Developing the Right Approach to Analyzing the Root Cause of a Problem
Most root cause analysis methods are easily learnt, which is one reason why the fishbone diagram and the 5-why method tend to be the most favored techniques. Ease of use and understanding, however, should not be the main criteria, because simple methods have limitations.
However, this is not to undermine the effectiveness of simple root cause analysis techniques. This article's purpose is to place emphasis on the right mindset and approach toward solving a problem and seeking solutions. Nonetheless, attitudes are developed and acquired by way of actual applications of one's understanding of the RCA discipline.
Ease of use could also lead to deciding on the most uncomplicated reason and solution—human error and eliminating the errant worker. Understand that the process of analyzing the primary cause is to seek workable solutions in order to avoid occurrence or recurrence and not to find fault.
Settling on human error is the easy way out but it does not resolve the problem, i.e., “human error as a causal factor for a particular adverse incident.”
In line with this, consider the following tips for root cause analysis:
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Pointers to Keep in Mind When Performing an RCA
The objective of the following guidelines is to ensure the observance of the right approach for conducting RCA in order to arrive at the most appropriate solution:
1. The team tasked to perform the analysis should have adequate training and should be spearheaded by an RCA expert.
Different ideas and perceived knowledge could easily muddle the information being evaluated. In having a competent leader at the helm, the team members will be guided on knowing when to draw the line in using hypothetical ideas. Fishbone diagrams, for one, allow the use of theoretical ideas but not all problems under study allow mere assumptions as the bases for determining a core reason, especially if the matter being investigated deals with actual incidents.
2. Acknowledge the fact that a problem exists. This is regardless if the incident has actually happened or is only an anticipated risk, for as long as the bases are factual.
This puts the issue of data gathering into the foreground as an essential requirement. Data sources from where inputs are derived should be real, verified and logical. The “cause and effect” principle has long been proven to follow a sequence of events. This is owing to the fact that for every antecedent to a causal factor there is always a deviation from the normal pattern. Perceive that every deviation was spurred by the abnormal occurrence at the critical stage where it originated.
Hence, team members should always be on the lookout for these deviations, validate and track their actual occurrence and keep them in mind when formulating the solutions.
3. Refrain from using data tainted by unfounded “value judgments.”
What are value judgments? To define this concept in layman’s term means that the data have been given weight as the bases for conclusions. Gather and use data as it is and avoid adding unconfirmed inferences. Otherwise, this will lead the entire RCA team into adding more inputs that were based on mere supposition. Again, keep in mind that the objective of the exercise is to arrive at a right solution for a real problem, regardless if it has happened or its occurence is still anticipated..
4. Formulate cause and effect questions that are bent on probing instead of speculating.
Whatever type of root cause analysis method being used, start the exercise on a right note by commencing with objectivity in mind. State the exact problem and the circumstances as to what actually happened. If profitability is the issue, give a statement as to how much the company is losing, and establish which product or which activity area is causing the decline in profits.
Avoid posing questions like “How could this be possible?" but instead ask “What made this possible?” Be straightforward by asking “What caused this to happen?” as a substitute to “What could have caused this to happen?”.
Please proceed to page 2 for more guidelines and tips for root cause analysis.
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5. Avoid conflicts during deliberations by recognizing the fact that not everyone shares the same perception as the others.
Differences of opinion may arise,and a gathering of different individuals can serve the purpose of looking at the problem from another angle. If everyone shares the same point of view, the ongoing discussions run the risk of being contained and unexplored. As long as the flow of ideas is based on facts that are related to the incident, all antecedents to a causal factor, even if viewed from a different perspective, will lead to the critical stage where it all began.
Image Credit: MS TRO all hands group by Jennifer Smits
6. Provide visual presentation of the problem being analyzed.
Ensure that everyone is in sync with the issues being discussed by furnishing the participants with visual aids. In a brainstorming session, multiple causes can be extracted, but they all emanate from only one core factor. Causal errors are easier to understand if there are clear images of how it all happened, of the circumstances surrounding the event and of the elements present during the incident. Here’s an example:
The problem was the slow delivery of ordered goods due to frequent power outages. The RCA team learned that the outages occurred frequently during stormy days, which brought about power surges that threw the circuit breakers. Hence the machine automatically shut down because of power failure. If a circuit breaker was easily thrown at a single power surge, it denoted that it could not withstand the occurrence of a brief overload. It was established that low production was due to the low amperage tolerance.
In this example, it was recommended that the fuse’s amperage rating be increased in order to avoid the frequently recurring power outages that were causing slowness in output production.
However, let's take this scenario further, wherein a fire broke out and razed the building to the ground. The arson investigators came to establish faulty electrical wiring as the root cause.
