August 7, 2009 | Mark Paradies

Root Cause Analysis Tip: Are Simple Techniques Sometimes the Best?

I received a piece of marketing material for a webinar claiming to teach “simple” root cause analysis techniques in just one hour.

The marketing material included the quote that these basic techniques:

are sometimes the best.

Of course, they lost all credibility with me when they claimed to teach root cause analysis in 60 minutes on the web. But the e-mail made me think …

What are the minimum tools needed to perform a good root cause analysis of a simple problem?

We’ve researched this question for over 20 years and I know the answer.

First, you need to understand:

Make the answer as simple as possible, but not simplier.” (Albert Einstein)

What is the minimum needed information to find a root cause?

1. You need to completely understand what happened before you can understand why it happened. And this understanding should NOT be made through verification of a hypothesis. Rather, the understanding should be an unbiased collection of evidence.

The tool that helps people build the story of what happened using evidence that is collected is a SnapCharT®. And example of a SnapCharT® can be found at this link:

Using the TapRooT® System-tm.jpg

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2. Next, you need to identify all the Causal Factors. These are the problems that, if removed, would have prevented the incident or reduced its severity.

There are two techniques that are taught in TapRooT® Training to help investigators identify Causal Factors. The first is the Four Question Method and the second is Safeguards Analysis.

3. Finally, to analyze what caused the Causal Factor, you need a robust root cause analysis tool. There are many substandard tools available so … be careful. Many “experts” recommend a tool they are familiar with without doing thorough research of the tools limitations and understanding the serious shortcomings of supposedly “simple” tools. But we have dedicated our lives to understanding root cause analysis and developing a tool that does not fall into the trap of being just simple but inadequate.

The TapRooT® Root Cause Tree® have been carefully designed and tested to provide the simplest tool possible while yielding robust root cause analysis for equipment and human performance related Causal Factors. The research basis is extensive, so I won’t provide it all here. But I will provide several links so that you can start to understand it…

However, some people continue to cling to inadequate tools because they are “easy” and “sometimes the best.” (Makes one wonder when they are “sometimes the worst.”)

Usually this insistance on using easy, inadequate tools is because the person has failed to do what is needed to make real root cause analysis possible.

What did they miss? See this link to learn what is needed for efficient and effective root cause analysis:

So these tools are the required minimum set (the essential tools) for a good root cause analysis. Anything less is root cause analysis malpractice.

We’ve found that a 2-day course is needed to effectively teach these tools to experienced investigators who want to apply them both reactively and proactively and then have them be used effectively.

So, don’t be fooled into economizing into “quick/easy” methods with fast but inadequate web based training. All you will get is inadequate investigations and recurring problems.

And if this approach seems to be too hard, consider skipping investigations altogether. If you aren’t going to perform an adequate investigation then you should consider that you may be better off by performing no investigation at all.

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