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Root cause analysis

This document provides information and steps for performing a root cause analysis when investigating failures or mishaps. It defines key terms like proximate cause, root cause, and root cause analysis. The root cause analysis process involves clearly defining the undesired outcome, gathering data, creating a timeline, developing a causal factors tree to identify all potential underlying causes, and determining the root causes and solutions to prevent recurrence.

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Root Cause Analysis
Investigating causes of failures & mishaps Stop and ask yourself… Did you really find the causes of the failure? Like icebergs, most of the problem is usually below the surface!
This is NOT Root Cause Analysis
Technical Proficiency • Once the accident happened how did Gene Krantz rely on the skills and expertise of his people? • How did Lovell work to initiate actions in the spaceship? Was he able to balance that with his technical responsibilities in the craft? How did he do it? • What steps does your unit take to maintain Technical Proficiency? Lessons from Apoll0 13
Teambuilding • How did Lovell contribute to the group process when Mattingly wanted to practice the docking procedure again after 3 hrs of practice? • When Krantz had the team in the classroom how did he establish the goal and then how did he go about motivating others to achieve the goal of returning the space craft safely to earth? • Did Lovell make the right call when faced with the challenge of forcing Mattingly to stay behind because of the fear of measles? • How does a leader successfully build a strong team, but then separate him or herself from the Team to make a critical decision? • How’s your Team doing? Lessons from Apoll0 13
Effective Communications • Even as everything is breaking loose in Mission Control, Gene Krantz asks his team to “Work the Problem.” He then listened to the experts report in on their areas of the mission. How did his effective comms set the stage for a successful recovery? • Krantz stated “Failure is not an option” and Lovell told his crew “I intend to go home.” By clearly stating their ideas and vision how did it direct the teams towards mission accomplishment? • Whose the best communicator you’ve ever worked with? What made them excel? Lessons from Apoll0 13
Vision Development & Implementation • JFK’s Vision: "I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to Earth.“ • How does a stated vision focus the unit and bring the crew together? • Lovell states; “Columbus, Lindberg, and Armstrong; it is not a miracle for man to walk on the moon, we just decided to go.” • What’s the vision at your unit? Has everyone decided “to go?” What can your unit do to get everyone “on board”? Lessons from Apoll0 13
Conflict Management • How did Lovell deal with stress and conflict in the LEM? • How did the CO2 challenge help the crew to overcome the conflict they were experiencing? • Is there more or less conflict when people are busy and focused or when there is less to do and folks have time on their hands? Why? • How did Krantz and Lovell go about alleviating conflict between the crew and the Medical team? Lessons from Apoll0 13
Decision Making & Problem Solving • How did the Team live the Competency of Decision Making and Problem Solving in working the “Power” problem to conclusion? • Right after the explosion Krantz’s asks Mission Control “What do we have on the Space Craft that’s good?” • Why did he ask this question? • How did it aid in making the correct decision to shut down the fuel cells? • Does everyone at your Teamt ensure that the Decision Makers have all the available and correct information? Why or Why not? Lessons from Apoll0 13
Creativity and Innovation • We’ve discussed a lot of positive leadership qualities during this session. How did Gene Krantz create an environment with his Mission Control team to ensure they were able to figure out how to solve the CO2 problem with a “Square Peg in a Round Hole!” • Lovell states at the end of the movie; “Thousands of people worked to bring the 3 of us back home.” How did creativity and innovation make the “Successful Failure” a reality? • How does your unit build on Lessons Learned? Lessons from Apoll0 13
Apollo 13 Questions on homework
Investigating causes of failures & mishaps When performing an investigation, it is necessary to look at more than just the immediately visible cause, which is often the proximate cause. There are underlying organizational causes that are more difficult to see, however, they may contribute significantly to the undesired outcome and, if not corrected, they will continue to create similar types of problems. These are root causes. Requirements for mishap reporting and investigating all mishaps and investigations must identify the proximate causes(s), root causes(s) and contributing factor(s).
