1. Root Cause Analysis: An Introduction
2007, Immel Resources LLC, Petaluma, California USA,

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

3. Common Problems (1 of 4) Source: Apollo Root Cause Analysis, DL Gano, Apollonian Publications, Yakima, WA, 1999
Only 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
2007. Immel Resources LLC

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

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

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

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

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

9. Cause and Effect Principle
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
Causes and effects part of infinite continuum of causes
2007, Immel Resources LLC

10. Cause and Effect: An Example
Effects Causes
Injury caused by Fall
Fall caused by Wet Surface
Wet Surface caused by Leaky Valve
Leaky Valve caused by Seal Failure
Seal Failure caused by Improper Maintenance
2007, Immel Resources LLC

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

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

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

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

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

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

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

18. Solution Guidelines Solutions should always be specific actions
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.
2007, Immel Resources LLC

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

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

21. Word to the Wise
Sometimes solution may do nothing -- causes are unique, probability of repeating may be low
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%)
2007, Immel Resources LLC

22. Realities
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
When this happens, devise plan to capture more information and causes, so if problem repeats, we will know more causes
2007, Immel Resources LLC

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