Simplifying Cause Analysis: A Structured Approach

By Chester D. Rowe

When the challenge is to get to the heart of a problem, you need a simple and efficient cause investigation methodology. And what would make a real difference would be an interactive map to lead you to the answer every time. Chester Rowe’s Simplifying Cause Analysis: A Structured Approach is your instruction book combined with the included downloadable Interactive Cause Analysis Tool you have been looking for.

The author intends this book for professionals like you, who have some familiarity with cause analysis projects and are looking for a simple and efficient cause investigation methodology –is a more effective and insightful way of asking “why?”

Introducing his multi-function event investigation tool, Chester Rowe says, “There are already many scientific tools to help us understand the physical causes for machine failures; the challenge now is to find a way of investigating human performance failure modes…humans are often a major source of slips, lapses, and mistakes.”

Supporting his instructions with diagrams, charts, and real-world examples from companies like yours, the author takes you step-by-step through planning, completing, and documenting your investigation:

• Chapter 1 gives you a process to determine the level of effort that your investigation should encompass, assess the level of effort needed, and determine the rigor needed. Your investigation needs to be as risk-informed as possible.
• Chapters 2 through 5 presents a new and innovative structure –rigorous yet intuitively easy to remember – to identify the underlying causes for the event (Cause Road Maps) and conduct the investigation.
• Chapter 6 introduces conceptual human performance models and tells you how to begin focusing on the human behaviors involved.
• Chapters 7 and 8 present you with methods, tools, and techniques for carefully interviewing personnel.
• Chapters 9 through 13 “put the pieces together,” showing you how to analyze and model the event, determine corrective action, and document the investigations and findings.

Chester Rowe developed the Cause Road Map over many years to provide a comprehensive taxonomy for every cause investigation. However, fully implementing the Cause Road Map requires the use of other tools to organize, analyze, and present the final results of your investigation. To get you started, Rowe includes his downloadable Interactive Cause Analysis Tool – an easy-to-use tool in familiar spreadsheet format – free with your verified purchase of the book.

• Language: English
• Publisher: Rothstein Publishing
• Release date: Nov 20, 2017
• ISBN: 9781944480479

Chester D. Rowe

Chester D. Rowe’s self-reliance and problem-solving abilities emerged early when, at age 14, he was given some parts for a ham radio receiver. To complete this project, he taught himself calculus and electronics. By the time his father died, when he was 16, Chet had designed the circuits for and then built this receiver using parts from discarded TVs. His father’s death pushed Chet into early adulthood and responsibilities to help his raise his siblings. After overcoming 16 years of financial and other obstacles, Chet earned a BS in Nuclear Engineering and an AS in Physics/General Studies. In addition, Chet has completed training equivalent to a degree in Electrical Engineering. Chet recently retired after over 40 years in the commercial nuclear industry. Chet is the creator of the Cause Road Map© Taxonomy and trained in Kepner-Tregoe, TapRoot®, PII, MORT, and other cause investigation and problem-solving techniques. As a result, he has been involved in more cause investigations than he can remember.

Book preview

Introduction

During a return trip from a conference on root cause analysis, I had the pleasure of sitting next to a mother who was taking her young daughters on their very first flight in a jet plane. As is typical, the three-year-old’s tool for finding the cause for our plane’s takeoff was to simply ask her mother why? While the mother’s answer that jet planes just needed to go very fast was sufficient to satisfy her daughter, aircraft engineers and scientists have gained a much more fundamental understanding of flight. Fortunately, the aviation industry is now much more concerned with why planes have accidents. In fact, because of the adverse social and economic impacts of accidents, most companies and industries are very concerned with preventing failures.

This book is intended for experienced individuals with some familiarity with cause analysis projects who are looking for simple and efficient cause investigation methodology. From this prospective, what is needed is an effective and insightful way of asking why? While there are numerous investigation tools for identifying the causes for problems, this book introduces a tool (the Cause Road Map) that is rigorous, yet is still intuitively easy to use and remember. As shown in Figure 0-1, studies have shown that most accidents and equipment failures are the result of some sort of human error.

Figure 0-1. Event Causes – Human vs Equipment

There are already many scientific tools to help us understand the physical causes for machine failures; the challenge now is to find a way of investigating human performance failure modes. Driven in part by the public outcry over seminal events such as airplane accidents and nuclear power plant accidents, several pioneers, like Jens Rasmussen and Dr. James Reason, have provided several powerful conceptual models to enable us to understand why humans are often a major source of slips, lapses, and mistakes. This book will translate some of these pioneering conceptual models into easy-to-use, cause investigation-related tools and templates.

