Tools to Achieve Performance Excellence

A Thoughtful Approach to Root Cause AnalysisAndrew KirschMaster Black BeltEnterprise ExcellenceECOLAB

Two Philosophical Assumptions

Three Imperfect DefinitionsEffect - A change in a state of being that results when something is done, or happens, or does not happen.

Cause Something that contributes to producing an effect

Root Cause One or a few of the most fundamental of a chain of causes that product an effect

5 Whys and the Washington MonumentProblem: Washington Monument required frequent, very expensive repairs.

1. Why? Frequent washing was damaging the monument.2. Why did it need to be washed so much? Pigeon droppings3. Why were the pigeons on the monument? To eat the spiders4. Why were there spiders on the monument? To eat the insects5. Why were the insects there? They are attracted to the brightly lit surface at sunset.

A Template for 5 Why AnalysisTips for Use: There is nothing magic about 5, but push yourself to go further than 1 or 2At some point you may find yourself going from the specific to the general (poor communication, political gridlock, lack of motivation) - back up and try to be more specific

Effect of Interest:1. Why?2. Why?3. Why?4. Why?5. Why?

Cause and Effect Diagram(Also called Fishbone or Ishikawa Diagram)Represents the relationship between an effect (problem) and its potential causes where causes are organized by categoriesCategories of CausesEffect of Interest

Cause and Effect DiagramWhy - Use of categories ensure a full range of potential causes have been consideredOvercome the theme effect by allowing the group to see the categories into which their ideas fall and dig deeper on those with fewer itemsHow Decide on a set of major categories before starting to brainstorm causesThe traditional categories for manufacturing are personnel, environment, machines, materials, methods, measurementsFor non-manufacturing use, might use the 4 Ps: Place, Procedures, People, Policies

Blending Fishbone and 5 Why MethodsEffect: Same1. Why? Have to pay a high price for the reagents in the quantities needed2. Why? xxxxxxxxxxxxx3. Why? xxxxxxxxxxxxxxxxxxx4. Why? xxxxxxxxxxxxxxxxxx5. Why? xxxxxxxxxxxxxxEffect: Cost of maintaining test kits for field employees too high1. Why? Must frequently replace reagents in the kits2. Why? The reagents are past expiration date3. Why? The shelf life of many of the reagents are a year or less4. Why? At the time that the shelf lives were determined, the software for recording the official shelf life only had two choices in the pulldown menu 6 months and 12 months!Corrective Action = Qualify and document a longer shelf life where possibleThe 5 Why method is often used with a Cause and Effect Diagram to drill down to a root cause

Limitations of a Simplistic AnalysisAn effect may require two or more causes to occur in the same place and timeThe analysis may be limited by the current level of knowledgeThe analysis may be based on conventional wisdom or restricted by prejudiceThe root cause may not be the easiest to fixAn effect may be part of a system loop

A Template for Two or More Causes per Level (per Why)

Effect1st Level Why2nd Level Why3rd Level WhyCause 1Cause 1.1Cause 1.1.1Cause 1.1.2Cause 1.2Cause 1.2.1Cause 1.2.2Cause 2Cause 2.1Cause 2.1.1Cause 2.2.2Cause 2.2Cause 2.2.1Cause 2.2.2Cause 3Cause 3.1Cause 3.1.1Cause 3.1.2Cause 3.2Cause 3.2.1Cause 3.2.2

Two or More Causes per Level (per Why)

Effect1st Level Why2nd Level Why3rd Level WhyWorker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot trafficCause 1The floor was wetCause 1.1 The drain was not workingCause 1.1.1PluggedCause 1.1.2Not checkedCause 1.2 The vessel had to be rinsedCause 1.2.1SOP requiresCause 1.2.2Cause 2 The workers shoes had poor treadCause 2.1 The shoes were 5 years oldCause 2.1.1Cause 2.2.2Cause 2.2 The shoes hadnt been replacedCause 2.2.1Thought okCause 2.2.2BusyCause 3The worker chose to go through this areaCause 3.1 Alternate route takes longer Cause 3.1.1Plant designCause 3.1.2Cause 3.2 No barrier to prevent Cause 3.2.1Not expectedCause 3.2.2

Considerations beyond Root CauseTradeoffsSpan of Influence or ControlLegality, Propriety, Respectfulness

Two or More Causes: Reconsidering the Washington MonumentProblem: Washington Monument repairs.

