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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. 

By Kevin Stewart

With all the preparation work (Honing your Facilitation Skills: Part 1) behind you, you’re now ready to start facilitating an Apollo Root Cause Analysis. Follow the steps below to ensure a smooth process and successful outcome.

  
Step 1. Introductions  

First, do some simple introductions and housekeeping. Cover things like:  

• Introductions all around
• The meeting guidelines: when to take breaks, phone and email policy, and so on
• The objective: we’re here to fix the problem, not appoint blame
• A review of the Apollo Root Cause Analysis methodology for those who may not be familiar with it (spend 15 – 45 minutes depending on the audience)
• Your role as facilitator: you may need to ‘direct traffic’ or change the direction of discussions to help them discover more causes or to reach effective solutions

Step 2. Timeline

It’s now time to capture the ‘story’. What has happened that brought you all here? Get several people to provide a narrative, and develop a timeline of events as you go.  

This timeline will prove very useful. It should reveal the event or issue that becomes your primary effect or starting point – and ensures that all the items beyond this starting point capture the group’s issues.    

In the example below, if I start from T1 I’ll discover why I left my iPad in the bathroom.  However if I start at T7 I will also discover why my check process didn’t function as desired.

While the time that each event occurs is important, it might not always be known. In these instances, you can represent the time sequence as simply T1, T2 and so on.

Step 3. Define the problem

You’re now ready to define the problem. Often, the problem definition comes out easily and everyone agrees. However, sometimes you’ll find that the group can’t arrive at a Primary Effect. In this case, as facilitator, it’s your job to regroup and ask some questions about why everyone is interested. Often, it’s about money.

One thing you don’t want to do is get stuck trying to find the perfect starting point. I’m reminded of a saying I heard once:

Dear Optimist and Pessimist,

While you were trying to decide if the glass was half empty or half full, I drank it!

Sincerely,

The Realist

The Apollo Root Cause Analysis methodology is robust enough to handle an imperfect starting point. If the problem changes or evolves as you go, just put it down as the new starting point, adjust the chart and go on!

Now that you have a defined problem, with its significance well understood, you’re now ready to start the charting process. The team should also know by now why they’re here, and how much time and money can be spent on the investigation. 

If you missed Part 1 of this article, you can read it here.

Would you like to learn more about the Apollo Root Cause Analysis methodology? Our 2 Day Root Cause Analysis Facilitators course is perfect for anyone needing to understand fundamental problem solving processes and how to facilitate an effective investigation.

By Jack Jager

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

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

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

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

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

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

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

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

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

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

So what is the “root cause” here?

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

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

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

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

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

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

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

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

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

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

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

So what criteria can we use to determine our choices?

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

and other criteria may also be considered.

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

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

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

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

In Summary

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

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

By Ned Callahan

Every organisation has unresolved problems. Some are greater than others.

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

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

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

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

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

Work-around’s for managed problems

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

Kick starting the process

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

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

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

Activation of Triggers

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

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

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

In summary

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

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

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

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

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

 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.