Root Cause Analysis: An Introduction Prepared for You by Barbara Immel, President, Immel Resources LLC, and Editor, Immel Report  2007, Immel Resources LLC, Petaluma, California USA,

Overview Common problems Common problems Understanding causes Understanding causes Problem definition Problem definition Identifying and implementing solutions Identifying and implementing solutions  2007, Immel Resources LLC

Common Problems (1 of 4) Source: Apollo Root Cause Analysis, DL Gano, Apollonian Publications, Yakima, WA, % of population are effective problem solvers (up to 30% in some industries) 20% of population are effective problem solvers (up to 30% in some industries) Key: Do not ask people to change their minds, but expand on what they already know Key: Do not ask people to change their minds, but expand on what they already know  Immel Resources LLC

Common Problems (2 of 4) People stop too soon, before they understand causes People stop too soon, before they understand causes “Root cause” myth “Root cause” myth –Assumes problem born from one source, and that causes are linear –Seeking solutions before knowing causes  2007, Immel Resources LLC

Common Problems (3 of 4) “Illusion” of common sense and single reality “Illusion” of common sense and single reality –Everyone has unique perceptions, knowledge, strategies & conclusions “Groovenation” “Groovenation” –Too focused on being right, justifying beliefs Storytellling Storytellling –Ignores cause and effect, tells good story, exhibits group think  2007, Immel Resources LLC

Common Problems (4 of 4) Poor writing Poor writing –Poor problem-solving, rule-based thinking, “filling in a checklist” mentality Categorical thinking Categorical thinking –Prejudice; putting everything and everyone in a “box”  2007, Immel Resources LLC

Ineffective Problem Solving (1 of 2) Incomplete problem definition Incomplete problem definition –Boss or expert’s opinion simply accepted; so busy tracking & trending but still failing miserably. Good problem-solving? Problem does not repeat. Unknown causal relationships Unknown causal relationships –Continue to ask “why” to point of ignorance; rather than rely on inferences or storytelling

Ineffective Problem Solving (2 of 2) Focus on solutions Focus on solutions –If do not clearly define problem, may solve wrong problem –Groovenation -- when seek what is familiar, favorite solution mindset -- preventing effective problem-solving –Authoritative and goal- driven individuals: Ready, Shoot, Aim! mentality with categorical thinking/groovenation  2007, Immel Resources LLC

Cause and Effect Principle Each effect has at least two causes in form of actions and conditions Each effect has at least two causes in form of actions and conditions An effect exists only if its causes exist at same point in time and space An effect exists only if its causes exist at same point in time and space Causes and effects part of infinite continuum of causes Causes and effects part of infinite continuum of causes  2007, Immel Resources LLC

Cause and Effect: An Example EffectsCauses EffectsCauses Injury caused byFall Injury caused byFall Fall caused byWet Surface Fall caused byWet Surface Wet caused byLeaky SurfaceValve Wet caused byLeaky SurfaceValve Leaky caused bySeal ValveFailure Leaky caused bySeal ValveFailure Seal caused byNot Failure Maintained Seal caused byNot Failure Maintained  2007, Immel Resources LLC

Primary Effect or Event Any effect of consequence that we want to prevent from happening Any effect of consequence that we want to prevent from happening Pain CB Injury CB Fall CB Slipped CB Wet CB Leaky Surface Valve Pain CB Injury CB Fall CB Slipped CB Wet CB Leaky Surface Valve  2007, Immel Resources LLC

Always at least Two Causes in Form of Actions and Conditions Primary effect caused by actions and conditions Primary effect caused by actions and conditions Actions Actions –Momentary causes bringing conditions together to cause an effect (action causes) Conditions Conditions –Causes that exist over time prior to an action (pre- existing conditions)  2007, Immel Resources LLC

Actions and Conditions Action Action Match Strike Match Strike Condition Condition Effect Dry Vegetation Effect Dry Vegetation Open Fire Caused By Open Fire Caused By Condition Condition Combustible Combustible Material Material Condition Condition Oxygen Oxygen  2007, Immel Resources LLC

Elemental Causal Set Made up of an effect and its immediate causes Made up of an effect and its immediate causes Causes include action and one or more conditions Causes include action and one or more conditions Causal sets, like causes, do not exist alone but are part of a continuum of causes with no beginning or end Causal sets, like causes, do not exist alone but are part of a continuum of causes with no beginning or end  2007, Immel Resources LLC

Why Storytelling Is Not Enough (Linear Language = Linear Thinking) Stories start in past while causal relationships start with present Stories start in past while causal relationships start with present Stories are linear while causal relationships follow branches of infinite set Stories are linear while causal relationships follow branches of infinite set Stories use inference to communicate meaning, while problems are known by sensed causal relationships Stories use inference to communicate meaning, while problems are known by sensed causal relationships

Complete Problem Definition What is the problem? What is the problem? When did it happen? When did it happen? Where did it happen? Where did it happen? What is the significance of the problem? What is the significance of the problem? Not “who” or “why” Not “who” or “why” Who places blame, Why is part of analysis Who places blame, Why is part of analysis  2007, Immel Resources LLC