Definitions Proximate Cause(s) (Direct Cause) • The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. • Examples of proximate causes: Equipment Human • Arched • Pushed incorrect button • Leaked • Fell • Over-loaded • Dropped tool • Over-heated • Connected wires
Root Cause(s) Definitions • One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome. Organizational factors • Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including but not limited to the system’s concept development, design, fabrication, test, maintenance, operation, and disposal. • Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions.
Definitions Root Cause Analysis (RCA) • A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. • RCA is a method that helps professionals determine: • What happened. • How it happened. • Why it happened. • Allows learning from past problems, failures, and accidents.
Root Cause Analysis - Steps 1. Identify and clearly define the undesired outcome (outage). 2. Gather data. 3. Create a timeline. 4. Place events & conditions on an event and causal factor tree. 5. Use a fault tree or other method/tool to identify all potential causes. 6. Decompose system failures down to a basic events or conditions (Further describe what happened) 7. Identify specific failure modes (Immediate Causes) 8. Continue asking “WHY” to identify root causes. 9. Check your logic and your facts. Eliminate items that are not causes or contributing factors. 10. Generate solutions that address both proximate causes and root causes.
Root Cause Analysis - Steps Clearly define the undesirable outcome. • Describe the undesired outcome. • For example: “software failed to deploy,” “transaction failed,” or “XYZ project schedule significantly slipped.” Gather data. Identify facts surrounding the undesired outcome. • When did the undesired outcome occur? • Where did it occur? • What conditions were present prior to its occurrence? • What controls or barriers could have prevented its occurrence but did not? • What are all the potential causes? • What actions can prevent recurrence? • What amelioration occurred? Did it prevent further damage?
Root Cause Analysis - Steps Create a timeline (sequence diagram) • Illustrate the sequence of events in chronological order horizontally across the page. • Depict relationships between conditions, events, and exceeded or failed barriers/controls. Exceeded- Failed Barrier Or Control Event Undesired Outcome Condition Event Event
Root Cause Analysis - Steps Create a timeline (sequence diagram) • If amelioration occurred (e.g., reboot server, move application to another server), this should be included in the evaluation to ensure that it did not contribute to the undesired outcome. Example: In the of a server reboot, the investigation should ensure that the reboot was the result of the mishap and a result of latent hardware defects. Exceeded- Failed Barrier Or Control Event Undesired Outcome Condition Event Event Exceeded- Failed Amelioration
Root Cause Analysis - Steps Example: simple timeline. Application failed to Go Live Operating system started up Lost transactions (Penalties paid) Tech. Used Wrong Method To Correct Server Powered Up Switch port in wrong VLAN
Root Cause Analysis - Steps Create an event and causal factor tree. (A visual representation of the causes that led to the failure or mishap.) • Place the undesired outcome at the top of the tree. • Add all events, conditions, and exceeded/failed barriers that occurred immediately before the undesired outcome and might have caused it. Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Server Powered Up Switch port in wrong VLAN
Root Cause Analysis - Steps Create an event and causal factor tree. • Brainstorm to ensure that all possible causes are included, NOT just those that you are sure are involved. • Be sure to consider people, hardware, software, policy, procedures, and the environment. Electric power tripped Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Server Powered Up Switch port in wrong VLAN Technicians not properly trained Power Supply Failed Port labeled incorrectly Switch labeled incorrectly NIC driver wrong
Root Cause Analysis - Steps Create an event and causal factor tree continued... • If you have solid data indicating that one of the possible causes is not applicable, it can be eliminated from the tree. Caution: Do not be too eager to eliminate early on. If there is a possibility that it is a causal factor, leave it and eliminate it later when more information is available. Electric power tripped Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Server Powered Up Switch port in wrong VLAN Technicians not properly trained Power Supply Failed Port labeled incorrectly Switch labeled incorrectly NIC driver wrong X
Root Cause Analysis - Steps Create an event and causal factor tree continued… • You may use a fault tree to determine all potential causes and to decompose the failure down to the “basic event” (e.g., system component level). Electric power tripped Application failed to Go Live Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Switch port in wrong VLAN Technicians not properly trained Switch labeled incorrectly Port labeled incorrectly Power supply failed NIC driver wrong Maintenance swap Diagram wrong with no re-label Confusing labels Operating system started up
