Simplifying Cause Analysis

A Structured Approach

Chester D. Rowe, Kristen Noakes-Fry

• Publisher: Rothstein Publishing
• Year: 2017
• eBook ISBN: 9781944480479
• Topic: Business
• Subtopic: Assicurazioni
• Index: Business

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.

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...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Acknowledgments
• Table of Contents
• Introduction
• Chapter 1: Getting Started
• Chapter 2: The Cause Road Map Taxonomy
• Chapter 3: Human Performance Related Maps
• Chapter 4: Machine/Material/Hardware Failure Maps
• Chapter 5: Using the Cause Road Map
• Chapter 6: Human Performance Basics
• Chapter 7: Effective Interviewing
• Chapter 8: Analysis Tools and Techniques
• Chapter 9: Event Modeling and Analysis Tools
• Chapter 10: Event Modeling and Analysis Tools
• Chapter 11: Extent of Condition and Extent of Cause
• Chapter 12: Corrective Actions
• Chapter 13: Documentation and Reporting
• Chapter 14: Final Thoughts
• About the Author
• Credits
• How to Get Your Free Download