Monthly Archives: September 2013

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Our latest eBook gives you access to all our top tips for conducting better root cause analysis investigations.

101 Root Cause Analysis Tips

We’ve covered root cause analysis from start to finish:

  • Gathering information

  • Assembling the team

  • Conducting the RCA

  • Implementing the solutions

  • Measuring the success of the corrective actions

  • Advertising your successes

  • Plus, a whole section of tips for the RCA facilitator

Get My Copy

By Kevin Stewart

Over the years of using the Apollo Root Cause Analysis methodology in the field, I’ve achieved a “normalization of deviance” when it comes to generating a common reality.  In general, it means that I don’t always think about it or discuss it much because it is just the way things are and have been for me.  So I thought I would reflect on this to remind myself how powerful a tool the Apollo Root Cause Analysis methodology is.

URubik Cube   Common Reality RCAnfortunately I can’t speak for other processes since the company I worked for standardized on the Apollo Root Cause Analysis methodology early on.  Since it worked for us we decided to spend our time using it instead of looking for the best process.  (I would be interested in others’ comments about generating a common reality utilizing other processes.)  So, my comments are from a single perspective but to use an old phrase – don’t tell me it can’t work – when others are doing it!  Hopefully other processes have equal success in this important aspect of RCA work.

In my corporate life we used to always be concerned with people who would nod their head yes to your face but internally were thinking – “it isn’t going to happen buddy”.  Many times this was associated with the first line supervision since they had the direct contact with the work force and could make or break any initiative regardless of whether it came from the highest levels or not.  It was very clear to me that if they saw the “WIIFM” (What’s in it for me), and agreed with it, that they could also be the biggest ally. 

After many tough lessons and some personal experience, this fact became painfully obvious to me – If the supervisor recognized the value to him by believing that something would actually solve a problem that caused him pain and anguish, he was more likely to support it and even take the lead in implementing the solution.  So how do we make this happen?

Most of us have heard the saying that “You support what you help to create”.  Well, the Apollo Root Cause Analysis methodology helps insure this happens by creating a common reality where everyone who participates in the team truly understands:

  • The value of the problem
  • What the solutions are

And more importantly –

  • How they will affect the problem

If they can see the causal connections and understand them, it is not a big stretch to see why chosen solutions will actually fix a particular problem, or “Primary Effect”, as we like to call it.

I have participated and facilitated in many RCA’s and have yet to leave one where everyone isn’t on board. I don’t think about this much, but that is the normalization of deviance. 

Why does it work?

My thoughts are that if you come out with an initiative and tell everyone that they will do it.  They have little choice in many cases, but they can dig in their heels and wait out the management change – then they don’t have to do it.  Why is this? 

My opinion is that everyone can either see or know that the initiative won’t fix the problem, or won’t work, or has been tried before, etc.  So why bother. 

I myself remember saying “How could that possibly solve the problem!?”  Or if it was some off-the-cuff initiative – perhaps my thoughts were “What problem are they trying to fix?”.  In either case, I saw no value in pursuing the initiative or helping since the work I was doing was helping to make my life or my corporation’s life easier or more efficient (and besides I can always wait out the 3-4 year management exchange period and not have to deal with it). 

The problem here is that they didn’t ask me what I thought, or they didn’t make the connection for me by telling me “WIIFM”.  Now if I had been part of the team, or could see the connection, that would be a horse of a different color.  This is why I believe the Apollo Root Cause Analysis methodology is so good at generating a common reality. People responsible for the solutions are usually part of the team, and if they are not, they can look at the chart and see the causal paths and everyone inherently knows that if you block off a street a car can’t go down that path (in other words, eliminate a cause path and the effect won’t happen).

So when you complete the analysis and ask around, everyone is in agreement because they all have participated, their input is on the chart, and they understand the flow and can speak about it. They also understand why implementing their solutions will be effective.  This, in a nutshell, is the common reality we need to insure the team is all rowing in the same direction.

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By Jack Jager

We are all problem solvers. Each and every one of us actively deals with problems on a regular, if not a daily basis. However, the crucial question is “Is everyone actually good at problem solving?”

Quality of investigations vary and the trend appears to be a practical application of the normal curve. There are some fantastic results from investigations and also some poor results. But, if your organisation is seeing  a whole pile of average investigations and average reports that result from them, then the effectiveness of your Investigation program can be improved.

Mediocrity occurs for a number of reasons. This article focuses on four aspects of your RCA program which, if not set up correctly, could be catalysts behind a consistent flow of mediocre root cause analysis investigations within your organization.

Mediocrity Sign Blog1)     A structure to support training

So, you’ve trained your employees in root cause analysis and you’re expecting to see some fantastic RCA results coming through. Right?

…Not so fast.

