Root cause analysis - Methodology

The ppt describes the methodology for root cause analysis of general industrial equipment failures / problems. The methodology is primarily based on patented Apollo root cause analysis method which in turn is adopted from metaphysics's doctrine of roots & causes. Approximately 2300 year ago, Aristotle first propounded the philosophy that everything in this universe is due to a cause. The same basic philosophy is adapted by Mr. Dean L. Gano to develop it into a very effective methodology for RCA of industrial problems / causes

1. Root Cause Analysis-Methodology Sandeep Gupta 1

2. Root Cause Analysis Root Cause Analysis is a systematic process Which helps in identification of causes behind an adverse event In a way that causes so identified are root causes not mere immediate obvious causes or symptoms Normally applied to Analyze past adverse events With an objective to find out solutions to prevent recurrence of adverse event in future 2

3. 3 Root Cause Analysis

4. 4 Roots Lies in different Layers Causes themselves may root from some other deeper / latent causes Primary - Physical Cause Secondary - Causes related human Errors Tertiary - Causes related to System deficiencies / policies Root Cause Analysis

5. Let us ask ourselves a couple of questions ? Are we really interested ONLY in finding out root cause ? 2. Should we really be interested ONLY in finding out root cause ? 5 Root Cause Analysis

6. In most of the cases our reply to these questions is a “Yes” But this “Yes” itself limits our capability to get to “RIGHT” root causes? Why ?? 6 Root Cause Analysis

7. Because if we try to get to root causes only, we generally end up with “GENERIC” root causes - the root causes which can not be acted upon to prevent recurrence of problem However Our ultimate objective is NOT to find out the root causes of the problems (adverse events already occurred) Rather It is to find out the solution(s) so that the same problem do not recur Hence we should reach up to those causes of the adverse event which could be controlled with our actions (solutions) 7 Root cause Analysis Problem Solving Root Cause Analysis

8. Questions which come into everybody’s mind Why we need to be trained separately in problem solving techniques when we know our subjects very well ? What exactly problem solving / root cause analysis skill is and how it can help me ? Doesn’t this skill come naturally to all intelligent persons ? 8 Root Cause Analysis

9. The way we think of a problem, is in itself, a deciding factor for possibility of getting solution(s) as outcome 9 Root Cause Analysis

10. What is wrong with our usual way of thinking ? We assume some MYTHS as REALITY Myth : There is a single root cause for each problem. A linear relationship exists between “Focus Event” and “Root Cause” ( 5 why method) Myth : Believe in existence of “prime root cause” which is not preceded by any other cause. There is an end point to “cause and effect” chain. Categorical, “fitting into pattern” thinking instead of critical thinking. Tendency to categorize causes into fixed types, patterns, stereotypes which we have learned through our experience 10 A B C D E F Root Cause Analysis

11. What is wrong with our usual way of thinking ? 11 Passing the buck to someone The buck stops here Root Cause Analysis

12. What is wrong with our usual way of thinking ? 12 Illusion of common sense / being too obvious Too obvious to question / to ask for further detail Perception that “what is being viewed by me” is the “only absolute & complete reality” and is also being viewed by others in same way Root Cause Analysis

13. Apollo Root Cause Analysis - A new way of thinking 13 Everything happens due to a reason (cause). Nothing happens on its own “by chance”. The notion of causality (cause and effect) is fundamental to our quest for understanding of events happening around us. Modern science had evolved around the same basic principle of “cause and effect” Around 350BC, Greek philosopher Aristotle said that there are four types of causes (explanatory factors) behind everything we see around us Root Cause Analysis

14. Apollo Root Cause Analysis - A new way of thinking 14 Aristotle’s doctrine of four causes in metaphysics Root Cause Analysis

15. Apollo Root Cause Analysis - A new way of thinking 15 Modern interpretation of cause and effect principle Root Cause Analysis

16. Apollo Root Cause Analysis - A new way of thinking 16 Modern interpretation of cause and effect principle Necessary elements of cause and effect relationship between two events Root Cause Analysis

17. Apollo Root Cause Analysis - A new way of thinking 17 This modern interpretation of “Cause and effect” principle is adapted by Dean L. Gano for investigating event based problems occurring in industries or elsewhere. Adaptation of this basic “cause and effect” principle is given the name of “Apollo Root cause analysis”. There are four basic premises of this principle 1. Cause and effect are same thing 2. Causes and effects are part of an infinite continuum of causes 3. Each effect has at least two types of causes – contributing conditions and trigger action 4. An effect exists only if its causes exist at the same point in time and space Root Cause Analysis