Effective Problem-Solving Define the problem Define the problem For major problems, create a cause and effect chart For major problems, create a cause and effect chart –Similar methods use logic trees, or fishbone diagrams Identify effective solutions Identify effective solutions Implement the best solutions Implement the best solutions  2007, Immel Resources LLC

Important Concepts Like a puzzle but no boundaries Like a puzzle but no boundaries Like a jigsaw puzzle, it will fit together if you persevere, have patience and tenacity Like a jigsaw puzzle, it will fit together if you persevere, have patience and tenacity How eat an elephant? One bite at a time (dividing problem into smaller parts focusing on separate primary events -- called chunking) How eat an elephant? One bite at a time (dividing problem into smaller parts focusing on separate primary events -- called chunking)  2007, Immel Resources LLC

Look for Causes in Actions and Conditions (1 of 2) Actions: momentary causes that bring conditions together to cause an effect Actions: momentary causes that bring conditions together to cause an effect Conditions: causes that exist over time prior to an action Conditions: causes that exist over time prior to an action Just concentrate on identifying and listing causes Just concentrate on identifying and listing causes  2007, Immel Resources LLC

Look for Causes in Actions and Conditions (2 of 2) For each “action” cause, ask what conditions had to be in place for that action to cause the effect For each “action” cause, ask what conditions had to be in place for that action to cause the effect For each “condition” cause, make sure have corresponding action For each “condition” cause, make sure have corresponding action Generally several “condition” causes and one “action” cause in each set Generally several “condition” causes and one “action” cause in each set  2007, Immel Resources LLC

Support All Causes with Evidence or Use a Question Mark Set a deadline to collect evidence Set a deadline to collect evidence Incorporate as much knowledge as possible given time constraints Incorporate as much knowledge as possible given time constraints Evidence: data that supports a conclusion Evidence: data that supports a conclusion  2007, Immel Resources LLC  2007, Immel Resources LLC

Identify Effective Solutions Solution: Solution: –An action taken upon a cause to affect a desired condition Criteria: Criteria: –1. Prevent recurrence –2. Be within your control –3. Meet your goals and objectives  2007, Immel Resources LLC

Solution Criteria Prevent recurrence Prevent recurrence Be within your control Be within your control Meet your goals and objectives Meet your goals and objectives Solution does not cause unacceptable problems Solution does not cause unacceptable problems Solution prevents similar occurrences, including at different locations Solution prevents similar occurrences, including at different locations Solution provides reasonable value for its cost Solution provides reasonable value for its cost  2007, Immel Resources LLC

Solution Guidelines (1 of 2) Sometimes solution appears beyond your control because need higher approval -- your hard work will help you “sell” your idea Sometimes solution appears beyond your control because need higher approval -- your hard work will help you “sell” your idea Sometimes good solutions come out of the blue, from nowhere (subconscious mind) Sometimes good solutions come out of the blue, from nowhere (subconscious mind)  2007, Immel Resources LLC

Solution Guidelines (2 of 2) Solutions should always be specific actions Solutions should always be specific actions Don’t include solutions such as “review, analyze, or investigate” (copout) Don’t include solutions such as “review, analyze, or investigate” (copout) Avoid denial and don’t say that you don’t know what the causes are. Implement mitigating solutions until you can investigate further. Avoid denial and don’t say that you don’t know what the causes are. Implement mitigating solutions until you can investigate further.  2007, Immel Resources LLC

Avoid These Favorite Solutions Punish Punish Reprimand Reprimand Replace broken part Replace broken part Investigate Investigate Revise the procedure Revise the procedure Write a new procedure Write a new procedure Change management program (re-engineer it) Change management program (re-engineer it) Redesign it Redesign it Put up a warning sign Put up a warning sign Ignore it -- stuff happens Ignore it -- stuff happens  2007, Immel Resources LLC

What Favorite Solutions Mean You may be in a rut You may be in a rut Chances are that the problem will repeat itself Chances are that the problem will repeat itself Favorite solutions usually mean you have identified your favorite causes Favorite solutions usually mean you have identified your favorite causes Revisit your ideas -- may have missed something or made an assumption Revisit your ideas -- may have missed something or made an assumption  2007, Immel Resources LLC

Word to the Wise Sometimes solution may do nothing -- causes are unique, probability of repeating may be low Sometimes solution may do nothing -- causes are unique, probability of repeating may be low Right solution is one that meets our criteria Right solution is one that meets our criteria About 5-6% of time, not capable of finding solution (knowledge of work processes we control about 95%) About 5-6% of time, not capable of finding solution (knowledge of work processes we control about 95%)  2007, Immel Resources LLC

Realities Sometimes we simply don’t know what happened (although we may know in time) Sometimes we simply don’t know what happened (although we may know in time) We stop looking because task is too expensive, time consuming or difficult We stop looking because task is too expensive, time consuming or difficult When this happens, devise plan to capture more information and causes, so if problem repeats, we will know more causes When this happens, devise plan to capture more information and causes, so if problem repeats, we will know more causes  2007, Immel Resources LLC

