Integrated Systems Management

CT068-3-M-ISM

Root Cause Analysis

MSc in Information Technology Management

MSc in Technology Management
 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?)

Module Code and Module Title Title of Slides

 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

Module Code and Module Title Title of Slides

 Step 1: Problem
Definition
• What is the problem?
• When did it happen?
• Where did it happen?
• What is the significance?
• NO Who – don’t place blame
(blame = avoidance and silence)
Work backward chronologically from event
Work forward chronologically to clarify (Paradies) Gano
Module Code and Module Title Title of Slides
 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
Module Code and Module Title Title of Slides
 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

Fire
Combustible material

Oxygen

Gano
Module Code and Module Title Title of Slides
 Cause and effect are same
thing
Effects “caused Causes
by”
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
Module Code and Module Title Title of Slides
Gano
 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 don’t know (ignorance point marked with
?)
– I don’t care (it fell because of gravity. Why
is there gravity? I don’t care)
Gano
Module Code and Module Title Title of Slides
 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 (1st hand experienced)
better

– 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
Gano
Module Code and Module Title Title of Slides
 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
Module Code and Module Title Title of Slides
 Phase 1

Broken Person
Wrist Caused Fell
By

Gano
Module Code and Module Title Title of Slides
 Phase 2
Hand
Stopped
Fall Caused
By
Etc.

Broken
Wrist Caused
By

Person
Fell Caused
By
Etc.

Gano
Module Code and Module Title Title of Slides
 Hand
Phase 3 Stopped
Fall
Excess Caused
Force Caused By
By
Evidence goes here
Broken Evidence goes here
Wrist Caused Employee
By Overweight

Evidence goes here

Wrist Evidence goes here
Position
Caused
By
Etc.
Evidence goes here
Gano
Module Code and Module Title Title of Slides
 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
Module Code and Module Title Title of Slides
 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

Module Code and Module Title Title of Slides

 Procedural violations

Normal At-Risk Reckless

Error Behavior Conduct
Intended No Yes Yes
action
Knew risk No No yes
of action

“Blame-free” sounds good, but what about

intentional actions. Marx suggests a “Just Culture”
Module Code and Module Title Title of Slides
 Mechanical Failures

• All unanticipated mechanical failures must

have a previous cause:
– Designed in error
– Manufacturing defect
– Mis-maintained
– Mis-operated

Module Code and Module Title Title of Slides

 Other causal conditions

• Physical • Individual
environment performance
• Leadership • Organizational
• Equipment environment
design • Knowledge, Skills, &
• Policies abilities
• Procedures • communication

Module Code and Module Title Title of Slides

 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.

Module Code and Module Title Title of Slides

 Report Preparation

• Cause and effect relationships must be

clear
• Don’t 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

Module Code and Module Title Title of Slides

 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)

Module Code and Module Title Title of Slides

 Reference

Presentation adapted from: Berry College:

http://facultyweb.berry.edu/jgrout/RootCaus
eAnalysis.ppt

Module Code and Module Title Title of Slides

 Question and Answer Session

Q&A

Module Code and Module Title Title of Slides