Root Cause Analysis
Many companies repeatedly experience the same type of incidents. Investigations indicate what seem to be the right solutions, yet the same type of incident occurs again and again! What are needed are investigation methods that, used in the right combination, will always leads to the right solutions, regardless of industry or setting.
Incident investigation, whether for safety, quality, or production, can be simple or complex depending upon the severity of the event. In principle, investigators would be trained to [a] discover the facts, [b] collect evidence,  ascertain the root cause(s), and  make recommendations in a written report. However, many investigators often seize on the first set of ‘symptoms’ as the Root Cause, rather than the Root Cause(s) themselves. This is why the same type(s) of incidents are often repeated.
Root Cause Analysis
Root Cause Analyses helps you get to the 'bottom' of events to prevent recurrence. A Root Cause is the most basic cause (s) identified as contributing to an incident, and that is within peoples control to fix. A number of tried and tested methods are available to help identify these most’ basic’ causes. These include ‘Influence & Causal Factor’ Charting, the ‘5 Why’s’, ‘Fishbone’ or ‘Ishikawa’ Cause & Effect Diagrams and Applied Behavioral Analysis (ABA). Each of these methods is in widespread use throughout industry with their pedigrees going back to the early 1970’s. BSMS trains investigators how to use each of these methods in various combinations to ensure all the angles have been covered.
Influencing & Causal Factors
‘Influencing & Causal Factor’ charting is a method used to diagrammatically represent a series of events that lead up to the incident, and any ‘contributors' associated with each event as shown below.
Identifying the associated ‘contributors' is often achieved with the ‘5 Whys’ method.
The 5 Why’s Method
A simple process, the ‘5 Why’s’ method helps you systematically peel away the layers of incident related symptoms until you arrive at a cause of a problem. Often, there is more than one cause! By repeatedly asking ‘Why?' 5 times for each aspect of an incident, you identify incident contributors and/or each cause, as shown in the example below of two flow control valves ‘tripping’.
Each 'Basic', 'Immediate' and 'Root' Cause can then be laid out into a ‘Cause & Effect Chart ‘(commonly termed a ‘fishbone’ diagram) to define and represent the causes as shown below. Importantly, ‘Fishbone Diagrams’ are also Root Cause Analysis tools in their own right, that again are often used in conjunction with the 5 Why’s’ method.
Applied Behavioral Analyses(ABA)
Although 'Root Cause Analysis often identifies the behaviors involved, it is rare for investigators to follow through to identify the 'true' drivers for these behaviors. Applied Behavioral Analyses (ABA) is a method that specifically examines the motivations for people's behavior that can be used in all areas of human activity. Combined with the other Root Cause Analyses it is an extremely powerful tool. As such it can be used as an adjunct to complement existing methods, or as a 'stand-alone' investigation method.
Causal Bucket Matrix
With each of the methods, our detailed matrix of ‘Causal Buckets’ can be used as a guide for investigators to assign each aspect of an incident into its Basic, Immediate And Root Causes. Always considered a work in progress, the matrix covers some 11 ‘Basic Cause’ Buckets, containing 39 ’Immediate Cause’ Buckets, which collectively contain some 350 universally applicable Root Causes.
BSMS Inc conduct both ‘Public’ and ‘In-house' Workshops to train investigators in Root Cause Analysis. We provide a free Root Cause Analysis Excel spreadsheet for each client, so that you can record your 'real' investigations as you go, and produce a final written report.