ROOT CAUSE ANALYSIS OVERVIEW by klutzfu47

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									ROOT CAUSE ANALYSIS OVERVIEW

Disclaimer - - Our training department compelled me to put this up front. None of this information is in no way to be confused as training, but is for entertainment purposes only. The person performing this presentation is not a professional trainer and has never been trained as a trainer and is not a member of any training organizations or training clubs. Your best bet is to ignore anything he presents, especially if he starts with the statement “This is a true story”

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Typical Questions Following an Event
– Who? – What? – When? ……did they do? ……did they do it? – Where? ……did they do it? ……did they do it? – Why?

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It’s not about blame, it’s about continuous improvement. We focus on the what, how, and why; not the who.
- Jeff Lyash
Progress Energy Florida, CEO

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Why Root Cause Analysis?
– Who? – What? ……did they do? – When? ……did they do it? – Where? ……did they do it? – Why? ……did they do it?

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Anatomy of Events
Initiating Action
Active Errors: Weak Skills, Failed, or Nonexistent Barriers Latent Errors: Organizational Weaknesses; Poorly Written Procedures, Failed, or Nonexistent Programmatic Barriers, Ineffective Management

Human Fallibility Programmatic Barriers
“Defense in Depth Model” Dr. James Reason, Managing the Risks of Organizational Accidents, 1997.

Organizational Barriers Management Barriers Event
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WHAT IS ROOT CAUSE ANALYSIS? (RCA)

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What is “Root Cause Analysis”
Term goes back to the 1960’s or ’70’s military incident investigations Consider the “prune the poison ivy” analogy – Dr. Bill Corcoran – 1980’s
If you cut off poison ivy at ground level, what happens? To completely remove it, you must pull the plant out by the roots What does the root system look like?

RCA refers to the network of deeper roots below the surface that must be removed to prevent recurrence.

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Why Perform RCA?
Determine what happened Determine why it happened Fix identified problems and Prevent recurrence of the same and similar problems
SAFETY QUALITY EFFICIENCY

Morale

Money

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Cost of Not Addressing Root Causes
Problems continue or get worse. Incorrect solutions implemented
– Wastes time and money

May result in regulatory fines, poor evaluations, legal action, poor public perception, etc.

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SIMPLE ROOT CAUSE
Problem Statement: You are on your way home from work and your car stops in the middle of the road.
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Why did your car stop?
Because it ran out of gas.

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Why did it run out of gas?
Because I didn't buy any gas on my way to work.

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Why didn't you buy any gas this morning?
Because I didn't have any money.

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Why didn't you have any money?
Because I lost it all last night in a poker game.

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Why did you lose your money in last night's poker game?
Because I'm not very good at "bluffing" when I don't have a good hand.
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BASIC STEPS
Secure the scene and evidence Event Review Team Formed Data Collection and Review Perform Event Analysis Determine Root Cause(s)/Validate Determine Corrective Actions Communicate Findings/Recommend Corrective Actions Perform Effectiveness Review
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Protected Investigations
Some severe circumstances (e.g., serious injury, regulatory infraction) may involve legally protected investigation You will be told by the sponsor and/or team leader of these cases (if in doubt ask) Corporate legal will be involved Primarily limits the way you perform the interviews, other data collection, and reporting
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The Sponsor
The highest-ranking manager responsible for completion of the RCA Normally not directly involved in the investigation Helps eliminate obstacles and helps the team get the resources and access Should not provide pre-judgments about causes and actions
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Collaboration & Independence
Collaboration: Working with others to confirm the facts and to develop effective corrective actions Independence: Drawing your own conclusions from the collection of facts

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Interviews
Single most powerful tool in conducting a root cause investigation Active listening is the single most important element in an interview

Interviews
Do them as soon as possible Fact finding, not fault Be prepared Take notes Follow-up questions Setting
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4 Steps Of An Interview
Preparation Opening Questioning process Closing

EVENT ANALYSIS METHODS
Task Analysis Change Analysis Barrier Analysis Event & Causal Factor Charting

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Root Cause

The fundamental cause or causes that, if corrected, will prevent recurrence of an event or adverse condition.

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Definitions
Extent of Condition: The population of items or issues with the same undesired condition as the item or issue that was the original subject of the RCA. Generic Implications: Other programs, processes, components, or activities that are reasonably susceptible to the failure modes and causes of the condition being evaluated.
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Corrective Action
Actions aimed at eliminating the root cause. Must meet following goals:
– Prevents recurrence – Within our control – Meets other business objectives (cost, etc)

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3 Types of Actions
Actions to Correct Condition: These are the actions required to address the originally identified deficiency and other deficiencies found during the Extent of Condition review. Actions to Prevent Recurrence: These are the actions that either target identified causes or create or bolster barriers to future similar events. Recommendations: These are actions that only address increasing process efficiency or ease. Consider these "good ideas" that don't meet the first two definitions.
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Questions?
Jeff Clark (727) 820-5475 jeff.clark@pgnmail.com


								
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