1. Why? Frequent washing was damaging the monument.2. Why did it need to be washed so much? Pigeon droppings3. Why? Pigeons AND a food source (spiders)4. Why? A nearby population of pigeonsSpiders AND a food source (insects)5. Why? A nearby population of spidersA nearby population of insectsAttraction for the insects (brightly lit surface).

5 Why for an Act of Gang Violence++++++

Role of Evidence/DataMakes all the difference between conventional wisdom and sound analysisA single instance is not strong proof of root causeEach link in the chain of causes should be verified with evidence/dataPhysical scientific studies (e.g. chemical analysis)Statistical studies (e.g. clinical trials)Behavioral studies (e.g. Hawthorne effect)Historical data review (e.g. drunk driving)Is/Is Not analysis

Is/Is Not AnalysisConsider the what, where, when, extent of the problem/deviation:What specific object has the problem/deviation?What is the nature of the problem/deviation?What similar object could have the problem/deviation but does not?What other problems/deviations might reasonably be observed but are not?Test if possible causes against the is and is not facts to rule out some, judge likelihood

ISIS NOT

Boiling it down Start with a fishbone diagram to enlarge your view of possible causesUse the 5 Why approach to go deepBe open to multiple causes at each levelUse simple (linear) 5 Why when possibleBe open to a system loopLook for data to support the chain of causesDecide on the root cause(s)Give preference to prevention at that causeFactor in tradeoffs, span of influence, etc. as appropriate

Summary of Tools DiscussedFishbone Diagram5 Why (Simple and Multiple Cause)Systems Thinking (the Loop)See Peter Senge, The Fifth DisciplineIs/Is Not AnalysisSee Charles Kepner and Benjamin Tregoe, The New Rational Manager

QUESTIONS?

*Good afternoon. What I want to do in this talk is to explain what is meant by root cause analysis and give you some tools to do it. But I also want to explain how NOT to do it, because there are more than a few traps you can fall into.

TR: But before getting to the tools of the trade, I want to begin with something very practical that is, a little philosophy! *We live in an age with a great diversity of philisophical assumptions, so I want to be very upfront about mine. My first is that

If this seems too obvious to be worth making explicit, I will refer you to a book written by an author of a book on Root Cause Analysis (Dean Gano) in the Introduction he write of a single Reality that there is no such thing. To me this is the philosophical equivalent of spitting into the wind because his assertion that there is no such thing as a single reality is itself a statement about reality, and hence is, so to speak, hoist on its own petard! For me, it is essential that we decide that we are trying to analyze a shared, single Reality else it is not even clear that there is any effect to find the cause of!

The second assumption is that all changes, including anything we might call an effect are caused. This is not to say that all effects are mechanically caused (such as Newtons first law), nor that every cause and effect are known or even knowable by science, but that no effect simply springs into being it has some antecedent that contributed to its presence in a particular time and place. Its almost hard to describe any alternative to this but think about how events can happen non sequator in a movie. If you are standing by a lake and hear a splash, it is absolutely human to ask, why did that happen? In psychology, an adult who didnt accept this would be said to indulge in magical thinking and be considered to have a pathology. But again, I want to be up front about it, lest someone here has a different view of life.

Of course this begs the question, what is an effect, a cause, and indeed a root cause.*These are the everyday meanings of effect, cause and root cause. They are not as precise as they might be, but they are operationally adequate for this talk.

