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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.

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.

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

If you are investigating an incident using Root Cause Analysis (RCA), what are the critical skills that you should possess as an RCA facilitator?

Here are five key skills that will help to make you a more effective facilitator.

1. Value all ideas equally

First of all, it is important to acknowledge all ideas – nothing is unimportant. Something that seems trivial now may hold a great deal of value later in the process. Discourage any negative feedback from the group. This, too, is a disincentive to proffer suggestions or ideas.

The goal of information gathering is to capture everything known about a problem, no matter where it fits into cause and effect relationships. Just by watching you write a comment on a yellow “stickie” or type into the holding area, the participants can see that you are acknowledging what they know. Later, if it fits in the cause and effect chart then it has value; if it doesn’t, then it will naturally fall off the chart.

Secondly, value each and every response, regardless of where it comes from. First and foremost, this will encourage a positive flow of information from participants. If the facilitator starts saying “No, that’s not right”, then people may think before speaking and slow the whole process down. They may even stop contributing to the discussion, censoring the information in their own minds and preventing it from being evaluated on its own merits. Similarly, if someone offers a suggestion which is ignored then participants can switch off – you have to be able to work rapidly or say, “Hold that thought while I finish writing this one”.

So remember … no put-downs allowed, from you or any other member of the group. Positive affirmation is the mode for the facilitator to get a productive session.

2. Be dynamic

As facilitator, you need to guide the direction of the group and yet still be alert for other cause paths that may crop up. You are the prime mover, controlling the focus of the group. Don’t be a bystander to the process. You are the conduit through which the group is interacting.

Ask questions that are as precise as possible. This will elicit better, more concise responses which make it easier to identify causes. Good questioning will also eliminate unnecessary discussion and storytelling from the group.

Once the information has been recorded, get the group to help you organise the information and then challenge the logic of the way that information is linked together. Your cause and effect chart needs to make sense – or it risks being challenged and disregarded by those who look at it.

Remember … being dynamic may not come easy or naturally, but it’s important to give it a go. In this mode, you should continually ask “why” questions.

3. Keep the analysis moving

Don’t let the investigation get bogged down in detail too soon. Get the first pass of the chart out and then refine it. If the first pass is a linear connection of causes, then so be it. Remember, this is the start of the cause and effect chart, not the finish.

A timeline is often a good place to start – ordering key events according to “when” they happened. Such a timeline does not address the question of “why”, but it could certainly initiate a more comprehensive search for causes.

Do not waste time at this point trying to judge or evaluate each cause. Simply ask “why” immediately after placing the cause on the chart to keep people focused and moving down a productive path.

Try not to allow individuals to dominate the analysis. Everyone is there for a purpose, and has information to contribute to the investigation. Ensure that all people have the opportunity to speak. Keep redirecting and asking for other inputs. If one group member is dominant, set some ground rules – try giving each participant a chance to say what they know in turn, working your way around the group.

Remember … adding the finer detail can happen later, but then the devil is always in the detail. The onus is therefore still on you to do this.

4. Be a good listener

Attentive listening skills are critical. You need to be able to hear more than one response at a time. Your ears should be like radar, picking up on all signals. Don’t miss a response while recording another. You need to record everything.

Being a good listener means keeping an open mind, suspending judgment, and maintaining a positive bias.

It also requires the efforts of the whole group – ask the group not to have discussions on the side, as they might come up with causes that should be included but may not be shared with the group. This will also help you to hear all responses more clearly.

Remember … delegating the recording of information could be useful if it will help you to listen more effectively.

5. Don’t profess to be an expert

Don’t profess to be the expert about the problem at hand. You were appointed to be the facilitator, an independent guide, without a vested interest in the outcome. Ask the others in the group to explain what they know so that everyone can follow and understand it. That is why they are there. Remember … you don’t hold all the answers. That isn’t why you are the facilitator or it shouldn’t be. A good facilitator plays dumb whilst still directing traffic and working the cause and effects paths to a reasonable stop point.

Conclusion

Every incident comes with its own challenges. Each time you facilitate, you will no doubt come up against a range of human behaviours, which you will have to manage.

It’s a great idea to debrief the process and your role in it with some of the people involved. They will no doubt provide valuable feedback that will help you improve.

Finally, have faith in the RCA process, and learn from each experience to build on your skills as a facilitator.

Read about the key steps in preparing for RCA success.