I recently attended a ThinkReliability training course titled Cause Mapping I: Effective Root Cause Analysis. Having a fair bit of experience with RCA, I was a bit concerned at first that this would not be the best use of my time. However, I was pleased by the end of the second day.

Some value came in the form of new tools to apply to investigations, and some value came in the form of a new twist on old concepts or reinforcement of valuable practices.

Advantages

• The key terms are all simple, standard, and from the dictionary. People will be able to understand the method without learning a whole new vocabulary. The absence of jargon will make it easier for the “uninitiated” to participate.
• Cause mapping can be documented from within Microsoft Excel with just a little knowledge. There is no expensive custom software to buy or learn.

Drawbacks

• The workshop would not be sufficient training for someone whose job responsibilities including cause analysis. There are many subjects that an industrial failure analyst should study in addition, including interview methods, common failure modes for industrial equipment, fracture analysis, simple tribology, and other ways and means of interpreting evidence.
• Less emphasis was given to structured means of data preservation and standards of evidence than I would have liked to see, even for an introductory workshop.
• Five whys was held up as example of a poor problem solving method. The point of five whys in Toyota (as I saw it) was that everyone participated in finding and solving problems. The details of using five whys is almost of secondary concern and beside the point. The innovative aspect of five whys was in the scope of participation.

Key Takeaways

• There is no such thing as a “root cause.” for any problem, there are many causes. Eliminating any one cause eliminates the problem. Asking what is the “root cause” makes as little sense as asking which part of an automobile is most necessary for it to function.
• Exploring the problem in terms of goals impacted gives opportunities to look at safety and compliance dimensions of a problem – even when a production loss initiates the investigation.
• The more causes that are identified, the more opportunities there will be to identify solutions.
• The more solutions we have for a problem, the more options we have to choose the best solutions. Implementing a few of the solutions may significantly decrease the risk of a repeat failure. It seldom makes sense to try to implement each and every solution.
• People often disagree about what the problem “is.” But they seldom. Disagree about the impact to the goals. Therefore, start the analysis with the impacts and proceed from there.
• The output of the process is not a root cause. The output is the best solution (among many) to the problem.
• When interviewing those close to the problem, show them the current state of the cause map. When they see that their involvement is only a small part of all the different causes, they may be less defensive about their role.
• When encountering resistance to sharing knowledge in the form of “It’s my fault and I won’t do it again,” it can help to shift gears to the process itself. Often, you will hear more about their difficulties (a.k.a. the causes) when talking about the process rather than the event.

Topics Covered

We generally followed the workbook, which included the following contents:

• Chapter 1: Introduction
• Chapter 2: Problems & Causes
• Chapter 3: Cause Mapping
• Chapter 4: People, Processes, Prevention
• Chapter 5: Complete Investigation
• Chapter 6: Facilitation and Documentation
• Appendix A: Exercises and Examples
• Appendix B: Reliability Basics
• Appendix C: Measuring Results
• Appendix D: After the Workshop

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