•  Chapter 1 will lay out a process to determine the level of effort should encompass. Having identified the kind of investigation needed, a strong, clear structure for conducting it is essential.

•  Chapters 2 through 5 presents a new and innovative structure to identify the underlying causes for the event (The Cause Road Maps) and conducting the investigation, while Chapter 6 introduces some conceptual human performance models and how to begin focusing on the human behaviors involved. Understanding that human behaviors are a critical part of any investigation, it necessarily follows that carefully interviewing personnel, as discussed in Chapter 7, is of utmost importance. Techniques and tools for this are presented in Chapter 8.

•  Finally, Chapters 9 through 13 detail how to put the pieces together: They analyze and model the event, determine corrective action, and document the investigations and findings. As noted above, the book introduces the use of the Cause Road Map, which I developed over my years in the business. (Also copyrighted as The Cause Roadmap©). This multi-function event investigation tool provides a structured approach to finding the underlying causes for events. It will provide a comprehensive taxonomy for every cause investigation. It is not, however, intended to be used alone. The Cause Road Map requires the use of other tools provided in this book and by others to organize, analyze, and present the results of your investigation.

This book will also present:

•  Investigation Rigor Selection Tool

•  Tool Types and Use Matrix

•  Common Cause Analysis

•  Commonalities Matrix

•  Interviewing Techniques

•  Comparative Event Line

•  Hardware/Material/Design Failure Evaluation Summary

•  Failure Modes and Effects Analysis Worksheet

•  Performance Evaluation Summary

•  Barrier Analysis

•  Event and Causal Factor Chart

•  The Why Tree (Described by and used with permission from Dr. William B. Corcoran) – 5 Why’s, Two Factor & Structured

•  Change Analysis

•  Task Analysis Worksheet

•  Corrective and Preventive Action Development Guidelines

•  A Rigorous Cause Analyses (RCA) Template

•  Structured Cause Investigation Report Template

•  Presentation Tips

•  A graphic to enable recognition and management of Knowledge-based decisions.

Recently, the European Joint Research Center-Institute for Energy (JRC-IE) published a comparative analysis of event investigation methods, tools and techniques. One of their principal conclusions was: Unstructured processes of root cause analysis put too much emphasis on opinions, take too long, and do not produce effective corrective measures or lasting results (Ziedelis & Noel, 2011).

The purpose of this book is to reduce the time it takes to perform a thorough and insightfull investigation through the use of simple, easy-to-use tools. Although this JRC-IE report did not address the Cause Road Map taxonomy, the above conclusion prompted a critical re-assessment of the structure, precision, and comprehensiveness of the tool set that I presented in my earlier book, The Excellence Engine Tool Kit. The new content in this current book resulted in part from this re-assessment as well as some more recent real-world experiences.

References

Ziedelis, S. & Noel, M. (2011). Comparative analysis of nuclear event investigation methods, tools and techniques. Retrieved from http://publications.jrc.ec.europa.eu/repository/bitstream/111111111/16341/1/reqno_jrc62929_jrc-str_fv2011-0513.pdf%5B1%5D.pdf

Chapter 1

Getting Started

Your organization has just experienced an event. Now you should decide how to go about conducting an investigation that will determine the cause(s) for the event and determine what corrective actions are needed. Before you begin, you need to ask:

•  What level of effort (people, money, and other resources) do you need to dedicate to the investigation?

•  Is this a small event with minor consequences?

•  Is it a catastrophic event with major equipment damage, or is it a precursor event that could have had significant consequences?

•  What level of management involvement is needed?

•  Is an investigation team needed? If so, who should lead it?

•  How big should the investigation team be?

•  Does this problem have widespread implications? What are some of them?

1.1 Two Tools to Begin the Investigation

This chapter introduces two tools to help your investigation get started in an orderly fashion.

•  Investigation Effort and Rigor Assessment Tool:

The purpose of the first tool is to:

  Determine the level of effort to devote to the investigation.

  Help minimize the possibility of emotions dictating the level of investigation.

  Recommend the level of investigative effort needed based upon consequences, risks, and uncertainties of the cause.

•  Checklist Tool:

The second tool is a checklist to help you and your investigation team organize your investigation effort. The checklist serves as a tickler to remind you of the things that should be considered for a successful investigation.

What type of event investigation tools should you use to help identify the cause(s) for the event? Investigation tools are not effective in certain situations.

Beginning with the Investigation Effort and Rigor Assessment Tool, before conducting any cause investigation or analysis, you will need to assess the level of effort needed and determine the rigor needed. To avoid emotional reactions (i.e., unwarranted levels of effort), as well as missed opportunities (i.e., not enough effort), the investigation needs to be as risk-informed as possible.

1.1.1 Investigation Effort and Rigor Assessment Tool

The Investigation Rigor Selection Tool (Figure 1-1) provides you with the framework for a risk-informed decision by first assessing the actual or potential consequences or attributes.

•  Actual or Potential Consequences.

The Actual or Potential consequences of the event or condition under consideration (measured as High, Medium, Low, or None):

  The probability or likelihood of recurrence for this event or condition, assuming that no corrective actions are taken (Measured as High, Medium or Low).

  The level to which corrective and preventative actions are Already Known or can be quickly determined without a cause investigation (Measured as Yes, No or Partial).

  The level to which the cause or causes of the event or condition are Already Known or can be quickly determined without a cause investigation (Measured as Yes, No, or Partial).

Note: As the consequences associated with different types of events and conditions differ among various industries and companies, this attribute will require you to develop a set of facility-specific examples for High, Medium, Low and No Consequence events or conditions.

Once you have completed the level of risk matrix and uncertainty matrix, you will be ready to select the level of investigation.

Figure 1-1. Investigation Effort and Rigor Assessment Tool

•  Level of Effort Output from Rigor Selection Tool

The output (Level of Effort) from this Investigation Rigor Selection Tool is one of the following:

Common Terms

Root Cause:

Among the many definitions of this term I’ve seen, I prefer the following:

The fundamental cause (or causes) of a chain of events which leads to an outcome or effect of interest.

The investigative effort to discover the root causes of an event is generally referred to as a Root Cause Analysis (RCA).

Apparent Cause:

In my presentation at the 2007 IEEE/HPRCT joint conference (Apparent Cause Evaluation Myths by Stephen M. Davis and Chester D. Rowe © 2007, The Excellence Engine LLC) I listed 11 different definitions for this term. Since this presentation I’ve identified many more. The only commonality between many of these definitions is use of the phrase the most probable cause. The problem is that a probable cause is not a learned cause. A probable cause is basically a best guess cause. Therefore, I reject all existing definitions in favor of:

The cause (or causes) within the chain of events closest to (or proximate to) the outcome or effect of interest.

The investigative effort to discover the apparent causes of an event is generally referred to as an Apparent Cause Evaluation (ACE).

a. Rigorous Analysis (or Rigorous Cause Analysis): A rigorous analysis typically identifies causal factors generally defined as including Latent Organizational Weaknesses.

Latent Organization example:

The organization’s management team has not enforced the company’s industrial safety program. This situation has resulted in the recent lost time accident and the industrial accident rate exceeding the company’s accident rate goal.

Another example:

The maintenance planning, maintenance and engineering organizations are not effectively aligned to implement preventive maintenance plans. This situation has caused delayed and missed preventive maintenance activities resulting in high unavailability of important equipment.

b. Structured Analysis (or Structured Cause Analysis): A structured investigation typically identifies causal factors known as Apparent Causes or Proximate Causes and is generally limited to the identification of error drivers/precursors and Flawed Defenses for human performance-related issues and to hardware failure modes for equipment problems.

Flawed Defense example: Training for check valve maintenance is general in nature and does not address the unique design of the check valve with the fixed hinge design.

Note: A Structured Analysis can identify causal factors just as fundamental as a Rigorous Analysis. Doing so, however, is less likely because the amount of evidence typically collected and analyzed for a Structured Investigation may not be sufficient for you to support the most fundamental causes.

Note: A Common Cause Analysis can be performed within the context of either a Rigorous Analysis or Structured Investigation. Refer to Chapter 5 for a Common Cause Analysis methodology.

Note: Rigorous Analysis and Structured Analysis often identify factors that did not directly result in the observed event, but did contribute to its significance, timing, impact or extent. These factors are known as Contributing Causes. Contributing causes should have corrective actions to address. Refer to Chapter 9 for information on corrective actions.

c. Limited Inquiry and Correction: A Limited Inquiry typically is simply a checklist-driven prompt investigation for human performance errors. You may also use it as a systematic troubleshooting effort for hardware failures. Limited inquiries typically identify the causal factors generally defined as Direct