ACE – How do you find the root causes?
First, for those not in the nuclear industry …
What is an ACE?
An ACE is an Apparent Cause Evaluation.
In the nuclear industry, management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).
So how do nuclear industry professionals perform an ACE?
There is no standard method. But many facilities use the following “system” for the evaluation:
- Don’t waste a lot of time performing the evaluation.
- Make your best guess as to the cause.
- Develop a simple corrective action.
- Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.
How does that work? Not so good. Read about my opinion of the results here:
That article is pretty old (2006), but my opinion hasn’t changed much.
So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:
Here’s a flow chart of the process…
For all investigations, you need to find out what REALLY happened. Then you make an important decision …
Is there anything worth learning here?
Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.
The example in the book is someone falling while walking on a sidewalk.
If you decide there IS more to learn, then a simplified TapRooT® Process is used.
This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.
That’s it. No Generic Cause Analysis and no fixing Generic Causes.
Want to learn more? Read the book. Get your copy here: