Root Cause Analysis Blog

 

A Look at 3 Popular Quick Idea Based Root Cause Analysis Techniques: 5-Whys, Fishbone Diagrams and Brainstorming

Posted: August 26th, 2015 in Root Cause Analysis Tips

Today’s root cause tip will walk through a few popular quick-idea based root cause analysis techniques used by many.

Do a quick search using Google or Yahoo search engines for “Root Cause Analysis Training” and these techniques often pop up in your internet browser: 5-Whys, Fishbone (Ishikawa) Diagrams, Brainstorming and of course, TapRooT® Root Cause Analysis. Now type in “free” or “quick root cause analysis templates” and you will not find TapRooT®. Is that good or bad? Of course my dad always taught me that what is earned and worked for was always more satisfying and led to a stronger sense of accomplishment. The end product also lasted longer.

Brainstorming

Why would a person search for root cause analysis training on the Internet? If I were to brainstorm the whys as defined in dictionary.reference.com:

 noun

- a sudden impulse, idea, etc.

- a fit of mental confusion or excitement. 

Origin

-1890-95; brain + storm; originally a severe mental disturbance

Then I might suggest the following “whys”:

  1. The person was bored.
  2. A student was doing research.
  3. A training department was assigned to find and schedule quick low cost training techniques that can be taught online.
  4. You were assigned to find good root cause training to solve problems.

Now those weren’t too many suggestions on my part. But there is hope, because brainstorming is best served in groups. As defined in wikeipedia.org:

Brainstorming is a group creativity technique by which efforts are made to find a conclusion for a specific problem by gathering a list of ideas spontaneously contributed by its members.

But we have to establish a few rules per wikipedia.org:

  1. Focus on quantity…. The more the merrier.
  2. Withhold criticism…. No why is a bad why and you might shut down the quantity given by others that were made fun of.
  3. Welcome unusual ideas
  4. Combine and improve ideas… we can build off other peoples’ whys for a really good why to solve a problem.

Okay with our new rules and group in place, we came up with more whys to why someone was searching for root cause analysis on the internet:

  1. The person was bored.
  2. A student was doing research.
  3. A training department was assigned to find schedule quick low cost training techniques that can be taught online.
  4. You were assigned to find good root cause training to solve problems.
  5. The current root cause techniques are not working very well.
  6. You are planning a party and this would be a great team game. (This one was my favorite suggestion)

Fishbone (Ishikawa) Diagrams

Brainstorming not quite good enough in our quest to solve why people are searching for root cause analysis on the internet you think? Let’s do a guided search for whys with our group using a Fishbone (Ishikawa) Diagram.

Fishbone1stgraphic
Now this tool also comes with some rules:

  1. Agree on a problem statement as a group. Ours is “why are people searching for root cause analysis on the internet?”
  2. The problem statement is placed at the head of the fish as seen in the diagram above.
  3. Now Brainstorm the major categories of the cause of the problem and list them underneath each category. For our fishbone from wikipedia.org, we are going use Methods, Machines, Material and Measurements.

a. Methods: How the process is performed and the specific requirements for doing it, such as policies, procedures, rules, regulations and laws

b. Machines: Any equipment, computers, tools, etc. required to accomplish the job

c. Materials: Raw materials, parts, pens, paper, etc. used to produce the final product

d. Measurements: Data generated from the process that are used to evaluate its quality

 Caution, there are many categories to chose from which may lead the group into different directions each time they use one. We could have also used the categories as listed in wikipedia.org:

The 7 P’s

Product/Service
Price
Place
Promotion
People/personnel
Process
Physical Evidence
 
The 5 S’s
Surroundings
Suppliers
Systems
Skills
Safety

Here is our refined fishbone. I have to admit, it does look a little better than the brainstorming list above. Did not take that much time at all.

2ndimage

  1. As each idea is given, the facilitator writes it as a branch from the appropriate category.
  • Again ask “why does this happen?” about each cause.
  • Write sub-causes branching off the causes. Continue to ask “Why?” and generate deeper levels of causes. Layers of branches indicate causal relationships.

