1 Cement 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 or
foul play?)
Neighbors had nails in sidewalls too (Police: who is it?)
Teenage prankster caught (parents: why did our child do this?)
2 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
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 that
it meets our goals and objectives and is within our
control
Purpose: prevent future events
3 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
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)
4 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Identify undesirable outcomes
Real speeding
Potential serious injury due to speeding
Can be multiple undesirable outcomes:
Accident leads to damaged car
Accident leads to passenger injury
Marx
5 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Step 2: Search for causes
Find at least one cause that can be acted upon such that it meets
our goals and objectives and is within our control
Ignition source
Combustible material
Oxygen
Fire
Gano
6 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Cause and effect are same thing
Gano
Effects caused
by
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
7 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Cause and effect are same thing
Toyota says ask why 5 times
If 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
8 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Create a causal tree
For each effect ask why?
Look for conditions and actions
Connect all causes with caused by
Support causes with evidence
Sensed (1
st
hand experienced)
Inferred (circumstantial, gauge readings, etc.
Intuition (inadequate effort
Emotional (how people felt about what happened)
Ask whys using depth first search
Return to square 1 and start again
b
e
t
t
e
r

Gano
9 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Create a causal tree
Find out:
What happened
What usually happens
What policies require to happen
* Look for:
Human error
Procedural violations
Mechanical failures
Other possible causes
Marx * More on these later
10 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Phase 1
Broken
Wrist
Person
Fell
Caused
By
Gano
11 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Phase 2
Broken
Wrist
Caused
By
Person
Fell
Hand
Stopped
Fall
Caused
By
Etc.
Caused
By
Etc.
Gano
12 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Phase 3
Broken
Wrist
Excess
Force
Caused
By
Wrist
Position
Hand
Stopped
Fall
Employee
Overweight
Caused
By
Caused
By
Etc.
Caused
By
Evidence goes here
Evidence goes here
Evidence goes here
Evidence goes here
Evidence goes here
Gano
13 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Test the strength of causal links
Direct causes
A directly causes B every time
Probabilistic
A increases the likelihood of B
Correlation
When A happens B seems to also happen
Basis for causation uncertain

Marx
14 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Language of human errors
Omissions: failed to do something required
Mistake: wrong intent, executed as planned
Slip: right intent, execution not as planned
Lapse: similar to slip
15 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Procedural violations
Normal
Error
At-Risk
Behavior
Reckless
Conduct
Intended action No Yes Yes
Knew risk of
action
No No yes
Blame-free sounds good, but what about
intentional actions. Marx suggests a Just Culture
16 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Mechanical Failures
All unanticipated mechanical failures must have a
previous cause:
Designed in error
Manufacturing defect
Mis-maintained
Mis-operated
17 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Other causal conditions
Physical environment
Leadership
Equipment design
Policies
Procedures

Individual
performance
Organizational
environment
Knowledge, Skills, &
abilities
communication
18 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Removing non-causal data
Failure to act is causal only if there is a pre-existing duty
to act.
Otherwise it maybe a prevention strategy

A lack of guard rails in the tunnel where Princess Di
crashed is often cited as a cause of her death, but French
government had no pre-existing duty to install guard rails.
19 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Report Preparation
Cause and effect relationships must be clear
Dont overstate, understate, or emotionalize report. It may
show up in court.
Negative descriptors may not be used
poorly, inadequate, unsafe, unreliable, and
complacency among many others
20 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Report Preparation
Eliminate possible biases:
Fundamental attribution error: lazy, aggressive,
jealous, happy
Us-them bias
Severity effect (large outcomes require large causes)
Temporal & spatial continuity (guilt by association)


21 Cement Technology Course Preparedand originaaly presented by Lafarge UK -June 2001 (EX BCTC)
Assignment
After the exam read up on the titanic
Create a causal tree for the Titanic disaster
Report the root causes you found using the guidelines in
this presentation
A starting place:
http://www.educationplanet.com/articles/titanic.html