RootCauseAnalysis[1]

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1Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)

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 orfoul play?) Neighbors had nails in sidewalls too (Police: who is it?)Teenage prankster caught (parents: why did our child do this?)


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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 thatit meets our goals and objectives and is within ourcontrolPurpose: prevent future events


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Step 1: Problem Definition

What is the problem?When did it happen?Where did it happen?What is the significance?

NO Who dont place blame(blame = avoidance and silence)

Gano

Work backward chronologically from event

Work forward chronologically to clarify (Paradies)


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Identify undesirable outcomes

Real speedingPotential serious injury due to speedingCan be multiple undesirable outcomes:

Accident leads to damaged carAccident leads to passenger injury

Marx


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Step 2: Search for causes

Find at least one cause that can be acted upon such that it meetsour goals and objectives and is within our control

Ignition source

Combustible material

Oxygen

Fire

Gano


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Cause and effect are same thing

Gano

Effects causedby

Causes

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


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Cause and effect are same thing

Toyota says ask why 5 timesIf continuum why not more?

Keep going until your answer to why is:I dont know (ignorance point marked with ?) I dont care (it fell because of gravity. Why is there

gravity? I dont 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 evidenceSensed (1 st hand experienced)Inferred (circumstantial, gauge readings, etc.Intuition (inadequate effort

Emotional (how people felt about what happened)Ask whys using depth first searchReturn to square 1 and start again

b e

t t e r

Gano



Create a causal tree

Find out:What happened

What usually happensWhat policies require to happen

* Look for:Human error

Procedural violationsMechanical failuresOther possible causes

Marx* More on these later



Phase 1

BrokenWrist

PersonFell

CausedBy

Gano



Phase 2

BrokenWrist

CausedBy

PersonFell

HandStopped

Fall

CausedBy Etc.

CausedBy Etc.

Gano



Phase 3

BrokenWrist

ExcessForce

CausedBy

WristPosition

HandStopped

Fall

EmployeeOverweight

CausedBy

CausedBy Etc.

CausedBy

Evidence goes here

Evidence goes here

Evidence goes here

Evidence goes here

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

CorrelationWhen A happens B seems to also happen

Basis for causation uncertain

Marx



Language of human errors

Omissions: failed to do something requiredMistake: wrong intent, executed as planned

Slip: right intent, execution not as plannedLapse: similar to slip



Procedural violations

NormalError

At-RiskBehavior

RecklessConduct

Intended action No Yes Yes

Knew risk ofaction

No No yes

Blame -free sounds good, but what aboutintentional actions. Marx suggests a Just Culture



Mechanical Failures

All unanticipated mechanical failures must have aprevious cause:

Designed in errorManufacturing defectMis-maintainedMis-operated



Other causal conditions

Physical environmentLeadership

Equipment designPoliciesProcedures

Individualperformance

Organizationalenvironment

Knowledge, Skills, &abilities

communication



Removing non-causal data

Failure to act is causal only if there is a pre-existing dutyto act.

Otherwise it maybe a prevention strategy

A lack of guard rails in the tunnel where Princess Dicrashed 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 clearDont overstate, understate, or emotionalize report. It may

show up in court.Negative descriptors may not be used

poorly, inadequate, unsafe, unreliable, andcomplacency among many others



Report Preparation

Eliminate possible biases:Fundamental attribution error: lazy, aggressive,jealous, happy Us-them biasSeverity effect (large outcomes require large causes)Temporal & spatial continuity (guilt by association)


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Assignment

After the exam read up on the titanicCreate a causal tree for the Titanic disaster

Report the root causes you found using the guidelines inthis presentation

A starting place:http://www.educationplanet.com/articles/titanic.html

Documents

RootCauseAnalysis[1]