If there is little structure to support the training in terms of:

  • a requirement to use the process,
  • mentoring and feedback provided to trainees,
  • or quality audits on their efforts,

Then you can expect to see a whole range in terms of the quality of investigations being submitted. If the majority of the investigations are average then the value of the training comes into question.

This has often been the stimulus to look for different training in an alternative methodology because the perception is that the process selected for use by the company is not meeting expectations, it’s not working, people are not using it, and people don’t like it, or it’s not getting the results…..and so on.

If any training is unsupported, the same outcome could occur. So is this a problem with the training or a problem with the structure that supports the training?

Two days of training or a week of training doesn’t make anyone an expert in anything. Each trainee sits somewhere along the learning curve at the start of the training and hopefully, if they have been paying attention, they move along the curve to a better place after the training. The purpose of the training is to skew the curve – to move the curve to the right so you have more investigations being completed to a higher standard.

The challenge for all companies is to work out how to move trainees from where each
individual sits on that learning curve after the training, to application of excellence within the discipline at which the training was directed.  Isn’t this what was originally intended?

For many individuals, this transition along the learning curve lacks clear structure and in many cases this structure simply does not exist. We train our people and then, figuratively speaking, throw them to the wolves expecting them to be the evangelists for the learning and the cure to all of our problems.

So what happens when we then get an average outcome? We don’t see the value in training more staff. And in this instance of problem solving, we will see a greater acceptance of mediocrity and of our inability to change this. It is essential that there is a feedback loop, whereby mediocre investigation reports are not accepted, or signed off.

Underpinning an effective investigation program requires managerial overview, whereby
managers are skilled in the RCA methodology and can challenge the outcome, provide positive recognition or insist on rework. If managers are not trained in the RCA method, then they are in the hands of the people who have been trained, and the danger is that mediocrity becomes the norm.

2)     Amount of time dedicated to investigations

How long does an investigation take? Should it be one hour?  Four hours? One day? One week?

There is no right answer.

If an investigation is warranted then it should be resourced to a point where an excellent result is possible. If that means you have 5 people in a room all day then so be it. The significance of the problem must warrant that level of support.  

Conducting a root cause analysis requires a dedication of time and resources to achieve a
desirable outcome. How much do your problems cost you after all? If you want your investigations to be effective, then you will need to support them to the level needed. A clear understanding of the organisation’s threshold limits that determine the level of response, is essential to ensure appropriate allocation of resources and time to attend or complete an investigation.

When you find yourself in a rush, ask yourself if you are simply satisfying the need to report, completing obligatory requirements, just meeting deadlines or is there a genuine opportunity to improve the business and make a difference.

3)     Involving the “right” people

If you don’t have the “right” people in the room – those with intimate knowledge or experience with the problem, then how good will the investigation will be?

Information is a key ingredient in all investigations and successful investigations require
that you have that information in the room in the form of the people who have the knowledge, data, evidence and reports.

Positive support and approval from management are necessary for people to be given the
time to attend the investigation.

4)     Having the “right” facilitator

Do you have the “right” person facilitating?

Good communication skills are important, both verbal and non-verbal. A willingness to be the facilitator should also be considered…someone who has the desire to do this job.

A good facilitator should be impartial, unbiased, willing to ask the dumb question, and arguably should not be the subject matter expert. A great facilitator recognises that the credit for a good investigation outcome belongs to the team, and he works deliberately to facilitate that outcome.

In summary

The cost of significant incidents has a direct impact on the bottom line. Incidents can cost a company hundreds-of-thousands or even multi-million dollars. Every incident or accident that occurs is an opportunity to learn. If we can learn effectively by doing a high quality RCA, then the goal of trying to prevent their reoccurrence is far more likely to be achieved.

The best results occur from investigations that are well supported, have the right facilitator, and have the right people involved who have been given sufficient time to understand the event so they can present the best report possible.

Getting these elements right will go a long way towards moving the quality of your RCA investigations away from mediocrity and towards excellence.

A key factor in establishing the framework for an effective RCA program is a common application standard, and easy to use reporting, and charting tools. The Apollo Root Cause Analysis methodology has been used for over 20 years to support effective Problem Solving. RealityCharting™ software has been developed to provide standardisation, as well as quality checks and help. RC Coach is an online support tool with easy to access refresher training to help individuals to keep learning beyond the classroom.

 

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By Jack Jager and Michael Drew

RealityCharting® software is powerful root cause analysis software used to assist facilitators and compliment the Apollo Root Cause AnalysisTM methodology. RealityCharting® is user-friendly and helps people better understand their problems and identify effective solutions that prevent recurrence. It is a tool to help you record and communicate your understanding of the problem. It is also effective in its ability to display your understanding of the problem to others.

Most people respond well to visual stimuli and your ability to present the information in this way is a great opportunity to get buy-in into your problem. It allows people to “see” the understanding of the problem. Read More →