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Actions or Conditions: What is the Difference and Why Does it Matter?

Posted by Jack Jager on Fri, Aug 12, 2016 @ 03:08 AM

One of the four basic principles in the Apollo Root Cause Analysis methodology is that for each effect there are at least two causes and these causes are either actions or conditions. bigstock--133288028_BWCropped.jpg

This principle causes you to think more critically, challenge causal relationships more consistently, and to understand that things are rarely as simple as they may seem.

One implication of this principle is that there should never be a straight line, or even a partial straight line of causes within a cause and effect chart. A straight line tells us that there are other causes that still need to be found or identified, and more questions must be asked.

In each causal connection we should see at least one action cause and one condition cause.

So what are actions and conditions?

Conditions exist—they refer to the current state of things. Take gravity for instance—it is there all the time. Gravity exists. So this cause would be a conditional cause.

Conditions must exist. They always exist alongside of any action.

An action cause is a cause which makes use of the available conditions. If the conditions didn’t exist, then the action would have no effect at all. The action cause is that moment in time when something happens. It is the thing that is different—the instigator or the catalyst of the effect that occurs.

Typically, there is one action and several conditions. Many of the action causes are also related to the things that people do. Action causes are readily seen and tend to be easily identified. When people tell the story of what happened they often list a series of actions, and relatively few conditions.  When we create a timeline or sequence of events, the initial straight line will be constructed mostly of actions. image_1.png

The Apollo Root Cause Analysis methodology demands an exhaustive search for both condition causes and action causes. If you only see half of the problem, will you really understand it? If you only find half of the causes, you will also only have half of the opportunities for controlling or mitigating the problem to an acceptable level.

Let’s take a look at an example – “An Object Fell Off a Platform”

“What happened to make the object fall?” would be a good question to ask. Let’s say someone kicked it off the platform. This is the direct cause of why the object fell, so this is considered an action cause. It is the ‘something’ that happened.  An action cause will typically be described using a noun/verb connection as in ‘object /kicked.’

But it’s not always that simple. There are other causes that have played a role in this scenario.  At this point in time it is important to challenge the concept of the linear connection of causes and keep searching for more.

The “Every Time Statement”

A useful tool to apply in this scenario is an “Every Time Statement.” The statement itself should be absolute in the sense that all causes in the connection need to be present. The same effect should happen each time the action occurs.

 So, every time you kick the object off the platform it will fall? No, not every time.

Why not?  Because, the object in question must be elevated. If you kick it while it is on the ground it will not fall.

So is this an action cause or a condition cause?

It is a state of where the object was at the time it was kicked. So in this instance this cause would be labelled as a condition.

Now that another cause has been identified, you can repeat the “Every Time Statement.”

Every time you kick the object off the platform and the platform is elevated, the object will fall. Every time?  Well, it will only be true if there is gravity in play. If there is no gravity present, then this statement will not be true. 

Is gravity an action or a condition? It’s not an event, it just exists. It was there when the problem occurred. This means that we would label this cause as a condition.

There are now three causes in this causal relationship, but have we identified every cause in that causal connection? At this point we have:

  1. Kicked object off platform
  2. The platform was elevated
  3. Gravity was present

Will the object fall every time?  Only if the object has a mass which is greater than that of air. If it were lighter than air, then it would not fall.

Is this cause an action or a condition? Again we observe that the object’s mass didn’t change. Its mass was what it was before the incident and had been so for some time. This makes this cause a condition.

Encourage people in the RCA group to actively look for the exception that makes a lie out of the “Every Time Statement.”  Every time you find an exception to this statement you have effectively identified another cause. Add it to your list of causes and repeat the “Every Time Statement.” When you can’t identify any other exceptions then you should have effectively identified every cause in that causal connection. The statement should now be absolute.

So what we have identified here is that there are at least four causes in this causal relationship that will influence whether an object will fall or not. In fact, every time something falls the same types of causes will be in play. The action cause will still need to occur, but this may come in different forms. The action can be different but it will still make use of the available conditions.

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To Sum Things Up

It is valuable to be able to label causes as either actions or conditions. The process of labelling causes demands that you find multiple causes for each connection. This in itself will challenge your understanding of the problem.

Understanding what the conditional causes are will also lead you to finding the most effective solutions for your problem - the hard controls. By actively engaging in challenging the logic of each and every connection within the cause and effect chart consistently, many more conditional causes will be found and more options of control will present themselves. When you have the ability to eliminate a conditional cause, substitute it, or engineer it out, then your solutions and their outcomes will be more consistent, reliable, and predictable. You can therefore, with a fair degree of certainty, declare that the problem will not recur.

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Topics: root cause analysis, rca success, rca skills, critical rca skills, root cause analysis tips

Incorporating Alternate Realities Into Your RCA - Science Fiction or Just Good Business?

Posted by Susan Rantall on Fri, May 29, 2015 @ 00:05 AM

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Author: Kevin Stewart

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

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

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

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

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

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

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

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

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

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

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Topics: root cause analysis, rca success, root cause analysis tips

Top 6 Sure-Fire Ways to Kill off a Root Cause Analysis Program

Posted by Lou Conheady on Wed, Sep 24, 2014 @ 15:09 PM

Author: Jack Jager

An effective root cause analysis process can improve business outcomes significantly. Why is it then that few organisations have a functioning root cause analysis process in place? 

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

1. Don’t use it.

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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 rectraining your staff urrence 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.

measuring success

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. 

 

Webinar Elements to Sustain a RCA Program
 

 

Topics: root cause analysis, rca success, rca skills, root cause analysis skills, root cause investigation, root cause of success, root cause analysis tips, success definition, root cause analysis program

How to Judge the Quality of an RCA Investigation

Posted by Lou Conheady on Tue, Sep 02, 2014 @ 14:09 PM

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). bigstock-Blank-checklist-on-whiteboard--68750128.jpg


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.

 

These are some of the things that I currently look at when I review the projects submitted by clients. I’d be interested to know about other things that may be added to the list.

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Topics: root cause analysis, rca facilitator, rca success, rca skills, root cause analysis skills, rca facilitation, root cause investigation, critical rca skills, root cause of success, root cause analysis tips, facilitation skills

Root Cause Analysts Tips & Tricks - 101 Ways to improve your RCA Investigations

Posted by Susan Rantall on Wed, Sep 25, 2013 @ 00:09 AM

 

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  • Gathering information

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  • Plus, a whole section of tips for the RCA facilitator

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Topics: root cause analysis, rca skills, rca facilitation, root cause investigation, critical rca skills, root cause analysis tips