Item number 4 gets into looking for causal relationships within our suggested causes which leads into our 5 whys discussion next.

5 Whys

Let’s take one of the “causes” listed above and get to a good root cause with our group to understand why people are searching for root cause analysis on the internet?

Here are the simple instructions for performing a 5 Whys as listed in wikipedia.org:

5 Whys is an iterative question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question “Why?” Each question forms the basis of the next question.

  1. Why are people searching for root cause analysis on the internet?

Answer: Because there is no database to search in on their computer and the boss wants training answers now.

  1. Why is there no database on the computer to search from?

 Answer: Because these are computers produced in 1995 and a knowledge database cannot be installed.

  1. Why do we not have new computers that can have databases installed?

 Answer the company is short money.

  1. Why is there no money left to purchase computers?

Answer: Because we have lost money on repeat incidents.

  1. Why do we have repeat incidents?

Answer: Because we do not have a good, effective, cost reducing Root Cause Analysis Process. I have a great solution for this problem….. look here for future courses in TapRooT® Root Cause Analysis.

Okay, I agree this was a very high level and superficial exploration of the 3 Popular Quick Idea Based Root Cause Analysis Techniques: 5-Whys, Fishbone Diagrams and Brainstorming.

However, the steps that we explored are valid steps and flow of the actual processes. The ending results from superficial creation of whys are very true and have been the cause for repeat problem occurrences.

If you are going to use these process, as they are often still required for everyday issue resolution for some and for others are actually considered their only root cause tools, then head off some of the issues with a couple of these best practice suggestions.

  1. Never start with Brainstorming. This is a great tool for suggesting corrective actions tied to actual root causes, but should not be used for evidence collection and figuring out why something happened.

What to do instead? Go Out And Look (GOAL). Never armchair troubleshoot from a conference table surrounded by people.

  1. Only use a Fishbone (Ishikawa) Diagram if:

a. You have collected evidence
b. You standardized and defined your fishbone cause categories
c. You have the right experts in the room
d. Cause or Corrective action ideas do not drive the actual what and why questions.

  1. Only use 5 Whys for trying to identify the actions or inactions that allowed an issue to occur and not the actual root causes. Why?

a. There is a tendency to look for only one cause when using the process; even if you ask 5 Whys for each action or inaction found on the Fishbone (Ishikawa) Diagram, there is still a tendency to look for only one cause in each section. I have never just had one cause for any problem that I have investigated.
b. It is not how many questions one asks but what one asks.
c. When used to collect evidence or understand evidence, there is a tendency for “group think” to occur that drives which direction the evidence and causation linkage goes. Look up the Space Shuttle issue tied to the o-ring failure for a group think example that was detrimental to life.
d. There is nothing to push the investigations outside what they know as a whole and what may be missing from the investigation. In that case, always bring in different knowledgeable and people new to the problem for constant checks and rechecks. Also look for outside industry best practices and knowledge to help get better investigations completed.

So in closing…..

  1. If it looks too easy and requires less work, you get what you put in it.
  2. If there is a large amount of guessing, you are also guessing at the corrective action.
  3. If the right expert is not in the room when using the tools explored, nobody will know what to ask or to verify.
  4. If the people using the process are the only thing driving the evidence collection, bias has a stronger natural tendency to take over.

I look forward to your examples of using these processes and also comments on some of the traps you did or did not avoid while using these 3 tools.

Weekly Wisdom: Even The Great Bambino had to strike out

Posted: August 25th, 2015 in Wisdom Quote

babe

“Every strike brings me closer to the next home run.” -Babe Ruth

How far away is death?

Posted: August 25th, 2015 in Video

Want to see more of these? “How Far Away is Death” is a column in our weekly eNewsletter (distributed every Tuesday) that is often a startling reminder of what can happen in the blink of an eye.  If you’d like to subscribe, contact Barb at editor@taproot.com.

