Author Archives: Ncallahan

Ned Callahan is an experienced Apollo Root Cause Analysis Instructor and facilitator with 15 years' management experience and over 15 years' experience in education in two stints. In his 3 years at ARMS, he has helped people from over 300 companies become better problem solvers.

Dean Gano’s emphasis on finding effective solutions to problems has directly challenged the commonly accepted notion that finding the “Root Cause” is the objective of any problem analysis. It is now appreciated that the identification of a root cause is a means to an end, rather than an end itself.  In fact, the “rootedness” of a cause is a function of an implementable solution being attached to it.

Another valuable characteristic of this method is its efficiency. Having facilitated a substantial number of problem analyses over the past three years, I am struck by the ease with which a team can be made to focus on a problem and avoid unnecessary and wasteful commentary or “stories” as Gano describes them.

The essential problem data, and impacts or consequences, are all acknowledged and documented as a first step in the process. The team members, being the stakeholders or their representatives, agree on the basic premise – the raison d’être –  for the team’s composition and existence is to prevent recurrence of the problem. This process rarely takes more than 30 minutes. Read More →

The need to establish the sequence of events during an investigation of an incident is well accepted. It is the process of creating order from chaos; the ordering of facts as they are understood by the participants, observers and managers, simultaneously and progressively filtered and distilled by available expertise. There is often a lack of information and more data needs to be collected. The process is mired in uncertainty about why and how “it” happened.  The intention of creating a fundamental understanding in order to prevent a recurrence is the ultimate goal.

Once the facts of an incident have been established, the sequence typically shows what happened from the very beginning of the event, or the chain of events which lead to the serious negative consequences.  One thing leads to another as defences break down or are circumvented. James Reason’s Swiss cheese analogy is often quoted. Read More →

Root Cause Analysis has a number of methods and systems – sold as products or tools –  under its umbrella. The simple fact is that RCA is a misnomer which creates false expectations.

One understanding of RCA suggests that it is a process of investigation which will reveal a single cause being the root of a problem, incident, or failure. Equally however, it could be interpreted as the analysis of a Root Cause.  Calling something a Root Cause pre-supposes certain characteristics which enable one to recognise it when it appears on a list or when you inadvertently stumble upon it. Another interpretation of a Root Cause is that it’s the culprit at the very beginning of a problem. Read More →