Solution Killers It will never work here. It will never work here. We’re too busy for that. We’re too busy for that. No one will buy it. No one will buy it. We already tried that once. We already tried that once. That’s not our policy here. That’s not our policy here. It isn’t in the budget. It isn’t in the budget. Good thought but impractical. Good thought but impractical. Top management will never go for it. Top management will never go for it. No one else is doing it that way. No one else is doing it that way. Wrong! Wrong! We’ve always done it this way. We’ve always done it this way. Good idea. I’ll get back to you (and never does). Good idea. I’ll get back to you (and never does).  2007, Immel Resources LLC

Solution Killers Caused by Fear of Change Never let solution-killer statement go unanswered, no matter who says it (use tact -- redirect focus -- discuss purpose, learning, growth, improvement) Never let solution-killer statement go unanswered, no matter who says it (use tact -- redirect focus -- discuss purpose, learning, growth, improvement) Play dumb -- ask them to explain why it does not work Play dumb -- ask them to explain why it does not work Never get into an argument about who is right and who is wrong Never get into an argument about who is right and who is wrong  2007, Immel Resources LLC

“Gano Rule” and “Yes-Anding” The Gano Rule The Gano Rule –Always sleep on important decisions –Gestation period –Sleep and play important to creativity and thinking Yes-Anding Yes-Anding –Avoid saying “but” –When team member says something you disagree with, empathize and then agree “Yes, and we could add to that with (own idea)”  2007, Immel Resources LLC

Training is Key Train all managers in fundamentals and basic tools Train all managers in fundamentals and basic tools Train everyone who solves problems daily how to facilitate problem- solving teams Train everyone who solves problems daily how to facilitate problem- solving teams Train each employee to understand cause and effect principle Train each employee to understand cause and effect principle  2007, Immel Resources LLC

When to Perform an Analysis Threshold criteria Threshold criteria –When should investigation be done? –Whenever you encounter unacceptable circumstances. –Define your threshold criteria in SOP. Periodically review and revise criteria. When in doubt -- it is probably better to do an investigation. When in doubt -- it is probably better to do an investigation.  2007, Immel Resources LLC

Evidence Preservation Policies should require evidence preservation Policies should require evidence preservation Put together a checklist to obtain all relevant data, including interviewing personnel Put together a checklist to obtain all relevant data, including interviewing personnel Have a plan to gather information as soon as possible after event Have a plan to gather information as soon as possible after event Identify key people, give them responsibility to gather information Identify key people, give them responsibility to gather information  2007, Immel Resources LLC

Define Responsibilities Establish committed investigation people to be on call 24 hours if 24-hour operation Establish committed investigation people to be on call 24 hours if 24-hour operation Start gathering information as soon as all safety issues dealt with Start gathering information as soon as all safety issues dealt with Lead investigator to start gathering data and make sure others doing assigned tasks Lead investigator to start gathering data and make sure others doing assigned tasks Everyone should pitch in Everyone should pitch in If problem doesn’t warrant time to fix it, then shouldn’t be worked on If problem doesn’t warrant time to fix it, then shouldn’t be worked on  2007, Immel Resources LLC

Use Simple Report Form Problem Definition Problem Definition Time Observed/Time Reported Time Observed/Time Reported Immediate Action Taken Immediate Action Taken Product Impact Product Impact Investigation Plan Investigation Plan Root Cause(s) Root Cause(s) Corrective and Preventive Actions Corrective and Preventive Actions Responsible Person/Due Dates Responsible Person/Due Dates Effectiveness Evaluation Effectiveness Evaluation Product Disposition Product Disposition  2007, Immel Resources LLC

Corrective and Preventive Action (CAPA) Tracking (1 of 2) Document each action in log and/or database Document each action in log and/or database Include responsible person, due date, brief description of required action Include responsible person, due date, brief description of required action Update log frequently Update log frequently Send out regular or written status reports Send out regular or written status reports  2007, Immel Resources LLC

Corrective and Preventive Action (CAPA) Tracking (2 of 2) If action cannot be done on time, require documented interim report and new due date If action cannot be done on time, require documented interim report and new due date Lack of commitment by management will cause program to fail Lack of commitment by management will cause program to fail CAPA should be agreed to and signed by those with authority and responsibility to implement CAPA should be agreed to and signed by those with authority and responsibility to implement Keep “nice to do” projects separate. Master log only those items resulting from formal investigations. Keep “nice to do” projects separate. Master log only those items resulting from formal investigations.  2007, Immel Resources LLC

Trending Helps identify where to put resources Helps identify where to put resources Use categorization/key words Use categorization/key words Funnel all categorization through 1-2 like-minded people; true for database input, too Funnel all categorization through 1-2 like-minded people; true for database input, too If have repeat events -- ineffective problem-solving or not important enough for your attention If have repeat events -- ineffective problem-solving or not important enough for your attention Work on all significant problems, and track total number Work on all significant problems, and track total number  2007, Immel Resources LLC

Review Common problems Common problems Understanding causes Understanding causes Problem definition Problem definition Identifying and implementing solutions Identifying and implementing solutions  2007, Immel Resources LLC

Thank You Thank you all for attending Thank you all for attending Joe Immel Joe Immel  2007, Immel Resources LLC