TapRooT® Public Courses in Canada

Posted: August 24th, 2015 in Courses

Toronto from Snake Island

Toronto, Canada

Upcoming TapRooT® Public Courses:

Edmonton | 2-Day | September 21, 2015

Calgary | 5-Day | October 5, 2015

Toronto | 2-Day | October 19, 2015

Montreal | 2-Day | October 26, 2015 (Language: French)

St. John’s | 5-Day | October 26, 2015

For more information regarding our public courses around the world, click here.

Monday Accident & Lessons Learned: Severe Hand Injury – What is the Root Cause?

Posted: August 24th, 2015 in Accidents, Video

This video is graphic. Don’t watch if the sight of blood makes you queasy…

Go to video …

(more…)

Public TapRooT® Course in Denver, CO

Posted: August 20th, 2015 in Courses, Local Attractions

800px-Denver_Montage

If you’ve never seen the Rocky Mountains in September or experienced the beauty of Denver, now is your chance! TapRooT® is offering a 2-Day Public Course that is filling up quickly. You will have the opportunity to not only learn the valuable TapRooT® root cause techniques, but also visit the one and only “Mile-High City”. The majestic mountains and national parks aren’t the only things worthy of a visit to Denver, though. Check out our entertainment and food suggestions below to begin planning your trip today!

Food:

Snooze: Whether you’re a breakfast person or not, everyone can enjoy Snooze. It’s not just typical breakfast items, you can find gourmet sandwiches, sweet breakfast treats and fresh vegetable and fruit plates.

Denver Biscuit Company: Famous for their “Mile-High” biscuits, they make biscuits of all flavors with a plethora of toppings to create something original and delicious.

Fruition Restaurant: Looking for a more gourmet, fine-dining experience? Look no further. Fruition is the number one restaurant in Denver for presentation, flavor and perfection. You can’t get better than that

Attractions: 

Denver Botanic Gardens: Find your inner-adventurer and take a stroll through these breathtaking gardens. The locals describe them as “serene and beautiful”, that’s my kind of adventure!

Denver Museum for Nature and Science: If the weather isn’t cooperating for an adventurous outing, Denver has you covered. Get all the nature indoors at this huge and highly-reviewed museum.

Denver Zoo: Not all zoos are the same; some have more animals, different species, larger exhibits, etc. But Denver’s zoo has it all. If you’re bringing the whole family on this trip to Denver, the zoo is one of the best spots!

Ready to REGISTER? Click here.

Interested in other Public Course dates? Click here.

Interested in an Onsite Course? Click here.

What does a bad day look like?

Posted: August 20th, 2015 in Accidents, Video

Just like this if you own a monster truck…

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

Senior Management & Root Cause Analysis

Posted: August 19th, 2015 in Performance Improvement, Root Cause Analysis Tips

What is the easiest way to tell a good root cause analysis program from a bad one?

The involvement of senior management.

How do you know if a root cause analysis program is about to fail?

Senior management changes and the new management shows no interest in the root cause analysis program.

What level of senior management is involved in the best root cause analysis programs?

All the way to the corporate board.

MANAGEMENT INVOLVEMENT

The answers to the three questions above show that senior management involvement is extremely important to the success of any root cause analysis program. The better the root cause analysis program, the more senior management involvement counts. That’s why I thought I’d take this time to explain how senior management should be involved in a root cause analysis program.

NewImage

CORPORATE BOARD

I’ve seen a few leading companies where the Corporate Board was knowledgeable of the safety/process safety/quality improvement programs. The best had a senior manager who was responsible for reporting key reactive and proactive statistics to a special board committee with primary responsibility for safety and other improvement efforts. The committee, that included the CEO, also was provided with overviews of the most serious incident investigations and summaries of improvement efforts.

This board’s interest ensured that people paid attention to the programs and that budgets weren’t slashed for key improvement initiatives (because they were supported by the board).

