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General summary of root-cause analysis (RCA) and some of the useful tools.

General summary of root-cause analysis (RCA) and some of the useful tools.

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Root Cause Analysis Presentation Transcript

  • 1. Root-Cause Analysis (RCA) by Mark Fawcett
  • 2. Contents
    • RCA Assumptions
    • RCA Goals
    • Definitions of “Root Cause”
    • Levels of Causes
    • Practical Indicators of Root Cause
    • Cognitive Biases to Avoid
    • Seven-Step Problem-Solving Model
    Created by M. Fawcett Last Updated: 1/5/2010
  • 3. RCA Assumptions
    • “ Beneath every problem is a cause for that problem.”
    • “ If the root cause of a problem is not identified, then one is merely addressing the symptoms and the problem will continue to exist.”
    • (Doggett, 2005)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 4. RCA Goals
    • Identify . . .
    • What happened,
    • How it occurred, &
    • Why “it” took place.
    • What we can do to prevent reoccurrence
    • (Rooney & Heuvel, 2004)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 5. Definitions of “Root Cause”
    • For practical purposes, root causes are . . .
    • Specific underlying causes
    • Causes which we can reasonably identify
    • Causes that we have the ability to resolve
    • Causes where we can think of effective solutions to prevent recurrence
    • (Rooney & Heuvel, 2004)
    • “ Root-cause analysis is a thinking process that makes use of data from a variety of sources to identify the basic reason(s) for the appearance of a problem.” (Horev, 2009)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 6. Levels of Causes
    • Physical Cause: Specific physical item that, if corrected / replaced would fix problem. (aka proximal or direct cause)
    • System Cause: Possible underlying cause of physical failure. (aka distal / latent cause)
    • (Okes, 2008)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 7. Levels of Causes — Example
    • Physical Cause: Organizations have a tendency to stop at the physical cause, which may be appropriate.
    • System Cause: Seek system cause for problems with a high frequency, cost, or risk of injury.
    • (Okes, 2008)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 8. Practical Indicators of Root Cause
    • Can identify no deeper causal factors
    • All agree that the cause is a root cause
    • The cause provides clarity and appears to make sense
    • The cause is something you can influence
    • (Pruess, 2003)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 9. Cognitive Biases to Avoid
    • “ A biased mind, which never sees the complete picture, cannot grasp the reality.” — Dali Lama
    • Barriers to Effective RCA
      • Cognitive Laziness: Instead of seeking the optimum result, we seek the first sufficient result.
      • Overconfidence: Pursuing evidence supporting our own beliefs rather than allowing the data to represent the truth.
      • (Okes, 2008)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 10. Cognitive Laziness (Satisficing)
    • Recency Bias
    • Assume the same cause for two recent problem symptoms and therefore, not performing a more rigorous investigation.
    • Availability Bias
    • Rely on the available data rather than collecting / generating more relevant and reliable data.
    • (Okes, 2008)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 11. Overconfidence
    • Anchoring Bias
    • Latching on to the first data and its indications while ignoring possibly conflicting evidence.
    • Confirmation Bias
    • Looking for and accepting only data the confirms our preexisting assumptions of the cause.
    • (Okes, 2008)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 12. Seven-Step Problem-Solving Model Created by M. Fawcett Last Updated: 1/5/2010 (Westcott, 2006)
  • 13. RCA Tools
    • A few examples of RCA tool include . . .
    • Five “Why’s” (5Y)
    • Current Reality Tree (CRT)
    • Interrelationship Diagram (ID)
    • Cause-and-Effect Diagram (CED)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 14. Five Why’s
    • Simplest method to determine root cause.
    • Drill deeper into problems until a root cause is found.
    • (Boukendour & Brissaud, 2005)
    • Problem: Car will not start.
    • Why: Dead battery.
    • Why: Bad alternator.
    • Why: Alternator belt broken.
    • Why: Belt used beyond useful life.
    • Why: Recommend maintenance not performed.
    • (Wikipedia, 2009)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 15. Five Why’s — Expanded Created by M. Fawcett Last Updated: 1/5/2010 (Westcott, 2006)
  • 16. Current Reality Tree (CRT)
    • Reflects most probable chain of causal factors contributing to a specific set of events. Aids in systems understanding. (Doggett, 2005)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 17. Interrelationship Diagram (ID)
    • Helps clarify mixed causal relationships of a complex problem. (Doggett, 2005)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 18. Cause-and-Effect Diagram (CED)
    • Sorts potential causes and organizes causal relationships.
    • Helps focus on problem content rather than history.
    • (Doggett, 2005)
    Created by M. Fawcett Last Updated: 1/5/2010
  • 19. Conclusion
    • System Causes: We should remember the difference between physical and system causes, understanding that solutions affecting the system causes provide more effective solutions.
    • Bias: We need to maintain our awareness of natural thinking biases, which can derail effective RCA.
    • 7 Steps: Although many tools exist for RCA, we should adhere to the basic seven-step problem-solving model to ensure objective and effective solutions.
    Created by M. Fawcett Last Updated: 1/5/2010
  • 20. Bibliography
    • Boukendour, S., & Brissaud, D. (2005). A phenomenological taxonomy for systemizing knowledge on nonconformances. Quality Management Journal , 12(2), 25-33.
    • Doggett, A. M. (2005). Root cause analysis: A framework for tool selection. Quality Management Journal, 12 (4), 34-45.
    • Horev, M. (2009). How to succeed in failure analysis and fail in root-cause analysis. Electronic Device Failure Analysis, 11 (3), 14-19.
    • Hughes, B., Hall, M., & Rygaard, D. (2009). Using root-cause analysis to improve risk management. Professional Safety, 54 (2), 54-55.
    • Okes, D. (2008). The human side of root cause analysis. Journal for Quality & Participation, 31 (3), 20-29.
    • Pruess, P. G. (2003) School leaders guide to root cause analysis using data to dissolve problems. Larchmont, NY. Eye on Education.
    • Rooney, J. J. & Heuvel, L. N. V. (2004). Root cause analysis for beginners. Quality Progress, 37 (7), 45-53
    • Westcott, R. T. (2006). The certified manager of quality/organizational excellence handbook (3rd ed.). Milwaukee, WI: ASQ.
    • Wikipedia. (2009). 5 Whys. Retrieved 1/5/2009 from http://en.wikipedia.org/wiki/5_Whys
    Created by M. Fawcett Last Updated: 1/5/2010
  • 21. Questions / Discussion