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									Root Cause Analysis
• You arrive at work 45 minutes late because
  of a flat (investigate what? Why flat or why
  late to work).
• Tire has nail in side wall (tire dealer:
  covered road hazard or foul play?)
• Neighbors had nails in sidewalls too
  (Police: who is it?)
• Teenage prankster caught (parents: why did
  our child do this?)
What is Root Cause Analysis
• Find the Root Cause(s) of “events” or
  “mishaps”
• Find at least one cause that can be
  acted upon such that it meets our goals
  and objectives and is within our control
• Purpose: prevent future events
 Step 1: Problem Definition
 •   What is the problem?
 •   When did it happen?
 •   Where did it happen?
 •   What is the significance?
 •   NO Who – don’t place blame
     (blame = avoidance and silence)
  Work backward chronologically from event
Work forward chronologically to clarify (Paradies)
                                                     Gano
Identify undesirable outcomes
• Real – speeding
• Potential – serious injury due to
  speeding
• Can be multiple undesirable outcomes:
  – Accident leads to damaged car
  – Accident leads to passenger injury

                                         Marx
Step 2: Search for causes
• Find at least one cause that can be acted
  upon such that it meets our goals and
  objectives and is within our control
                      Ignition source
 Fire                 Combustible material

                      Oxygen
                                              Gano
Cause and effect are same thing
  Effects        “caused Causes
                   by”
  1. Injury              Fall
  2. Fall                Wet surface
  3. Wet surface         Leaky valve
  4. Leaky valve         Seal failure
  5. Seal failure         Not maintained

       1       2     3       4          5
            A continuum of causes
                                            Gano
  Cause and effect are same thing
• Toyota says ask why 5 times
• If continuum why not more?
• Keep going until your answer to why is:
  – I don’t know (ignorance point marked with ?)
  – I don’t care (it fell because of gravity. Why is
    there gravity? I don’t care)


                                                 Gano
     Create a causal tree
   • For each effect ask why?
         – Look for conditions and actions
   • Connect all causes with “caused by”
   • Support causes with evidence
         –   Sensed (1st hand experienced)
better




         –   Inferred (circumstantial, gauge readings, etc.
         –   Intuition (inadequate effort
         –   Emotional (how people felt about what happened)
   • Ask whys using depth first search
   • Return to “square 1” and start again
                                                               Gano
   Create a causal tree
  • Find out:
     – What happened
     – What usually happens
     – What policies require to happen
  • * Look for:
     – Human error
     – Procedural violations
     – Mechanical failures
     – Other possible causes
* More on these later                    Marx
Phase 1


Broken   Caused   Person
 Wrist     By      Fell




                           Gano
Phase 2
                     Hand
                                Caused
                    Stopped       By
                                            Etc.
                      Fall
Broken   Caused
 Wrist     By


                  Person   Caused
                                     Etc.
                   Fell      By



                                             Gano
        Phase 3                                       Hand
                                                     Stopped              Caused
                           Excess Caused               Fall                 By
                           Force By                  Evidence goes here
                           Evidence goes here
Broken           Caused
                   By                                Employee
 Wrist
Evidence goes here
                                                     Overweight
                           Wrist                     Evidence goes here


                          Position              Caused
                                                  By
                                                              Etc.
                          Evidence goes here

                                                                            Gano
 Test the strength of causal links
• Direct causes
   – A directly causes B every time
• Probabilistic
   – A increases the likelihood of B
• Correlation
   – When A happens B seems to also happen
   – Basis for causation uncertain

                                             Marx
    Language of human errors
•   Omissions: failed to do something required
•   Mistake: wrong intent, executed as planned
•   Slip: right intent, execution not as planned
•   Lapse: similar to slip
   Procedural violations
                  Normal    At-Risk Reckless
                  Error     Behavior Conduct
     Intended     No        Yes      Yes
     action
     Knew risk    No        No       yes
     of action

    “Blame-free” sounds good, but what about
intentional actions. Marx suggests a “Just Culture”
 Mechanical Failures
• All unanticipated mechanical failures must have
  a previous cause:
   –   Designed in error
   –   Manufacturing defect
   –   Mis-maintained
   –   Mis-operated
    Other causal conditions
•   Physical environment   • Individual
•   Leadership               performance
•   Equipment design       • Organizational
•   Policies                 environment
•   Procedures             • Knowledge, Skills, &
                             abilities
                           • communication
 Removing non-causal data
• Failure to act is causal only if there is a pre-
  existing duty to act.
• Otherwise it maybe a prevention strategy

  A lack of guard rails in the tunnel where Princess
  Di crashed is often cited as a cause of her death,
  but French government had no pre-existing duty
  to install guard rails.
 Report Preparation
• Cause and effect relationships must be clear
• Don’t overstate, understate, or emotionalize
  report. It may show up in court.
• Negative descriptors may not be used
   – “poorly”, “inadequate”, “unsafe”, “unreliable”, and
     “complacency” among many others
 Report Preparation
• Eliminate possible biases:
   – Fundamental attribution error: “lazy”, “aggressive”,
     “jealous”, “happy”
   – Us-them bias
   – Severity effect (large outcomes require large causes)
   – Temporal & spatial continuity (guilt by association)
 Assignment
• After the exam read up on the titanic
• Create a causal tree for the Titanic disaster
• Report the root causes you found using the
  guidelines in this presentation
• A starting place:
   – http://www.educationplanet.com/articles/titanic.html

								
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