VP/DIVISION MANAGER

Of course, VPs or Division Managers were interested in their division’s reactive and proactive improvement performance. What VP or Division Manager wouldn’t be if the Corporate Board was going to see their statistics. They wanted to be able to manage performance so they became involved in improvement efforts. The held divisional meetings to review progress and presentation of root cause analyses of their biggest problems. They held Plant Managers and Unit Leaders responsible for their performance making improvement programs succeed.

PLANT MANAGERS

Involved Plant Managers demand good root cause analysis and schedule reviews of detailed root cause analyses of significant problem investigations. They make sure that their key improvement programs are staffed with well trained, insightful leaders and that they have plentiful staff and budget to perform investigations, review reactive and proactive statistics, sponsor training throughout the plant, and look outside the company for improvement ideas. They are the site sponsors of the improvement programs. They are trained in the root cause analysis tools being applied at the plant. Because they are trained, they offer insightful critiques of the investigation presentations. They reward employees for their participation in root cause analyses and the improvement programs.

WHAT DOES YOUR COMPANY DO?

Is your senior management involved in performance improvement?

Do you have best practices for management involvement that I’ve missed and should be included here?

What do you need to do to improve your management involvement?

If you have support, are you ready for management turnover?

Rome wasn’t built in a day. Don’t worry if your program doesn’t have all the management support that it needs. But don’t ignore your program’s shortcomings. Work on getting more management support all the way up to the corporate board.

When safety/improvement performance is seen as equally important, you know you have achieved a level of support that most improvement managers can only dream about.

Find and Fix the Root Causes of Equipment Related Failures

Posted: August 19th, 2015 in Courses, Equipment/Equifactor®

Don’t end up “fixing” the same equipment problems over and over again. Don’t let equipment issues cause quality, operations, and safety issues. Find the real root causes of your equipment reliability issues and develop effective fixes that will keep them from happening again by using this systematic process.

Did you know that we have 3-day and 1-day courses? What’s the difference? 3-Day Courses include the 1-Day Equifactor® Course along with the 2-Day Incident Investigation and Root Cause Analysis Course so you have it all in one. The 1-Day courses are just the separate Equifactor® course that requires a previously taken 2-Day course along with it, not necessarily all in one trip.

Why take an Equifactor® course? You will not only receive invaluable knowledge for your business, but also a Free single-user copy of TapRooT® Software. (A $2890 Value!) You can’t get a better deal than that.

Still deciding? Watch the video below to hear our Equifactor® instructor, Ken Reed, talk about why this course is right for you.

 

Steps to register for the course and Free Software.

1) CLICK HERE

2) Select a 1-Day Equifactor® Course of your choice (Having already taken a 2-Day course or accompanying it with a 2-Day course)

3) Register for the course and add it to your cart

4) Done!

 

Upcoming Equifactor® Public Courses:

Austin, TX | July 16, 2015

Edmonton, Canada | July 24, 2015

Sale, Australia | August 6, 2015

Don’t Waste A Good Crisis

Posted: August 19th, 2015 in Career Development, Career Development Tips

pablo(9)

Yep, oil prices are still down.  With oil below $50/barrel, revenues in the oil exploration business side are nowhere near what they were when oil was at $100/barrel.  Many are struggling to stay afloat.

So what do you do?

One of our clients had a great thought.  He said, “Don’t waste a good crisis.”  What he meant was, while revenues are down, you may find yourself cutting back on your core business.  For the exploration guys, this might mean less drilling.  Fewer rigs probably means less opportunity to cause incidents associated with drilling.  Therefore, your investigation teams are NOT performing as many root cause analyses, and therefore, proficiency drops.  Your options are:

1) Stop performing root cause analyses

2) Exercise your investigation teams on other items.

He had mentioned that this is a prime time to do things that you may not have had time to do before.  For example, his company is going back to review old incident reports.  They’re doing a deep analysis, looking for commonalities and repeat issues.  In other words, they are taking this time to improve their processes.  When business picks back up, they want to be in even better shape than they were before.  They want to be leaner, make fewer mistakes, waste less time, keep their people and the environment safer, and save money.