Root Cause Analysis - Steps Create an event and causal factor tree continued… • A fault tree can also be used to identify all possible types of human failures. Didn’t Perceive System Feedback Application failed to Go Live Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Switch port in wrong VLAN Didn’t Understand System Feedback Operation system started up Correct Interpretation Incorrect Decision Correct Decision But Incorrect Action Perception Error Interpretation Error Decision-Making Error Action-Execution Error Rule-Based Error Knowledge-Based Error Skill-Based Error
Root Cause Analysis - Steps Create an event and causal factor tree continued… • After you have identified all the possible causes, ask yourself “WHY” each may have occurred. • Be sure to keep your questions focused on the original issue. For example “Why was the condition present?”; “Why did the event occur?”; “Why was the parameter exceeded?” or “Why did the condition fail?” Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control
Root Cause Analysis – Steps Continue to ask “why” until you have reached: 1. Root cause(s) - including all organizational factors that exert control over the design, fabrication, development, maintenance, operation, and disposal of the system. 2. A problem that is not correctable by IT or IT contractor. 3. Insufficient data to continue.
Root Cause Analysis- Steps The resultant tree of questions and answers should lead to a comprehensive picture of POTENTIAL causes for the undesired outcome Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control X WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
X X WHY WHY Failed Exceeded Barrier or Control WHY Event #2 Occurred WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed Check your logic with a detailed review of each potential cause. • Verify it is a contributor or cause. • If the action, deficiency, or decision in question were corrected, eliminated or avoided, would the undesired outcome be prevented or avoided? > If no, then eliminate it from the tree. Root Cause Analysis- Steps Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred X Failed Exceeded Barrier or Control X X X X X X X X WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY X X X X X X X X X WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
Root Cause Analysis - Steps Create an event and causal factor tree continued… • The remaining items on the tree are the causes (or probable causes). necessary to produce the undesired outcome. • Proximate causes are those immediately before the undesired outcome. • Intermediate causes are those between the proximate and root causes. • Root causes are organizational factors or systemic problems located at the bottom of the tree. PROXIMATE CAUSES INTERMEDIATE CAUSES ROOT CAUSES Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Failed/Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed/Exceeded Barrier or Control
Root Cause Analysis- Steps Some people choose to leave contributing factors on the tree to show all factors that influenced the event. Contributing factor: An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. If this is done, illustrate them differently (e.g., dotted line boxes and arrows) so that it is clear that they are not causes. Contributing Factors Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Failed/Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed/Exceeded Barrier or Control WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
No IP connection to VLAN assigned Incorrect server static address used incorrectly Engineer did not read correct label network Root Cause is Much Deeper Keep Asking Why Investigating Causes of Failures & Mishaps Application failed to Go Live Technician Used Wrong Method to Correct Lost transaction (Penalties paid) Switch port in wrong VLAN Operation system started up
Investigating Causes of Failures & Mishaps VLAN changed in unrelated move Application failed to Go Live No IP connection to network VLAN incorrectly Incorrect server static address used assigned Engineer did not read correct label Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Switch port in wrong VLAN Operating system started up No Quality Inspection Insufficient Quality Staff Insufficient Budget Procedure Incorrect Not Updated Correct Interpretation Incorrect Decision Decision-Making Error New Task Insufficient Anomaly Training Training Does Not Exist Not Under Configuration Mgmt Insufficient Training Budget Organization Under Estimates Importance of Anomaly Training
Root Cause Analysis- Steps Generating Recommendations: At a minimum corrective actions should be generated to eliminate proximate causes and eliminate or mitigate the negative effects of root causes. When multiple causes exist, there is limited budget, or it is difficult to determine what should be corrected: • Quantitative analysis can be used to determine the total contribution of each cause to the undesirable outcome . • Fishbone diagrams (or other methods) can be used to arrange causes in order of their importance. • Those causes which contribute most to the undesirable outcome should be eliminated or the negative effects should be mitigated to minimize risk.
Definitions of RCA & Related Terms Cause (Causal Factor) An event or condition that results in an effect. Anything that shapes or influences the outcome. Proximate Cause(s) The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. Also known as the direct cause(s). Root Cause(s) One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome. Root Cause Analysis (RCA) A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. Event A real-time occurrence describing one discrete action, typically an error, failure, or malfunction. Examples: pipe broke, power lost, lightning struck, person opened valve, etc… Condition Any as-found state, whether or not resulting from an event, that may have safety, health, quality, security, operational, or environmental implications. Organizational Factors Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including but not limited to the system’s concept development, design, fabrication, test, maintenance, operation, and disposal. Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions. Contributing Factor An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. Barrier A physical device or an administrative control used to reduce risk of the undesired outcome to an acceptable level. Barriers can provide physical intervention (e.g., a guardrail) or procedural separation in time and space (e.g., lock-out-tag-out procedure).
MIR Process / Forms Major Incident – Severe Business impact: • service, system or infrastructure component not functioning adequately to enable business process • total loss of service, system or infrastructure component Major Incidents can also be considered to be those which do not entirely impede the use of the service, system or infrastructure component such as: • continuous slow response • general degradation of service • Refer: http://thinkingproblemmanagement.blogspot.com

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Root cause analysis

  • 1.
  • 2.
    Investigating causes offailures & mishaps Stop and ask yourself… Did you really find the causes of the failure? Like icebergs, most of the problem is usually below the surface!
  • 3.
    This is NOTRoot Cause Analysis
  • 4.
    Technical Proficiency •Once the accident happened how did Gene Krantz rely on the skills and expertise of his people? • How did Lovell work to initiate actions in the spaceship? Was he able to balance that with his technical responsibilities in the craft? How did he do it? • What steps does your unit take to maintain Technical Proficiency? Lessons from Apoll0 13
  • 5.
    Teambuilding • Howdid Lovell contribute to the group process when Mattingly wanted to practice the docking procedure again after 3 hrs of practice? • When Krantz had the team in the classroom how did he establish the goal and then how did he go about motivating others to achieve the goal of returning the space craft safely to earth? • Did Lovell make the right call when faced with the challenge of forcing Mattingly to stay behind because of the fear of measles? • How does a leader successfully build a strong team, but then separate him or herself from the Team to make a critical decision? • How’s your Team doing? Lessons from Apoll0 13
  • 6.
    Effective Communications •Even as everything is breaking loose in Mission Control, Gene Krantz asks his team to “Work the Problem.” He then listened to the experts report in on their areas of the mission. How did his effective comms set the stage for a successful recovery? • Krantz stated “Failure is not an option” and Lovell told his crew “I intend to go home.” By clearly stating their ideas and vision how did it direct the teams towards mission accomplishment? • Whose the best communicator you’ve ever worked with? What made them excel? Lessons from Apoll0 13
  • 7.
    Vision Development &Implementation • JFK’s Vision: "I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to Earth.“ • How does a stated vision focus the unit and bring the crew together? • Lovell states; “Columbus, Lindberg, and Armstrong; it is not a miracle for man to walk on the moon, we just decided to go.” • What’s the vision at your unit? Has everyone decided “to go?” What can your unit do to get everyone “on board”? Lessons from Apoll0 13
  • 8.
    Conflict Management •How did Lovell deal with stress and conflict in the LEM? • How did the CO2 challenge help the crew to overcome the conflict they were experiencing? • Is there more or less conflict when people are busy and focused or when there is less to do and folks have time on their hands? Why? • How did Krantz and Lovell go about alleviating conflict between the crew and the Medical team? Lessons from Apoll0 13
  • 9.
