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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 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.

Our latest eBook gives you access to all our top tips for conducting better root cause analysis investigations.

We've covered root cause analysis from start to finish:

• Gathering information

• Assembling the team

• Conducting the RCA

• Implementing the solutions

• Measuring the success of the corrective actions

• Advertising your successes

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

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 Kevin Stewart

As is so often the case, sometimes we simply forget to wonder why. 

Have you heard the one about the daughter that saw her mother cut the ham in half before cooking it at the Christmas gathering and asked why?  “Well mom said we’ve always done it that way, but Grandma is here and I learned from her, so she can tell you why!”  So the daughter asks Grandma, “Why does mom cut the ham in half before cooking it?”  Grandma says, “Well Dear, I’ve always done it that way and I suppose your mother is just following suit. We’re in luck though, Great Granny is here and I learned from her, so why don’t you see if she knows.”  So she goes to Great Granny and asks, “Why does mom cut the ham in half before cooking it?”  “Oh dear!” says Great Granny.  “That is simple. When I was cooking Christmas dinner I didn’t have a pan big enough so I cut it in half and put it into two pans!!”

Perhaps we have forgotten to wonder why about 5 Whys?  I’m all for using the right tool for the right job, but what job was 5 Whys designed for? 

According to Wikipedia, it was developed by Sakichi Toyoda  and was adapted for the Toyota Production System (TPS) by Taiichi Ohno.  While not an expert on 5 Whys by any stretch, I do know the premise of TPS was to eliminate waste.  Everything was predicated on that simple notion, and all of the other tools were built to help them achieve that goal.  So I don’t think it is a giant leap to make the assumption that the 5 Whys was part of that.   I’m always interested in others thoughts, so I offer up that the 5 Whys was not designed as a tool to solve complicated problems that have many twists and turns to root cause, but rather as a simple tool that was supposed to help the operator on the floor become engaged in the problem solving methodology, and in the process, eliminate waste. 

If this is truly the case, then one can make the assertion that just because you have a hammer – everything isn’t a nail.

By this I mean that the 5 Whys can be used successfully in a simplified manner where the consequences are low, the time is short, and the tool is used close to the time of the incident.  This would mean that there would not be a lot of evidence or verification necessary because the consequences are low. In addition, suggested changes could be reviewed by supervisors and operators for validity before being put in place without a fear of major consequences.

So that leads us to the question – is the biggest problem with 5 Whys that in many cases we may be attempting to solve problems the tool wasn’t designed for? 

If it truly was designed for an operator to fix small problems that he recognized at the time they happened, then he wouldn’t have a lot of time. The problems wouldn’t be big and complicated, and the consequences were only that he would continue to waste time and money until the problem got fixed.  

In summary:

Let the consequence determine the need for validation. The 5 Whys are just “caused by…” statements that we don’t need to delve into when using the method for its intended purpose - analyzing a simple problem.

RC Simplified™ is the perfect tool to conduct 5 why investigations. It is free, readily available and simple to use. If the investigation requires a report or follow up, simply convert RC Simplified™ to an Apollo investigation in RealityCharting®. This provides for reporting, documenting actions and finding solutions. They are the perfect combo - 5 whys + RC Simplified™

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.

You’ve investigated an incident, and now it’s time to write up your report. This report should document what you’ve found, and the corrective actions needed to prevent recurrence or mitigate the problem to an acceptable level.

At the heart of a good report is a strong, clear executive summary.

What does an executive summary look like? Is it a dot point affair? Is it a few one-liners that capture the critical elements of the issue? Or do you tell a story that recreates everything? Is it something in-between?

While it is certainly not the case that “one size fits all” – particularly given that different companies have different needs and policies – there are some golden rules that can be applied in crafting the perfect executive summary.

Be brief.

An executive summary should be brief and to the point. Yet it must still convey critical information, such as:

• The cause and effect paths identified in the investigation
• Lessons about the causal relationships culminating in the incident
• Rationale behind why certain corrective actions have been recommended

It should only take a few minutes to read. For a manager whose time is precious – and hence will likely not read the full report – the executive summary is their insight into the full investigation.

Be factual, but clear.

An executive summary should be factual, yet written for easy reading.

Everyone should be able to understand it, so avoid words that confuse people. Stick to clear, simple language that is easily read and interpreted.

Avoid ambiguity and generic language, which may lead to alternate interpretations of the information. For example, citing “mechanical failure” could refer to any or all mechanical failures. A root cause analysis targets a very specific failure – a seized motor, for instance – which has very specific causes.

An example: “… a temporary loss of cognitive function.”

An ore truck, fully laden with coal, was driving out of a mine. The engine “died” and the ore truck rolled backwards, hit a bank and flipped over. There was considerable damage but no injuries.

An investigation was launched, and a report produced. This report stated that “the driver had a temporary loss of cognitive function.”

