Getting Root Cause Analysis to Work for You

I was recently engaged by a client to conduct failure analysis on a large (and expensive) hydraulic cylinder off an excavator. This hydraulic cylinder had been changed-out due to leaking rod seals after achieving only half of its expected service life. Inspection revealed that apart from the rod seals, which had failed as a result of the 'diesel effect', the other parts of the hydraulic cylinder were in serviceable condition.

So, the root cause problem elimination. It's really just a structured approach to eliminate problems...that's all it is. It's what usually happens when people say they do root cause, in my experience, this is the morning meeting and someone says motor tripped-out costing production loss. So, what happens in the morning meeting, now I haven't been to yours, but somewhere, the first thing people say is this a maintenance problem or is this an operations problem.

Lately, I’ve been asked to provide root-cause analysis training more than ever before in my 14 years as an independent quality/lean consultant. This is interesting in the age of Six Sigma, especially because “analyze” is the heart of DMAIC (define, measure, analyze, improve, control). I find this interesting in this age of lean, in which the lean tools that are taught to so many people are only possible solutions to good root-cause analysis. I began to wonder, “Why does root-cause analysis suck?,” and I came up with the following possible root causes. You decide which apply to your company by asking “Why?” somewhere around five times until you find the systemic reason(s) that it sucks at your company. Drum roll, please . . .

If I have an unwanted situation which consumes resources and tends to happen in a repeated fashion then there is a possibility that it might be beneficial to figure out what is really causing this situation to occur and remove it so the situation does not occur again. This is generally referred to as Root Cause Analysis, finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms.

DOE Order 5000.3A, "Occurrence Reporting and Processing of Operations Information," investigation and reporting of occurrences (including the performance of root cause analysis) requires the and the selection, implementation, and follow-up of corrective actions. The level of effort expended should be based on the significance attached to the occurrence. Most off-normal occurrences need only a scaled down effort while most emergency occurrences should be investigated using one or more of the formal analytical models. A discussion of methodologies, instructions, and worksheets in this document guides the analysis of occurrences as specified by DOE Order 5000.3A.

What we need to do today is make management aware through education and awareness that our cultures live with these chronic events that typically end up costing 100 times more than the occasional sporadic event. Unfortunately, the sporadic events get all the attention. When our cultures are enlightened, we will begin to enjoy the fruits of our efforts in the form of return on investment (ROI) figures as high as 7000-8000 percent. Then the believers will come.

Root Cause Analysis has the potential of CHANGING people, IF the leader of the investigation knows of this potential. Far from “just another problem-solving exercise,”the root cause analysis should SLOW PEOPLE DOWN to the extent that they can see the truth of the incident under inquiry, WHATEVER THE TRUTH MIGHT BE. This paper focuses on two parts of our human nature which are large obstacles to root cause discovery, i.e., our unwillingness to slow down, and our unwillingness to let go of certain basic assumptions about life. Warning: This paper is designed to challenge the way you think about Root Cause Analysis.