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Asking Better Questions to Determine Root Cause

written by: ciel s cantoria • edited by: Donna Cosmato • updated: 2/4/2014

Are you asking the right root cause questions to get to the bottom of things? Scientific methods have proven that deciding on human errors as the root cause doesn’t solve the problem. One has to probe deeper to unravel the systems or the process failures that are the core reason.

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    Organizing the Questions

    800px-Questions english-french 

    Your project has a problem, but before you can fix it you need to identify the root cause. In order to conduct proper analysis, you must ask the right questions. A method suggested by Kepner-Tregoe® suggests applying the 5-Why tool. This enables the analyst to arrive at a problem that is already near the core reason.

    How the Five-Why Tool Works:

    • “A number of workers have been going on an extended disability leave."
    • "Why?"
    • “They have been diagnosed with lung cancer."
    • "Why?"
    • “The workplace has poor ventilation and is suspected of having high radon levels".
    • "Why?"
    • "The building is located in one of EPA's radon identified areas ".

    Therefore, the presence of radon emissions in the workplace is the primary problem to be addressed. In establishing this as the main issue, the questions used in the root cause analysis helped us draw closer to the root cause.

    Below is the framework for traditional data gathering to help determine the root cause:

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    Traditional Framework for Data Gathering

    1. Identify the problem The first step is a brief description of the incident and why it is considered as a problem. The problem is identified by asking a series of questions.

    What happened?

    This question probes not only on what was visible at the time of the incident but also the conditions felt or sensed by the interviewees.

    • Was it dark, stormy or under regular lighting conditions?
    • Was the temperature humid or below freezing or normal room temperature?
    • Was the environment hostile or were the workers engaged in playful jousts before the incident?
    • Did the workers notice anything different such as a thumping sound or a flickering of the light?
    • Did they smell anything before or after the incident?

    The description may be brief but it should aim to describe in full.

    When did the event happen?

    The answer could be easily stated as the date and time the event transpired. Additional questions can fully explore any peculiarities present in relation to the time of the event.

    • Were all the workers present on that day?
    • Were the smoke alarm and the sprinkler systems installed after or before the incident?
    • Was it a regular working day?
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    What area was affected?

    It’s not just about the area and how it was affected, but also what was included in the area.

    • Are there exhaust shafts for the exhaust fans?
    • What was the function of the person nearest to the source of emissions?
    • Was it customary for that person to be there?
    • How long has that person been assigned to that particular area?
    • Do heavy rains and floods affect the area?
    • How old is the building?
    • Are there cracks or crevices that allow the emissions to flow through?
    • How high are the levels of the radon emissions?
    • Are there other chemicals kept inside the room?

    Hence, probing questions regarding susceptibility of a particular work stage or worker to the occurrence of error, breakdowns or unauthorized operation, can be determined.

    • How are workloads and processes assigned?
    • What are the types of work given to trainees?
    • Is the type of work one that requires the wearing of protective masks?
    • How frequently do the exhaust fans undergo repairs?
    • How old are the exhaust fans and the shafts?
    • Are employees overworked?
    • Are employees properly compensated?
    • Do they go on paid leave time?
    • Are there training preparations and manuals?
    • Are there any external services added to the processing system?
    • Are there consultants or experts that give advice or opinions?
    • Are hazardous materials being used?
    • Are there other departments affected by the emissions?

    What records are available for the affected area?

    Investigations will center mostly in the area where most workers on disability leave are assigned.

    • Does the department maintain log books or other forms of records to monitor or record releases, arrivals, inspections, visitors and time logs?
    • Is the required OSHA (Occupational Safety and Health Administration) log for incident reports up to date?
    • Are there any adverse OSHA findings that affect the company?
    • Are there any records of complaints filed by concerned civic organizations or the EPA (Environmental Protection Agency)?
    • Are there documents to support claims that emissions are being monitored?
    • Is there a documented emergency and crisis plan?
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    2. Establish the Procedures or Process Employed

    What procedural steps were being followed by the workers?

    Here the questions are best formulated by mapping out a process flow diagram to determine the order by which the procedures take place. This is also where human factors come into focus as the performers of the action that led to or those who were affected by the events.

    3. Prepare a Problem Analysis Worksheet for the Answers Gathered:

    To maintain an organized method of analysis, each set of questions are categorized as answers to:

    a. Systems or procedural failures

    b. Failure that is inherent to the location

    c. Failure to maintain informational records or documentation

    For every answer gathered, place it under a descriptive columns: Is a Cause and Could be a Cause but is not.

    We now analyze why there are an increasing number of employees going on an extended disability leave by re-organizing our answers.

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    Is a Cause:

    • The conditions of exhaust shafts and the exhaust fans.
    • The building’s antiquity.
    • The cracks or crevices in the walls that allow the cold draft to flow through.
    • The purported high levels of radon emissions.
    • The frequency by which exhaust fans undergo repairs.
    • The poor efficiency of the exhaust fans and the shafts.
    • Other hazardous materials used.
    • Other departments affected by the emissions.
    • Additional external services applied to the processing system.
    • There are no consultants or experts to give advice or opinions.
    • There are no documents to support claims that emissions are being monitored.

    Could be a Cause but is not:

    • The function of the person nearest to the source of emissions.
    • The need for that person to occupy the area.
    • The length of time that the worker has been assigned to that particular area.
    • Other chemicals kept inside the room.
    • The methods of assigning workloads and processes.
    • The types of work given to trainees.
    • The work requires the wearing of protective masks.
    • Employees are overworked.
    • Employees don’t go on paid leave time.
    • There are no training preparations and manuals.

    It has been ascertained that there is lack of consultancy services and that there are no documents to support the organizations’ claim that the place is being tested for emissions. There is also evidence that the employees are overworked and are not supported by training manuals. Hence the analyst could not readily decide if radon emissions were the cause since doing so entails making recommendations for building renovations.

    However, there are still other factors to investigate such as the fully depreciated state of the building and its inefficient exhaust vents as well as the presence of other chemicals in the workplace. Gathering data through interview processes may be long and tedious, but if one asks the right questions, the analyst can be confident of getting better results.


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