This is not clear. What actually happened was that the driver fell asleep. Why didn’t they just say that in the report? Perhaps the report’s writer was trying to protect the driver from undue criticism. Yet, of course the driver didn’t mean to fall asleep.

The purpose of an investigation is not to point the finger, but to prevent a recurrence. So instead of focusing on “who”, a “why” question is needed in this example to elicit more specific, factual responses.

Avoid technical jargon.

Don’t fall into the trap of assuming that everyone will be able to follow your technical or task-specific jargon. Likewise with abbreviations or acronyms. Try to avoid this type of language.

Instead, write the report for a non-technical audience. This will make it easier for a broader readership to interpret and make sense of it, and reduce the number of questions you field once the report is published.

Use “caused by” language.

With reference to the cause and effect chart you created during the investigation, use “caused by” language to join the causes together. So A was caused by B and C; B is caused by D, E and F; and C was caused by G and H (where the letters represent the causes depicted in the chart).

This approach is simplistic, and deliberately so. It summarises the chart in a language that is easy to follow. It is factual and gets to the point. It avoids “storytelling” and the different interpretations that come from such an approach.

In summary

By following the advice above, you will find that an executive summary is quick and easy to read – and doesn’t take long to write, either.

Be aware that every organisation’s needs are different, and yours may have specific rules around what an executive summary should contain. If you have no template to follow, then use the advice above to craft the perfect executive summary for your investigation.

 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.

To be, or not to be, that is the question:
Whether ’tis Nobler in the mind to suffer
The Slings and Arrows of outrageous Fortune,
Or to take Arms against a Sea of troubles…

“To be or not to be” is the opening phrase of a soliloquy in William Shakespeare’s play “Hamlet”. It is perhaps the most famous of all literary quotations, but there is deep disagreement on the meaning of both the phrase and the speech. Whilst we won’t be solving that disparity in this article, we will discuss the disagreements amongst the global engineering community as to whether the 5 Whys process is sufficient enough to effectively identify the root causes and ultimately, the solutions, for a particular problem.

Why – Why – Why – Why – Why?

The 5 Whys is a question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem.

The technique was originally developed by Sakichi Toyoda and was used within the Toyota Motor Corporation during the evolution of its manufacturing methodologies. It is a critical component of problem-solving training, delivered as part of the induction into the Toyota Production System. The architect of the Toyota Production System, Taiichi Ohno, described the 5 Whys method as “the basis of Toyota’s scientific approach . . . by repeating why five times, the nature of the problem as well as its solution becomes clear.”

However, whilst the tool may have had success in the automotive industry it has received criticism from within other industries for being too basic and not complex enough to analyze root causes to the depth that is needed to ensure that solutions are identified and the problem is fixed.

There are several reasons for this criticism of the 5 Whys method:

• Tendency for investigators to stop at symptoms rather than going on to lower-level root causes
• Inability to go beyond the investigator’s current knowledge – cannot find causes that they do not already know
• Lack of support to help the investigator ask the right “why” questions
• Results are not repeatable – different people using 5 Whys come up with different causes for the same problem
• Tendency to isolate a single root cause, whereas each question could elicit many different root causes
• Considered a linear method of communication for what is often a non-linear event

Many companies we work with for training and engineering services successfully utilize the 5 Why technique for very basic incidents or failures. By utilizing the correct placement of triggers, organizations can use the 5 Why for its basic problem solving and then move to a form of Cause and Effect analysis like the Apollo RCA method for more complex problems.

A disciplined problem solving approach should push teams to think outside the box, identifying root causes and solutions that will prevent reoccurrence of the problem, instead of just treating the symptoms.

Any effective problem solving technique should meet the following six criteria:

1. Clearly defines the problem
2. Clearly delineates the known causal relationships that combined to cause the problem
3. Clearly establishes causal relationships between the root cause(s) and the defined problem
4. Clearly presents the evidence used to support the existence of identified causes
5. Clearly explains how the solutions will prevent recurrence of the identified problem
6. Clearly documents criteria 1 through 5 in a final RCA report so others can easily follow the logic of the analysis

RealityCharting has come up with a simple, free tool that can be used to help with a 5 Why investigation. RC Simplified™, the free to download version can be utilized on smaller issues as it allows the user to build a cause and effect chart that is no greater than 4 causes high and 5 causes deep. This means the user of a 5 Whys approach can create a Realitychart using the same thought process adopted in the Apollo Root Cause Analysis methodology. It also demonstrates a non-linear output to what was originally considered a linear type problem.

So when looking for problem solving tools or root cause methodologies, be willing to “think outside the box” and utilize a number of resources depending on the complexity of the problem and the significance of the incident. We believe that the 5 Why’s approach definitely has a time and place to be utilized. However, if the problem is more complex, don’t limit yourself to a 5 Why approach as you will likely not be satisfied with the solutions generated.