September 10, 2007 | Mark Paradies

Part II – Lean Root Cause Analysis by Mark Paradies & Kevin McManus

To read Part I of this article, click here, or click here for a note about a conference where we did a Lean Root Cause Analysis exercise.

The article continues below…

Become Proactive

Since waste is the enemy of Lean, one very Lean concept is to avoid the waste proactively and thereby save the resources that you would have spent investigating accidents and incidents.

How do you become proactive? The best way is to:

• Perform audits, assessments, or observations,
• Find problems before they cause accidents or incidents,
• Analyze and fix those problem’s root causes, and
• Trend proactive assessment results to predict developing generic problems.

Truly proactive companies identify the root causes of problems (and fix them) BEFORE they cause serious accidents. Think of this approach using the famous “iceberg model.”


Companies can use a risk targeted observation program to catch and fix small but significant problems to prevent big accidents or quality issues (the tip of the iceberg).

Fixing many small but significant problems is much more efficient (Lean) than waiting for big, costly problems to point out systemic weaknesses.

Using advanced trending techniques can also be a part of this proactive approach. The results of the observations can be trended to spot developing generic problems that require more significant, systemic corrective actions.

Efficient Investigations

Once a company has done all that it can do to prevent unnecessary investigations, the next step to Lean root cause analysis is to apply Lean concepts to the investigation process. This application of Lean could start with value mapping of your investigation process and the removal of waste. In extensive work with companies around-the-world, we have spotted many wasteful investigation practices. These observations have led us to the following list of suggestions to make investigations more efficient (Lean):

• Plan investigations by using a SnapCharT®.
• Keep the investigation teams small.
• Assign the right people to the team.
• Plan efficient team meetings.
• Track the time spent on investigations. (What gets measured gets improved!)
• Have trained, experienced team facilitators and team members.
• Pre-plan evidence collection (before the incident occurs).
• Record radio communications and control room actions (video/audio).
• Have a black box for key plant parameters.
• Have an investigation “go kit.”
• Learn to perform effective interviews. (Most interviewing techniques are not effective.)
• Eliminate blame from investigations. (Willing participants are much more effective than trying to sift through lies & half-truths told to avoid blame.)
• Use effective/efficient investigation techniques.
• Don’t jump to conclusions. Let the evidence guide the investigation.
• Use in-process peer reviews of investigations and post-investigation grading to save management time and encourage investigator learning.
• Don’t perform generic cause analysis (common cause or extent of condition reviews) on small problems.

Adopting these basic efficiency concepts can save 20% to 80% of your investigation effort (depending on the inefficiency of your current efforts). Also, these efficiency ideas can make your proactive root cause efforts super-efficient and thereby produce a much bigger return on the time and effort invested in proactive improvement.


Lean includes an improvement tool called Kaizen (change for the better). Simply put, Kaizen is the continuous improvement of a process. One thing often overlooked is continuous improvement of a root cause analysis program.

How do you continuously improve your root cause analysis? Try these ideas:

• Evaluate weaknesses in your root cause analyses by using the The Good, the Bad, & the Ugly Spreadsheet (see the Root Cause Analysis Blog entry on 3/21/07).
• Use investigation grading to encourage continuous improvement (see the Root Cause Analysis Blog entry on 4/14/07).
• Use the techniques described in Appendix C of the new TapRooT® Book (available January, 2008).
• Write an improvement plan and track your implementation progress.
• Benchmark your root cause analysis system and adopt best practices from industry leaders. The TapRooT® Summit is the best place to do this. The next Summit is scheduled for June 25-27, 2008, in Las Vegas.
• Watch for more improvement ideas in the Root Cause Analysis Blog.
• Use TapRooT®. We use the latest research and user feedback to continuously improve!

Start Improvement Now!

These ideas may be common sense but common sense is often overlooked. Don’t be happy with wasteful root cause analysis. Apply Lean to your root cause analysis and get the most from your improvement efforts.

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