root cause analysis: an introduction prepared for you by barbara immel, president, immel resources...

Root Cause Analysis:An Introduction

Prepared for You by Barbara Immel, President, Immel

Resources LLC, and Editor, Immel Report

Ó2007, Immel Resources LLC, Petaluma, California USA, www.immel.com

Overview

• Common problems• Understanding

causes• Problem definition• Identifying and

implementing solutions

Ó 2007, Immel Resources LLC

Common Problems (1 of 4)Source: Apollo Root Cause Analysis, DL Gano, Apollonian Publications, Yakima, WA, 1999

• 20% of population are effective problem solvers (up to 30% in some industries)

• Key: Do not ask people to change their minds, but expand on what they already know

Ó 2007. Immel Resources LLC

Common Problems (2 of 4)

• People stop too soon, before they understand causes

• “Root cause” myth– Assumes problem

born from one source, and that causes are linear

– Seeking solutions before knowing causes



• “Illusion” of common sense and single reality– Everyone has unique

perceptions, knowledge, strategies & conclusions

• “Groovenation”– Too focused on being

right, justifying beliefs

• Storytellling– Ignores cause and

effect, tells good story, exhibits group think



• Poor writing– Poor problem-

solving, rule-based thinking, “filling in a checklist” mentality

• Categorical thinking– Prejudice; putting

everything and everyone in a “box”


Ineffective Problem Solving (1 of 2)

• Incomplete problem definition– Boss or expert’s

opinion simply accepted; so busy tracking & trending but still failing miserably. Good problem-solving? Problem does not repeat.

• Unknown causal relationships– Continue to ask “why”

to point of ignorance; rather than rely on inferences or storytelling

Ineffective Problem Solving (2 of 2)

• Focus on solutions– If do not clearly define

problem, may solve wrong problem

– Groovenation -- when seek what is familiar, favorite solution mindset -- preventing effective problem-solving

– Authoritative and goal-driven individuals: Ready, Shoot, Aim! mentality with categorical thinking/groovenation


Cause and Effect Principle

• Each effect has at least two causes in form of actions and conditions

• An effect exists only if its causes exist at same point in time and space

• Causes and effects part of infinite continuum of causes


Cause and Effect: An Example

• Effects Causes• Injury caused by Fall• Fall caused by Wet

Surface• Wet caused by Leaky

Surface Valve• Leaky caused by Seal

Valve Failure• Seal caused by Not

Failure MaintainedÓ 2007, Immel Resources LLC

Primary Effect or Event

• Any effect of consequence that we want to prevent from happening

• Pain CB Injury CB Fall CB Slipped CB Wet CB Leaky Surface Valve


Always at least Two Causes in Form of Actions and Conditions• Primary effect caused

by actions and conditions

• Actions– Momentary causes

bringing conditions together to cause an effect (action causes)

• Conditions– Causes that exist over

time prior to an action (pre-existing conditions)


Actions and Conditions

• Action• Match Strike

• Condition• Effect Dry Vegetation• Open Fire Caused By• Condition• Combustible• Material• Condition

• OxygenÓ 2007, Immel Resources LLC

Elemental Causal Set

• Made up of an effect and its immediate causes

• Causes include action and one or more conditions

• Causal sets, like causes, do not exist alone but are part of a continuum of causes with no beginning or end


Why Storytelling Is Not Enough(Linear Language = Linear Thinking)

• Stories start in past while causal relationships start with present

• Stories are linear while causal relationships follow branches of infinite set

• Stories use inference to communicate meaning, while problems are known by sensed causal relationships

Complete Problem Definition• What is the problem?• When did it happen?• Where did it happen?• What is the

significance of the problem?

• Not “who” or “why”• Who places blame,

Why is part of analysisÓ 2007, Immel Resources LLC

Effective Problem-Solving

• Define the problem• For major problems,

create a cause and effect chart– Similar methods use

logic trees, or fishbone diagrams

• Identify effective solutions

• Implement the best solutions


Important Concepts

• Like a puzzle but no boundaries

• Like a jigsaw puzzle, it will fit together if you persevere, have patience and tenacity

• How eat an elephant? One bite at a time (dividing problem into smaller parts focusing on separate primary events -- called chunking)


Look for Causes in Actions and Conditions (1 of 2)

• Actions: momentary causes that bring conditions together to cause an effect

• Conditions: causes that exist over time prior to an action

• Just concentrate on identifying and listing causes


Look for Causes in Actions and Conditions (2 of 2)

• For each “action” cause, ask what conditions had to be in place for that action to cause the effect

• For each “condition” cause, make sure have corresponding action

• Generally several “condition” causes and one “action” cause in each set


Support All Causes with Evidence or Use a Question Mark• Set a deadline to

collect evidence• Incorporate as

much knowledge as possible given time constraints

• Evidence: data that supports a conclusion

• 2007, Immel Resources LLC

Identify Effective Solutions

• Solution:– An action taken

upon a cause to affect a desired condition

• Criteria:– 1. Prevent

recurrence– 2. Be within your

control– 3. Meet your

goals and objectives


Solution Criteria

Prevent recurrenceBe within your controlMeet your goals and

objectives Solution does not cause

unacceptable problems Solution prevents

similar occurrences, including at different locations

Solution provides reasonable value for its cost


Solution Guidelines (1 of 2)

• Sometimes solution appears beyond your control because need higher approval -- your hard work will help you “sell” your idea

• Sometimes good solutions come out of the blue, from nowhere (subconscious mind)


Solution Guidelines (2 of 2)

• Solutions should always be specific actions

• Don’t include solutions such as “review, analyze, or investigate” (copout)

• Avoid denial and don’t say that you don’t know what the causes are. Implement mitigating solutions until you can investigate further.