How many times have you seen companies stumble when they ramp back up?  They are less proficient, they’ve let their equipment languish, they’ve let their skills degrade.  Suddenly, business picks up.  They go through a period of rapid hires, bringing on new people that may or may not still be proficient at their jobs.  The investigations teams suddenly find themselves busy, but they, too, have lost their proficiency.  Investigations take longer, and they’re not as in-depth.  Lots of wasted time, money, reputation, and (worst case) lives.

All of this can be avoided by taking advantage of the down-time.  Use your skilled workers to their fullest.  I know those engineering teams have sharpened their pencils, looking for better, safer, and cheaper ways of extracting oil.  Your investigation teams should be doing exactly the same thing.  They should be looking at your processes, finding the repeat failures and incidents, and putting more robust corrective actions in place right now.

Where are the inefficiencies in your processes?  What repeat mistakes have your people made in the past, and how can we prevent them from happening again tomorrow, when business is again booming?

I thought that was a great attitude.  Don’t waste this great opportunity.  Don’t waste a good crisis.

=======================================

Do you like reading quick yet empowering tips like this? Contact Barb at editor@taproot.com and have them delivered to your inbox every Tuesday.  Just type “subscribe” in the subject line.  Our eNewsletter has career development tips, root cause tips, job postings, and even a joke to keep it light.

Weekly Wisdom: Know your purpose

Posted: August 18th, 2015 in Wisdom Quote

purpose

“Definiteness of purpose is the starting point of all achievement.” -W. Clement Stone

How far away is death?

Posted: August 18th, 2015 in Video

Want to see more of these? “How Far Away is Death” is a column in our weekly eNewsletter (distributed every Tuesday) that is often a startling reminder of what can happen in the blink of an eye.  If you’d like to subscribe, contact Barb at editor@taproot.com.

TapRooT® Implementation Team at National Grid wins Chairman’s Award for Safety

Posted: August 17th, 2015 in Summit Videos, Video Depot

The caring, commitment, and dedication of TapRooT® Users to find and fix problems and potential problems at their companies always impress me and many times leave me in awe of what they accomplish within their company and for their fellow employees. It is such a joy to all of us here at System Improvements when we get to hear about our clients’ success using the TapRooT® System. View the video below and see why National Grid is a great example of what I mean. A special thanks goes to National Grid for sharing this video with us.

Monday Accident & Lessons Learned: Hand Injuries

Posted: August 17th, 2015 in Video

This is the first in a few video hand safety videos. It is from the Industrial Minerals Association of North America. The program presents the “Take Five for Finger Safety” program. Many of the lessons shared are from lessons learned from accidents.

How effective is the “pay attention” advice? How many times will we see this in future videos?

Monday Motivation: Haters

Posted: August 17th, 2015 in Video

Remembering an Accident: Sayano-Shushenskaya Hydro Power Plant Disaster

Posted: August 17th, 2015 in Accidents, Video

On August 17, 2009, 75 people were killed when a turbine failed at the Sayano-Shushenskaya Power Station in the southern region of the Russian Federation. The turbine that failed had been vibrating for a long time before the accident occurred. A report published in Power Magazine suggests that it was predictable and preventable. The report revealed the terror of that day:

image“Water was washing away people from the turbine gallery into the river. Some of them were later caught and rescued. Some were not. The staff later learned that the turbine gallery was not equipped with proper emergency exits. There were also some miraculous rescues. One worker was washed by the torrent of water filling the turbine gallery up into the ceiling, where he managed to grab some ventilation equipment and hold on until being rescued. Others led employees to safety using cell phones as flashlights.”

http://www.powermag.com/investigating-the-sayano-shushenskaya-hydro-power-plant-disaster/

Have worst case scenarios at your facility ever kept you awake at night? View our course listing and learn how to go deeper into the causes of human error and equipment failure to find and fix the real root causes:

http://www.taproot.com/courses

 

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