    Decision Making &Problem Solving • How did the Team live the Competency of Decision Making and Problem Solving in working the “Power” problem to conclusion? • Right after the explosion Krantz’s asks Mission Control “What do we have on the Space Craft that’s good?” • Why did he ask this question? • How did it aid in making the correct decision to shut down the fuel cells? • Does everyone at your Teamt ensure that the Decision Makers have all the available and correct information? Why or Why not? Lessons from Apoll0 13
  • 10.
    Creativity and Innovation • We’ve discussed a lot of positive leadership qualities during this session. How did Gene Krantz create an environment with his Mission Control team to ensure they were able to figure out how to solve the CO2 problem with a “Square Peg in a Round Hole!” • Lovell states at the end of the movie; “Thousands of people worked to bring the 3 of us back home.” How did creativity and innovation make the “Successful Failure” a reality? • How does your unit build on Lessons Learned? Lessons from Apoll0 13
  • 11.
  • 12.
    Investigating causes offailures & mishaps When performing an investigation, it is necessary to look at more than just the immediately visible cause, which is often the proximate cause. There are underlying organizational causes that are more difficult to see, however, they may contribute significantly to the undesired outcome and, if not corrected, they will continue to create similar types of problems. These are root causes. Requirements for mishap reporting and investigating all mishaps and investigations must identify the proximate causes(s), root causes(s) and contributing factor(s).
  • 13.
    Definitions Proximate Cause(s)(Direct Cause) • The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. • Examples of proximate causes: Equipment Human • Arched • Pushed incorrect button • Leaked • Fell • Over-loaded • Dropped tool • Over-heated • Connected wires
  • 14.
    Root Cause(s) Definitions • One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome. Organizational factors • Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including but not limited to the system’s concept development, design, fabrication, test, maintenance, operation, and disposal. • Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions.
  • 15.
    Definitions Root CauseAnalysis (RCA) • A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. • RCA is a method that helps professionals determine: • What happened. • How it happened. • Why it happened. • Allows learning from past problems, failures, and accidents.
  • 16.
    Root Cause Analysis- Steps 1. Identify and clearly define the undesired outcome (outage). 2. Gather data. 3. Create a timeline. 4. Place events & conditions on an event and causal factor tree. 5. Use a fault tree or other method/tool to identify all potential causes. 6. Decompose system failures down to a basic events or conditions (Further describe what happened) 7. Identify specific failure modes (Immediate Causes) 8. Continue asking “WHY” to identify root causes. 9. Check your logic and your facts. Eliminate items that are not causes or contributing factors. 10. Generate solutions that address both proximate causes and root causes.
  • 17.
    Root Cause Analysis- Steps Clearly define the undesirable outcome. • Describe the undesired outcome. • For example: “software failed to deploy,” “transaction failed,” or “XYZ project schedule significantly slipped.” Gather data. Identify facts surrounding the undesired outcome. • When did the undesired outcome occur? • Where did it occur? • What conditions were present prior to its occurrence? • What controls or barriers could have prevented its occurrence but did not? • What are all the potential causes? • What actions can prevent recurrence? • What amelioration occurred? Did it prevent further damage?
  • 18.
    Root Cause Analysis- Steps Create a timeline (sequence diagram) • Illustrate the sequence of events in chronological order horizontally across the page. • Depict relationships between conditions, events, and exceeded or failed barriers/controls. Exceeded- Failed Barrier Or Control Event Undesired Outcome Condition Event Event
  • 19.
    Root Cause Analysis- Steps Create a timeline (sequence diagram) • If amelioration occurred (e.g., reboot server, move application to another server), this should be included in the evaluation to ensure that it did not contribute to the undesired outcome. Example: In the of a server reboot, the investigation should ensure that the reboot was the result of the mishap and a result of latent hardware defects. Exceeded- Failed Barrier Or Control Event Undesired Outcome Condition Event Event Exceeded- Failed Amelioration
  • 20.