The RCA team overlooked the physical structure and all the electronic equipment and devices in it. As a result, they failed to consider the fact that the entire building circuitry could no longer withstand or accommodate the increased amperage rating. This is where a visual aid would be most useful as it would help in the process, recalling and focusing on every existing element present in a particular incident.
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7. Aim to tackle the bigger issue by analyzing the overall impact of the adverse situation.
In order to avoid half-baked solutions, and very important among tips for root cause analysis, every member should have a mindset at tackling the biggest problem that has the most potential to happen. That way, the end point of all inquiries can be determined. Still, if the problem presents latent causes, then this is indicative of a larger problem.
A reference to latent cause means a causal factor that lies dormant or causes that are hidden but are discovered by way of in-depth analysis. This can be any form of a problem-causing trigger factor that can only be perceived once it has developed into a full-blown causal factor or pre-discovered if a thorough analysis is performed.
One way to explore this is to review all documentations and discussions before deciding that the group has arrived at the ultimate solution.
Image Credit: Random systemic errors by MK aka "CosmoCurio"
8. Capture all discussions in a recorder and document them in spreadsheets in order to organize a comprehensive compilation of the RCA performed.
Reviewing all deliberations and discussions is an important step to undertake before deciding on a root cause and its solutions. The objective of the review is to ensure that all possibilities have been considered and not merely to validate the end result of the analysis.
The facilitator, therefore, has to make sure that the round of ideas compiled leads to a flow of discussion, which covers and explores all other inter-related activities.
Please proceed to the third and last page, where we explain tips for root cause analysis such as recording, documenting, generalizing and testing the RCA procedures and solutions.
8. Capture all discussions in a recorder and document them …(continued from page 2)
The criticality of this issue is that a solution tends to be half-baked because it addresses only the underlying factor that triggered the event. What about the related resources, activities or processes that are affected by the incident? Has the team arrived at a corrective action to bring back a destabilized condition to its normal stage? Has the discussion deliberated on the interdependence of one work process to another in order to discover the latent causes?
An example would be human resources and the matter of coming up with a plan of action that will allay employees’ fears over a workplace accident. Otherwise, they will continue to work under a cloud of constant fear for their safety, which can cause unbearable stress and leads to an unhealthy workplace situation. Stress is known to cause sleeplessness, edginess, short tempers, lack of tolerance and subsequently health disorders that spur workplace conflicts, absences, long-term disability leaves or increase in voluntary turnovers. These will all boil down to lowered production levels plus additional recruitment costs.
If such conditions prevail, the overall impact on the business is a loss of profits, since management has to deal with more problems, which could have been addressed before their occurrences.
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9. Refrain from generalizing the recommended solutions.
Avoid recommending all-in-one solutions that are based on the premise that solving the root cause will solve all other problems related to a problem's occurrence. This can be likened to a scenario where the established root cause of an outbreak of “dengue fever” in the building is a broken pipe that has resulted in an undetected flooding in the basement area. The flooded area thus became a breeding ground for mosquitoes as the known carriers of the said illness.
Since the building is ascertained to be old, and the pipes have aged or weakened due to the expansion of water at freezing-point temperatures, the easiest solution would be to replace all pipes. This is in anticipation of the possibility that all other pipes will burst in the near future. However, freezing temperatures and expansion of water under these conditions are unavoidable and recurring.
Hence, other recommendations to consider include (1) increasing the insulation in the basement area, (2) wrapping the pipes with insulating materials, (3) installing a frost protection thermostat to serve as a monitoring control, and (4) adding a drainage outlet to prevent water coming from other sources to accumulate. Consider also that the same condition can happen in the upper floors where water pipes can be affected by the same elements and natural occurrence. This could lead to even greater problems where there are electrical wirings to contend with. The bottom line is to be specific when recommending solutions. That way, management will perceive the immensity of the problem.
10. Test the results of the recommended solutions.
Test the effectiveness of the recommended solutions, or check out the conditions of establishments that have encountered similar problems and have adopted the same solutions. There may be other post-solution effects brought about by material variations, which were overlooked at the point of recommendation.
Image Credit: Frozen collector pipes of an ice rink by World Wide Ice Professionals/Wikimedia Commons
These tips for root cause analysis are intended to serve as guidelines to ensure that the right solutions are provided once the right root cause has been established. However, readers are advised that the solutions provided are only examples to illustrate the guidelines. Every adverse incident or dilemma has its own characteristics as far as data, human element, organizational policies, structure, geographic location and industry are concerned; hence the RCA team is expected to formulate solutions based on their factual and related information.
Maintenance World.com by Dunn, Alexander (Sandy): Getting Root Cause Analysis to Work for You lifted from https://www.maintenanceworld.com/Articles/plantmaintenance/root-cause-analysis.pdf