As regards the definition of Effect, the reason I included the last phrase is for cases like a failure to water a plant. We may say that the lack of water caused a change in the state of the plant.

Notice that my definition of Cause allows for the possibility that it may take more than one cause to produce a single effect of interest. More on that later.

Finally, regarding root cause I didnt say the first cause that would have created a contradiction. Take the example of a dandelion in your lawn which threatens to spread seeds around. We could say quite literally that the tap root of that weed is the root cause but we couldnt call it the first cause, because there was some other dandelion whose seed produced this plant. But for the dandelion plant at hand, we could call it the fundamental cause.

TR: Ok, so what are some tools for doing root cause analysis? One of the most common is called asking the 5 whys*This is such a clear-cut example of a root cause analysis. Like peeling an onion, one layer at a time. Whats more, it demonstrates the real power of root cause analysis because the solution to the problem was so elegant once the root cause was determined: they simply turned the lights on 1 hour later! [pause]

It would have been possible to address the problem at any of the steps but like the dandelion, the best solution was to address the fundamental nature of the problem, rather than higher up the sequence of causes.

For those who want a clear-cut tool they can walk away with, here is a template for 5 Why analysis [explain]

I have also added two tips for its use.

TR: Another common tool for root cause analysis is .*This is the one and only example that reflects a real situation at EcolabAs an example of #1, a spin out on the road may be causes by tires with less tread in conjunction with a slipper surface such as ice or rain. Low tread tires alone may not be enough, nor ice or rain if the tires are in good shape.

To illustrate #2, Imagine trying to do a root cause analysis on the black plague during the middle ages there simply wasnt enough basic knowledge of infection to be able to do it successfully. We know much more about that today, but there are other areas where we are still speculating.

Somewhat different is #3 this is where we THINK we know something. For personal safety, the conventional wisdom may be that our safety training is deficient, or our workers careless, or our management uncommitted, etc. and if so, that will tend to be the default root cause of many accidents.

For the last two, well look at a couple of specific examples to make those points.

TR: But first, how should we modify our 5 Why template to allow for the possibility of two or more causes per effect*You can make something more visually appealing than this if you have software for making flow charts but the main thing is that each level of Why make have more than one cause. In fact I would say that it is almost always useful to think in terms of multiple causes per level. Usually a failure of some sort involves both a risky condition and a trigger event.

Example: gas fumes and lighting a match

*Notice that for Cause 3, you would probably say that Cause 3.1 is more fundamental than 3.2, and that 3.1.1. is the most fundamental reason why the worker went through this area. However it would be incredibly expensive to redesign the plant to address the risk of an accident. So we might opt to make a barrier. Maybe we could create a full wall that made it impossible for the worker to go that route, or maybe we settle for a handrail and a sign, but notice that we have departed from the dogma of fixing the root cause. The point is that there are practical considerations.*

Tradeoffs a full wall may eliminate this risk but increase the risk of entrapment in case of a fire. We should try to prevent solders from getting hurt but at some point, theyd have to stop being soldiers!

Span of Influence or Control sometimes the best remedy is beyond your control or even your influence. To keep a 2 year old out of the street might ideally be done by logic but in practice you may just have to put up a fence and remain vigilant that no holes develop.

Certain remedies to root cause might violate legal norms or those of propriety or respect. Sadly, some police have gone too far in trying to get after fundamental causes of crime. Or even if we believe that love of money is the root of all evil, we might not want to open re-education camps for all instead of a criminal justice system!*So what looked like a very straightforward root cause analysis is really more complex. But even if we had mapped all of these causes, we would, I think, have concluded that the fundamental cause triggering this chain of causes was the decision to light the surface at sunset.

TR: Finally, a simplistic root cause analysis might miss out on the fact that some effects are part of a system loop.For this kind of situation, you have to intervene wherever you can since the notion of fundamental cause breaks down

TR: *Any questions?

Finally, thank you for your attention!*