    Root Cause Analysis- Steps Example: simple timeline. Application failed to Go Live Operating system started up Lost transactions (Penalties paid) Tech. Used Wrong Method To Correct Server Powered Up Switch port in wrong VLAN
  • 21.
    Root Cause Analysis- Steps Create an event and causal factor tree. (A visual representation of the causes that led to the failure or mishap.) • Place the undesired outcome at the top of the tree. • Add all events, conditions, and exceeded/failed barriers that occurred immediately before the undesired outcome and might have caused it. Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Server Powered Up Switch port in wrong VLAN
  • 22.
    Root Cause Analysis- Steps Create an event and causal factor tree. • Brainstorm to ensure that all possible causes are included, NOT just those that you are sure are involved. • Be sure to consider people, hardware, software, policy, procedures, and the environment. Electric power tripped Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Server Powered Up Switch port in wrong VLAN Technicians not properly trained Power Supply Failed Port labeled incorrectly Switch labeled incorrectly NIC driver wrong
  • 23.
    Root Cause Analysis- Steps Create an event and causal factor tree continued... • If you have solid data indicating that one of the possible causes is not applicable, it can be eliminated from the tree. Caution: Do not be too eager to eliminate early on. If there is a possibility that it is a causal factor, leave it and eliminate it later when more information is available. Electric power tripped Application failed to Go Live Operating system started up Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Server Powered Up Switch port in wrong VLAN Technicians not properly trained Power Supply Failed Port labeled incorrectly Switch labeled incorrectly NIC driver wrong X
  • 24.
    Root Cause Analysis- Steps Create an event and causal factor tree continued… • You may use a fault tree to determine all potential causes and to decompose the failure down to the “basic event” (e.g., system component level). Electric power tripped Application failed to Go Live Technician Used Wrong Method to Correct Lost transactions (Penalties Paid) Switch port in wrong VLAN Technicians not properly trained Switch labeled incorrectly Port labeled incorrectly Power supply failed NIC driver wrong Maintenance swap Diagram wrong with no re-label Confusing labels Operating system started up
  • 25.
    Root Cause Analysis- Steps Create an event and causal factor tree continued… • A fault tree can also be used to identify all possible types of human failures. Didn’t Perceive System Feedback Application failed to Go Live Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Switch port in wrong VLAN Didn’t Understand System Feedback Operation system started up Correct Interpretation Incorrect Decision Correct Decision But Incorrect Action Perception Error Interpretation Error Decision-Making Error Action-Execution Error Rule-Based Error Knowledge-Based Error Skill-Based Error
  • 26.
    Root Cause Analysis- Steps Create an event and causal factor tree continued… • After you have identified all the possible causes, ask yourself “WHY” each may have occurred. • Be sure to keep your questions focused on the original issue. For example “Why was the condition present?”; “Why did the event occur?”; “Why was the parameter exceeded?” or “Why did the condition fail?” Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control
  • 27.
    Root Cause Analysis– Steps Continue to ask “why” until you have reached: 1. Root cause(s) - including all organizational factors that exert control over the design, fabrication, development, maintenance, operation, and disposal of the system. 2. A problem that is not correctable by IT or IT contractor. 3. Insufficient data to continue.
  • 28.
    Root Cause Analysis-Steps The resultant tree of questions and answers should lead to a comprehensive picture of POTENTIAL causes for the undesired outcome Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control X WHY Failed Exceeded Barrier or Control WHY Failed Exceeded Barrier or Control WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
  • 29.
    X X WHY WHY Failed Exceeded Barrier or Control WHY Event #2 Occurred WHY Condition Existed or Changed WHY Failed Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed Check your logic with a detailed review of each potential cause. • Verify it is a contributor or cause. • If the action, deficiency, or decision in question were corrected, eliminated or avoided, would the undesired outcome be prevented or avoided? > If no, then eliminate it from the tree. Root Cause Analysis- Steps Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Event #1 Occurred X Failed Exceeded Barrier or Control X X X X X X X X WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY X X X X X X X X X WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
  • 30.
