Root Cause

To successfully carry out this mission, a root-cause investigation needs to be evidence-driven in accordance with a rigorous application of the bedrock of all root-cause methodologies: the Scientific Method. Consistent with the Scientific Method, underlying assumptions have to be questioned and conclusions have to be consistent with the available evidence, as well as with proven scientific facts and principles. Sometimes root-cause investigations fail to fulfill their primary mission and the failure recurs. In that regard, diagnosing the root cause of root-cause investigation failures is, in itself, an interesting topic. Here are three common reasons why some root-cause investigations fail their mission.

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 . . .

Hidden but powerful forces within our organizations are causing people to make serious mistakes. Until someone deals with these forces, they will continuously but unpredictably snare people into doing things they should not do. These forces are like a “trap,” waiting to catch the next person. The most proactive of all industrial action might be to identify and remove these latent traps. But all our attempts to identify and remove these latent causes of failure start at the human. Humans do things “inappropriately,” for “latent” reasons.

Root Cause Analysis (RCA) is a useful tool for trouble shooting breakdowns and efficiently coming to a solution. I propose the following seven points for successful implementation of RCA that will naturally result in increased profits.

Many different factors contribute towards the failure of a pump. Some factors that did not seem to have contributed to earlier failures were not examined or considered and may become the cause of failure under other situations. Failures do not occur suddenly. Usually there are many symptoms, which signal a failure situation and are generally termed as potential failure modes. The ignorance of such symptoms almost always leads to failure. Below are two case studies pertaining to mechanical seal systems, a vital component of pumps operating in running process plant.

As a teacher and a practitioner of root cause analysis, I see not only the physical motions of going through such an effort, but also the psychology behind what makes or breaks it. When you consider the effort that goes into determining root causes and developing recommendations, why should it be such a hard sell to get something done?

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.