since they can be very subjective.

• Are the causes void of conjunctions? If they have conjunctions there may be multiple causes in the statement. Words such as: and, if, or, but, because.

• Is there valid evidence for each cause? If causes don't have evidence they may not belong in the analysis or worse yet solutions may be tied to them and be ineffective.

• Does each cause path have a valid reason for stopping that makes sense? It is easy to stop too soon and is sometimes obvious. For example, if a cause of “no PM” has no cause for it so that the branch stops, it would seem that an analyst in most cases would want to know why there was no PM.

• Does the structure of the chart meet the process being used? If it is a principle-based process then it should be easy to check the causal elements to verify that they satisfy those principles. These might be causal logic checks or space time logic checks or others that were associated with the particular process.

• Is the chart or analysis completed? Does it have a lot of unfinished branches or questions that need to be answered or action items to complete?

• Is the chart or analysis completed? Does it have a lot of unfinished branches or questions that need to be answered or action items to complete?

• Are the solutions SMART (Specific, Measurable, Actionable, Relevant, and Timely)? Or do they include words like: investigate, review, analyze, gather, contact, observe, verify, etc.

• Do the solutions meet a set of criteria against which they can be judged?

• Do the solutions address specific causes or are they general in nature?  Even though they may be identified against specific causes if they don’t directly address those causes then it may still be a guess.

• If there is a report, is it well written, short, specific and cover just the basics that an executive would be interested in? Information such as cost, time to implement, when will it be completed, a brief causal description and solutions that will solve the identified problem are the requisites.

 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.