18. Apollo Root Cause Analysis - A new way of thinking 18 Premise 1 : Cause and effect are same thing The same event can be seen as “effect” of its predecessor event and “cause” of its successor event. They are like two faces of the same coin. Root Cause Analysis Effects Causes Pain Caused By Injury Injury Caused By Fall Fall Caused By Oil on surface Oil on surface Caused By Leakage from oil pump Leakage from oil pump Caused By Shaft Seal failure Shaft Seal failure Caused By Oil seal not changed from last two years

19. Apollo Root Cause Analysis - A new way of thinking 19 Premise 2 : Causes and effects are parts of an infinite continuum of causes . We always start with an effect (having adverse consequences), that we want to prevent from recurring. We continue to identify causes, till the time, we reach at a point, where we can not find answers to question “why”. This point is called “ point of ignorance” The effect, where we start at, is called “primary effect” or “Focus Event” Which effect should be considered as primary effect depends on our perspective. Primary effect is a point in the “cause –effect” chain, where we choose to focus and begin asking “why” Root Cause Analysis Perspective Objective behind RCA Primary effect Safety engineer To prevent recurrence of similar injury Injury Maintenance engineer To prevent recurrence of pump seal failure Seal failure

20. Apollo Root Cause Analysis - A new way of thinking 20 Root Cause Analysis The more we know, the more we realize that we don’t know. As every time we ask “why”, and proceed along a cause path, we come to our point of ignorance. At this point, we no longer have answers, but that is only due to limitation of our knowledge & understanding of the phenomena in hand. This premise says that each cause effect chain extends up to infinity; hence denies the existence of “Absolute root cause”

21. Apollo Root Cause Analysis - A new way of thinking 21 Root Cause Analysis Within one set of effect-causes there exist more effect-cause sets. The more deeply we understand relationship between the effect and its cause, more we discover intermediate causal sets, called baby steps Ev ery causal relationship can be broken into smaller and smaller pieces with each shortening of the reference time frame. They are there, but are forgotten or unknown to all observers. Baby steps are found by looking between the causes, but they are often elusive. The more we ask why, the closer we get to understanding specific causal relationships; but the fact is, we will never know all of them.

22. Apollo Root Cause Analysis - A new way of thinking 22 Root Cause Analysis

23. Apollo Root Cause Analysis - A new way of thinking 23 Premise 3 : Each effect has at least two types of causes – contributing conditions and trigger action . Action causes are causes that interact with conditions to cause an effect. Conditions are causes that exist in time prior to an action bringing them together to cause an effect Action causes are most easily recognized whereas condition causes are normally ignored either these being too trivial, too obvious or our lack of understanding of that phenomena Root Cause Analysis

24. Apollo Root Cause Analysis - A new way of thinking 24 Root Cause Analysis “ Why Open Fire?” we see that three condition al causes exist in the form of Match Exists Combustible Material Exists and Oxygen Present. However the fire is created only at the moment the match strike occurs. In this example, a match strike is the action cause ; and as soon as that match strike happens, we have a fire. It takes all three conditions and one action for fire to happen .

25. Apollo Root Cause Analysis - A new way of thinking 25 Premise 4 : An Effect Exists Only if Its Causes Exist in the Same Space and time Frame. Every effect, we observe in the physical world is caused by at least one action cause coming together with existing conditional causes in the same relative space. A causal relationship is made up of conditional causes with a history of existence over time combining with another cause in some defined time frame to create an effect The range of the “time and space frame” has to be judged with respect to type of effect. If somebody throws a stone in this classroom and at the same time a glass pane of car in USA gets shattered then it does not make “throwing stone” a valid cause of “shattering pan“ in USA Root Cause Analysis

26. Apollo Root Cause Analysis - A new way of thinking 26 Root Cause Analysis If all these causes did not exist at the same time frame and space, the spoon would not have fallen. For example if Had the spoon already been on the floor OR The girl is sitting in a space shuttle where there is no gravity OR If the girl had not freed it from her grip At the same time frame and space, the effect of falling of spoon would occur Effect : Spoon fell off on the floor from a little girl’s hand while taking her dinner. This effect has at least three causes Gravity exists The condition of holding the spoon at some height exists Her action of letting the spoon free from grip

