Jack Jager AMPEAK 2014 Presentation - 6 steps for a successful root cause analysis
6 Critical Steps for a
Successful Root Cause
• Do we want it ?
• How do we achieve it?
• Conduct the RCA
• Challenge what you know
• 3 forms
• Collected information
• Stored information
• Information that employees accumulate
• Once an incident, an accident, an
unwanted event has occurred how do we
• Information is critical!
• How do we collect it?
• This must be timely!
• Someone must own it
• A clear understanding of what your risk
matrix declares as investigation trigger
points is vital.
• Access your CMMS systems
• How good is your information??
• Abbreviated or Generic descriptions
• Electronic Data
Information that employees accumulate
• People have experience and knowledge to
• Ensure that you have the right people in
• Room and amenities
• Data, Reports
• Visual stimuli
• Who owns this task?
Step 3 ….Conduct the RCA
• Get the right facilitator
• Good at it/ ?
• Who doesn’t have a vested interest in the
• Should it be the subject matter expert?
• What are the attributes of a good
• Knows the process
• Good listener
• Keeps control of the group
• Good communicator
• Can remain neutral
• Respects all contributions
Step 4….Challenge your charts
• How do you know you have “got it”?
• Review your cause and effect chart
• Critical challenge is the key
• Be consistent
• Be logical
• Follow the rules
• Have evidence to support the information
Step 4….Challenge your Charts
• Demand excellence in the cause and
• The chart reflects what you know
• It is an iterative process
• A quality chart can be an effective
• Be specific
Excellence in Charting
• A lot can be gained from making the effort
in trying to achieve the best possible chart.
• Will it ever be perfect?.......Rarely
• Opportunities for improvements can
however be identified.
• At the end of the day the chart becomes
the validation for the choices made
regarding corrective actions.
• Effective communication is the key
• Who should be able to read the report?
• Time is valuable
• Kiss principle
Reporting ….Key elements
• Clear defining statement
• The cause and effect chart and also the
cause and effect summary
• Corrective actions assigned to critical
causes…..ownership needs to be given
and due dates set
• Attendees, cost information, appendices
• Easy to say….. hard to prove
• Measure the impact of any changes that
• Success breeds success
Attitude to Root Cause Analysis
Positive or Negative???
Lack of support?
• LEARNING FROM THE INCIDENTS AND
EVENTS THAT HAPPEN IS VITAL TO AN
INDUSTRY TRYING TO MAKE
• THE NEED TO BE EFFECTIVE IN THE ART
OF ROOT CAUSE ANALYSIS THEREFORE
• TO BE SUCCESSFUL IN THIS PURSUIT REQUIRES …
• THAT EFFECTIVE STRUCTURES EXIST THAT GATHER
INFORMATION CONTINUALLY AND ALSO IMMEDIATELY
AFTER AN EVENT
• STRUCTURES THAT SUPPORT AND ALLOW SOUND
PREPARATION TO OCCUR ARE IN PLACE
• THAT COMPANIES TRAIN EMPLOYEES TO THE LEVEL
THEY NEED TO BE EFFECTIVE FACILITATORS
• THAT THE IMPLEMENTATION OF CORRECTIVE ACTIONS
IS ASSURED AND THAT WE MEASURE THE IMPACT OF
• If you are willing to accept investigation
reports that are less than what they should
be ….then that is what you are most likely
• If it is worth doing then it is worth doing
• Success in the performance of Root
Cause Analysis will happen more
consistently when clear process structures
are in place and when positive
management support is given to the