Root Cause Analysis Meets Goals for Safe, Reliable
and Efficient Operations
by Mark Paradies

Exactly what is Root Cause Analysis? It is the systematic evaluation of problems to find basic causes that, when corrected, will improve performance by preventing or significantly reducing the likelihood or consequences of repeat problems. Root Cause Analysis can be used to analyze accidents, incidents, or near-miss events that cause safety, production, maintenance, or quality problems. Or it can be used proactively to find and fix the causes of problems before accidents, incidents, process upsets, or maintenance problems occur.

Root Cause Analysis is a recognized industry good practice and is required by law by several federal/industry regulations including regulations provided by the EPA, OSHA, FDA, FAA, FCC, NRC, DOE, DOT, MSHA, MMS, and JCAHO.

Why Should You Find Root Causes?
Before you solve any problem, you should ask yourself, "Is this problem worth solving?" If the answer is yes, then you should consider Root Cause Analysis. Solving problems without Root Cause Analysis is like trying to hit a ball blindfolded. It is possible, but you won't be very effective. Good Root Cause Analysis takes the blindfold off to let people see exactly what's causing problems. And this is not just the superficial symptoms, but the in-depth causes that, when corrected, make performance noticeably better. Therefore, beyond regulatory requirements, you can cost justify Root Cause Analysis based on savings from improved performance.

What is Wrong with Root Cause Systems?
Root Cause Analysis has been around since antiquity. The first formal teaching of it was by Socrates. He taught students cause and effect. Since then people have developed new tools to try to help problem solvers find root causes. These tools include cause and effect diagrams, brainstorming, fish bone diagrams, fault trees, five whys, and even Spin-a-Cause™.

So why are there so many problems that need to be solved? First, we are good at creating problems or forgetting the answer to problems we once solved. Second, most root cause tools don't help very much. Why? They are hard to learn and use (you must be an expert). They don't provide guidance past the user's own knowledge or assumptions (especially in the area of human performance). When used by different people on the same problem, they produce widely varying results. They aren't easy to explain to management. One might say that they just don't work well (Sorry, Socrates!) What problem solvers need is a fast, easy way to find root causes that produces accurate results.

Can You Build A Better Mousetrap?
Since many root cause systems have such glaring faults, you might be tempted to build a better system. Unfortunately, this is a lot like deciding you need transportation and starting to design and build your own car. To get something good takes overwhelming effort.

Luckily, you don't have to build your own system. Why? Because the work has already been done for you. Over a decade has been spent researching human performance, researching and developing the best root cause analysis tools, and tying these tools together into an investigation system. This included formal user testing and informal focus group appraisals from hundreds of users.

The system has been made robust, reliable, and easy-to-use so that it produces repeatable results that help users improve performance. People can be helped to understand the system by the creation of effective, interactive training so new users get up to speed quickly. Now there's advanced training to enhance expertise. A licensing and a train-the-trainer program for companies that want to teach their own courses has been developed. Optional software to enhance productivity is also available. This includes a patent pending computerized root cause analysis tool to take users past their own knowledge and a Corrective Action Helper® Module to get them to develop more effective fixes. The programs are built around a relational database with a report generator and corrective action tracking. And now companies can get as much from their data as possible with advanced trending software and training. We've come a long way since Socrates!

Mark Paradies is President of System Improvements, Inc. of Knoxville, TN. They can be reached at 865-539-2139 or for more information at www.taproot.com