Apparent Cause Evaluation, (known as ACE to many), is often used to quickly figure out a fix for a problem that does not need a true root cause analysis because it is not a critical issue. Usually a risk matrix helps a company determine whether a problem is critical. Criteria in the matrix can include likelihood of it occurring, cost and extent of injury or a fatality. Even while teaching TapRooT®, we do not suggest that everything get a root cause analysis, so why the question mark next to “using an ACE … ?”
Simple, there is not one issue that I have been asked to review that had Causal Factors (behavior of people, equipment or process) that were “brand spanking new”. The only difference in the past with these known Casual Factors was the extent of damage or injury that occurred this time. So why were the previous Causal Factors not effectively analyzed or corrected?
Often I see the issue as not having a solid list of company specific issues known High Potential Issues (HPIs), which would then require a TapRooT® level root cause analysis regardless of the extent of cost or if there is no injury. A friend once told, “a near miss is a gift for what should have happened!”
Here are some HPI examples dependent on industry:
1. Uncontrolled Vehicle Movement
2. Fall of Equipment, Material or People
3. Near Miss with Controlled Vehicle
4. Loss of Control of Moving Loads
5. Out of Specification Product (upstream or downstream)
6. Loss of Control of Sterile Environment
By the way, every one of the examples above ended up being a Causal Factor for a serious problem. So take a little time and Go Out And Look (GOAL) and observe the daily activities that require control of energy, product or environment and build your list of HPIs. Then investigate them with TapRooT® when they occur.
After all, do you really want to wait until a major accident happens to refresh your knowledge of our process? Heck, if you catch it early enough with HPIs, you will never have to get to that major incident.
Category: Root Cause Analysis Tips
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