Root Cause Analysis
This course is and introduction to Root Cause Analysis (RCA) and Problem-Solving concepts. Throughout the course, concepts are made concrete through reference to real-life examples brought to the course by the participants, as well as selected examples from other situations and organisations.
After an introduction to some key psychological phenomena that inhibit the problem-solving capabilities of individuals and teams, the course introduces a formal 12 step process – supported by appropriate methods, tools and techniques – to overcome these phenomena, and builds individual skills through practice.
The course concludes by discussing how best to ensure that RCA techniques are successfully implemented and utilised within participants’ organisations.
"Day 1 - Course Content Introduction
• Why do we need Root Cause Analysis?
• Why most traditional problem-solving processes fail"
"12 Steps to Effective Root Cause Analysis • Is there a problem?
o Natural variability
o One-off ""significant"" events
o Repetitive ""chronic"" events"
· Which problems should we investigate?
· Elements of good problem definition
Case Study:
· Select a recent, real problem from participants' work place
· Define Problem
Step Two – Preserving and Collecting Data
· Treat the scene as a crime scene
· What data should we collect?
· What tools can we use?
· What stops us from collecting data?
· Interviewing – some tips
Case Study:
· Examine and evaluate data from the case study example
Step Three – Minimising Further Consequences
· What can be done to minimise immediate consequences?
· Temporary fixes
Case Study:
· What was/could have been done in the case study example?
Step Four – Arranging the Analysis Team
· Team-based vs individual problem solving
· Successful problem-solving in teams
· Facilitator role
Case Study:
· Assess the case study example – who should be involved?
Step Five – Analysing the Data
· Cause-effect principles
· Physical Root Causes
· Human Root Causes
· System (Latent) Root Causes
· Searching for patterns and comparisons
· Conducting a 5 Whys analysis
· Preparing a Cause-Effect diagram
Case Study:
· Develop a Cause-Effect diagram for case study example
Day 2
Recap of Day 1
Step Six – Verifying hypotheses and validating causes
· Verifying hypotheses – could the "cause" lead to the event?
· Validating causes – was the "cause" actually present?
· Dealing with uncertainty
Case Study:
· Identify additional data requirements and collection methods for case study example.
Step Seven – Developing Solutions
· Characteristics of good solutions
· How do we identify solutions?
o Eliminating causes
o Minimising effects
· Solution Killers
Case Study:
· Develop solutions for the case study example
Step Eight – Selecting Recommended Solutions
· Assessing alternatives
Case Study:
· Assessing the recommended solutions for the case study example
Step Nine – Communicating Findings and Recommendations
· Developing a written report
· Developing a verbal presentation
Case Study:
· Prepare and present a brief presentation for the case study example
Step Ten – Implementing Outcomes
· Obtaining approvals
· Tracking implementation progress
· Getting proactive work done in a reactive maintenance environment
Case Study:
· Plan implementation activities for the case study example
Step Eleven – Tracking for Results
· Developing and implementing tracking metrics
Case Study:
· Propose tracking metrics for the case study example
Step Twelve – Institutionalising the Process
· Senior management support
· Policies and procedures
· Consistent process
· Resources
· Tracking Implementation Compliance
Course Summary
· Fix it once, fix it forever