    Root Cause Analysis- Steps Create an event and causal factor tree continued… • The remaining items on the tree are the causes (or probable causes). necessary to produce the undesired outcome. • Proximate causes are those immediately before the undesired outcome. • Intermediate causes are those between the proximate and root causes. • Root causes are organizational factors or systemic problems located at the bottom of the tree. PROXIMATE CAUSES INTERMEDIATE CAUSES ROOT CAUSES Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Failed/Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed/Exceeded Barrier or Control
  • 31.
    Root Cause Analysis-Steps Some people choose to leave contributing factors on the tree to show all factors that influenced the event. Contributing factor: An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. If this is done, illustrate them differently (e.g., dotted line boxes and arrows) so that it is clear that they are not causes. Contributing Factors Event #2 Failed or Exceeded Barrier or Control Undesired Outcome Event #1 Condition WHY Event #1 Occurred WHY Event #1 Occurred WHY Failed/Exceeded Barrier or Control WHY Event #2 Occurred WHY Event #2 Occurred WHY Condition Existed or Changed WHY Condition Existed or Changed WHY Failed/Exceeded Barrier or Control WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY WHY
  • 32.
    No IP connectionto VLAN assigned Incorrect server static address used incorrectly Engineer did not read correct label network Root Cause is Much Deeper Keep Asking Why Investigating Causes of Failures & Mishaps Application failed to Go Live Technician Used Wrong Method to Correct Lost transaction (Penalties paid) Switch port in wrong VLAN Operation system started up
  • 33.
    Investigating Causes ofFailures & Mishaps VLAN changed in unrelated move Application failed to Go Live No IP connection to network VLAN incorrectly Incorrect server static address used assigned Engineer did not read correct label Technician Used Wrong Method to Correct Lost transactions (Penalties paid) Switch port in wrong VLAN Operating system started up No Quality Inspection Insufficient Quality Staff Insufficient Budget Procedure Incorrect Not Updated Correct Interpretation Incorrect Decision Decision-Making Error New Task Insufficient Anomaly Training Training Does Not Exist Not Under Configuration Mgmt Insufficient Training Budget Organization Under Estimates Importance of Anomaly Training
  • 34.
    Root Cause Analysis-Steps Generating Recommendations: At a minimum corrective actions should be generated to eliminate proximate causes and eliminate or mitigate the negative effects of root causes. When multiple causes exist, there is limited budget, or it is difficult to determine what should be corrected: • Quantitative analysis can be used to determine the total contribution of each cause to the undesirable outcome . • Fishbone diagrams (or other methods) can be used to arrange causes in order of their importance. • Those causes which contribute most to the undesirable outcome should be eliminated or the negative effects should be mitigated to minimize risk.
  • 35.
    Definitions of RCA& Related Terms Cause (Causal Factor) An event or condition that results in an effect. Anything that shapes or influences the outcome. Proximate Cause(s) The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. Also known as the direct cause(s). Root Cause(s) One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome. Root Cause Analysis (RCA) A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. Event A real-time occurrence describing one discrete action, typically an error, failure, or malfunction. Examples: pipe broke, power lost, lightning struck, person opened valve, etc… Condition Any as-found state, whether or not resulting from an event, that may have safety, health, quality, security, operational, or environmental implications. Organizational Factors Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including but not limited to the system’s concept development, design, fabrication, test, maintenance, operation, and disposal. Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions. Contributing Factor An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. Barrier A physical device or an administrative control used to reduce risk of the undesired outcome to an acceptable level. Barriers can provide physical intervention (e.g., a guardrail) or procedural separation in time and space (e.g., lock-out-tag-out procedure).
  • 36.
    MIR Process /Forms Major Incident – Severe Business impact: • service, system or infrastructure component not functioning adequately to enable business process • total loss of service, system or infrastructure component Major Incidents can also be considered to be those which do not entirely impede the use of the service, system or infrastructure component such as: • continuous slow response • general degradation of service • Refer: http://thinkingproblemmanagement.blogspot.com