Avoid These Favorite Solutions• Punish• Reprimand• Replace broken part• Investigate• Revise the procedure• Write a new procedure• Change management

program (re-engineer it)• Redesign it• Put up a warning sign• Ignore it -- stuff happensÓ 2007, Immel Resources LLC

What Favorite Solutions Mean

• You may be in a rut• Chances are that the

problem will repeat itself

• Favorite solutions usually mean you have identified your favorite causes

• Revisit your ideas -- may have missed something or made an assumption


Word to the Wise

• Sometimes solution may do nothing -- causes are unique, probability of repeating may be low

• Right solution is one that meets our criteria

• About 5-6% of time, not capable of finding solution (knowledge of work processes we control about 95%)


Realities

• Sometimes we simply don’t know what happened (although we may know in time)

• We stop looking because task is too expensive, time consuming or difficult

• When this happens, devise plan to capture more information and causes, so if problem repeats, we will know more causes


Solution Killers

• It will never work here.• We’re too busy for that.• No one will buy it.• We already tried that once.• That’s not our policy here.• It isn’t in the budget.• Good thought but impractical.• Top management will never

go for it.• No one else is doing it that

way.• Wrong!• We’ve always done it this way.• Good idea. I’ll get back to

you (and never does).Ó 2007, Immel Resources LLC

Solution Killers Caused by Fear of Change

• Never let solution-killer statement go unanswered, no matter who says it (use tact -- redirect focus -- discuss purpose, learning, growth, improvement)

• Play dumb -- ask them to explain why it does not work

• Never get into an argument about who is right and who is wrong


“Gano Rule” and “Yes-Anding”• The Gano Rule

– Always sleep on important decisions

– Gestation period– Sleep and play

important to creativity and thinking

• Yes-Anding– Avoid saying “but”– When team member

says something you disagree with, empathize and then agree “Yes, and we could add to that with (own idea)”


Training is Key

• Train all managers in fundamentals and basic tools

• Train everyone who solves problems daily how to facilitate problem-solving teams

• Train each employee to understand cause and effect principle


When to Perform an Analysis• Threshold criteria

– When should investigation be done?

– Whenever you encounter unacceptable circumstances.

– Define your threshold criteria in SOP. Periodically review and revise criteria.

• When in doubt -- it is probably better to do an investigation.


Evidence Preservation

• Policies should require evidence preservation

• Put together a checklist to obtain all relevant data, including interviewing personnel

• Have a plan to gather information as soon as possible after event

• Identify key people, give them responsibility to gather information


Define Responsibilities

• Establish committed investigation people to be on call 24 hours if 24-hour operation

• Start gathering information as soon as all safety issues dealt with

• Lead investigator to start gathering data and make sure others doing assigned tasks

• Everyone should pitch in• If problem doesn’t

warrant time to fix it, then shouldn’t be worked on


Use Simple Report Form

• Problem Definition• Time Observed/Time

Reported• Immediate Action Taken• Product Impact• Investigation Plan• Root Cause(s)• Corrective and

Preventive Actions• Responsible Person/Due

Dates• Effectiveness Evaluation• Product DispositionÓ 2007, Immel Resources LLC

Corrective and Preventive Action (CAPA) Tracking (1 of 2)

• Document each action in log and/or database

• Include responsible person, due date, brief description of required action

• Update log frequently• Send out regular email

or written status reports


Corrective and Preventive Action (CAPA) Tracking (2 of 2)

• If action cannot be done on time, require documented interim report and new due date

• Lack of commitment by management will cause program to fail

• CAPA should be agreed to and signed by those with authority and responsibility to implement

• Keep “nice to do” projects separate. Master log only those items resulting from formal investigations.


Trending• Helps identify where to

put resources• Use categorization/key

words• Funnel all categorization

through 1-2 like-minded people; true for database input, too

• If have repeat events -- ineffective problem-solving or not important enough for your attention

• Work on all significant problems, and track total number


Review

• Common problems• Understanding

causes• Problem definition• Identifying and

implementing solutions


Thank You

• Thank you all for attending

• Joe ImmelÓ 2007, Immel Resources LLC

root cause analysis: an introduction prepared for you by barbara immel, president, immel resources...

Documents

immel report2007

barbara immel

effect principleeach

conditionsprimary effect

conditionsan effect

eventany effect of consequence

apollo root cause analysis

effective problem solvers