27. Apollo Root Cause Analysis - A new way of thinking 27 Root Cause Analysis

28. Apollo Root Cause Analysis - A new way of thinking 28 Root Cause Analysis

29. Apollo Root Cause Analysis - A new way of thinking 29 RCA should be performed as systematic investigation using an established RCA method (Apollo Root cause analysis method) with the outcome of root causes and solutions. Root Cause Analysis The RCA Process Step Tasks to be performed Define the problem Define the primary effect. Collect data and the facts of what happened, where, when and significance. Analysis & Validation Use Apollo RCA reality charting method to establish cause and effect relationships. Validate the different causes with evidence Find possible solution Identify the causes which can be acted upon to control them. Identify as much solutions as possible ( A solution is a set of actions which can be taken to remove a particular cause to prevent recurrence of primary effect ). Establish the best feasible solution(s). Implement solutions Make action plan to implement solution with time line and responsibility. Review the implementation status periodically

30. Apollo Root Cause Analysis - A new way of thinking 30 Facilitator to define and state the problem (primary effect). Do not assume that everybody in the room knows all the facts of the problem occurred. Root Cause Analysis The RCA Process – Define the problem

31. Apollo Root Cause Analysis - A new way of thinking 31 A complete problem definition should include four elements What is the problem ? When did it happen ? Where did it happen ? What is significance of the problem ? The what of the problem is the adverse consequence of the event. This is the effect we do not want to recur. Hence we call it as primary effect. It is a noun verb statement such as “kiln stopped”, “person injured”, fan stopped ” The when of the problem is time when the primary effect occurred . The where of the problem is location of primary effect The significance of the problem the value the primary effect has on the organization. Root Cause Analysis The RCA Process – Define the problem

32. Apollo Root Cause Analysis - A new way of thinking 32 Create and Apollo cause and effect chart This has four steps Start what caused the primary effect to happen Look for causes in actions and conditions Connect all causes with “caused by” Support causes with evidence or use “?” As causal relationship is developed, continue to ask and answer “why” until you either reach point of ignorance or choose to stop. Root Cause Analysis The RCA Process – Analysis and validation

33. Apollo Root Cause Analysis - A new way of thinking 33 Root Cause Analysis The RCA Process – Analysis and validation The action cause is expressed as noun ( computer) and verb ( failed). The conditional causes are normally are of the form “ (noun ) Exists” or “(noun) present” When expressing cause and effect relationships, we should always attempt to follow these conventions .

34. Apollo Root Cause Analysis - A new way of thinking 34 Root Cause Analysis The RCA Process – Analysis and validation Creating the Apollo cause and effect chart is an iterative process. Follow “square One Loop” It means follow a single cause path of Apollo cause and effect chart until collective point of ignorance is reached, and then starting over again with the primary effect (back to square one) and repeating the process Each cause should be supported by evidence of its existence in Apollo causes and effects chart. Assign someone to find more facts, for each cause that does not have evidence ( represented with a question mark “?” temporarily) Often it is beneficial to start the chart by listing all possible causes. As causes may not have evidence at this time, the connecting logic may be “OR” rather than “AND ”. As evidences for causes are collected and established, the “OR” logic disappears and final “AND” logic should only remain i.e. the primary effect is caused by “cause A” AND “Cause B” AND “Cause C” and so on

35. Apollo Root Cause Analysis - A new way of thinking 35 Root Cause Analysis The RCA Process – Find Possible Solutions Solution act on one or more causes in the cause and effect chart. The causes, which can be acted upon by possible solutions, need not be at the extreme right of cause effect chart. They can be located anywhere in the Apollo cause effect chart. Solutions must meet the following criteria Prevent recurrence Should be within our control As there are a no. of causes , hence there are a no. of solutions Start on the right side of the cause and effect chart and begin challenging the causes to find out possible solutions. Following question should be asked to find out solutions. 1 . Why that cause exists ? 2. What we could do to remove , change or control it such that the primary effect does not occur If no possible solution could be found for causes on extreme right side, move to the causes located next on left side of the chart and repeat same exercise.

36. Apollo Root Cause Analysis - A new way of thinking 36 Root Cause Analysis The RCA Process – Find Possible Solutions