User:Patricia Gorman

Root Cause Analysis System for Problem Solving and Problem Avoidance
A common sense cultural transformation. That magical voice in your head allows you to turn disasters into palm trees and sunrises. By Pietro Savo

At home or on the job, the multiple projects and tasks we manage usually operate in less-than-perfect mode, with errors, mistakes, or problems cropping up. But contrary to popular wisdom, failure does not build character…it only wastes time, effort and money. Problems typically evolve into costly crises not because of one individual’s actions, but because the person or organization failed to establish a process or an environment that aided clear decision-making to avoid the problem from occurring in the first place. Root cause analysis is a methodology for problem solving and problem avoidance that can be taught to anyone, anywhere, anytime. Those who practice it recognize how to solve less-than-perfect situations quickly and efficiently. Root cause analysis transforms an organizational culture that reacts to problems to a new culture that solves problems before they escalate. This method allows organizations to significantly reduce the costs associated with errors, and reallocates these resources to more profitable (and enjoyable) activities. Problem avoidance is the responsibility of everyone in your organization and your life: From the CEO, to the floor sweeper, to family and friends. Root cause analysis obtains its energy from people who observe, who question. Once all those in your organization understand the variability, the solution, and the process improvement, mistake proofing is around the corner.

How does one learn to apply this skill? First, it's necessary to learn how to recognize the root cause of a problem, and then take appropriate actions to prevent the recurrence of the problem or failure. Second, one learns to recognize and address the warning signs or symptoms of a problem even before that problem manifests itself. The real cost savings comes from becoming a problem anticipator. Root cause analysis training transforms an organization's culture so that it can avoid the failure all together.

Unfortunately, sometimes things fail and a fundamental failure of a process happens and can be a sum of many processes combined into one result. Historically, our effort or function has performed without a flaw, and then something called process variability worms its way into our project, function or life. We then find ourselves scrambling to meet deadlines, satisfy our boss, make delivery and be competitive.

Story-time: My front right tire on my new auto became flat because a roofing nail became imbedded in it. My first pass at conducting root cause analysis led to the nail being the root cause of the tire failure. However, it was not, because the cardboard box that held the nails had collapsed. My second guess was that the failed box caused the tire failure. But this was not the root cause: The roof leaked during a rainstorm, the box got wet, and it collapsed because of the weight of the nails. The fundamental failure was caused by the leaky roof. Until we eliminated that condition by fixing the roof, we would continue to witness some sort of failure. Our current culture teaches us to march forward, allow for error, hope for the best, and re-work the product if it doesn't come out right. But it doesn't have to be that way. Historically, operation budgets have allocated an extra 15 to 25 percent to pay for failures, rejection, waste, and the human resources to make things right. To avoid these resource-draining activities, I teach organizations to recognize and address variability as it occurs. For example, the person nearest to the problem will already understand the solution. He or she may already be making adjustments in the process to make it work. Unfortunately, these adjustments are seldom documented and disappear when the key person leaves that shift. This is called the hidden factor.

Another common scenario: Someone may have noticed a change in the process, and did not think it was important. Others may have observed that the change was so gradual that it seemed insignificant until a failure or problem occurred. Variability or change should become a red flag to begin investigating.

Even simple SPC (statistical process control) is a reactive process. Root cause analysis cannot be applied until one has collected enough data. By that point, the process may have already experienced problems and incurred unnecessary costs. Root cause analysis can mean the difference between keeping and losing your customer base. Customer perception is a very difficult thing to measure until the customer's perception of your organization is so poor they stop buying your products or using your services or…drinking your milk. My oldest son drank sour milk on two separate occasions. To this day, he will not drink milk. The root cause seemed simple enough: My wife always saves the sour milk for baking; she even labeled the container sour. However, my son was only three years old and had not yet learned to read. He's 15 years old today and he still won't drink milk. What happens if one of your sour milks escapes to your customer? Your customer may not want to drink your milk again and find something else to quench their thirst. For this important reason, problem avoidance social training becomes an essential necessity! It is a proven fact that most of the failures and problems that plague industry are chronic. This means that they happen more than once for the same reason. Furthermore, out of all of the chronic failures that a company experiences in a given year, 20 percent represent 80 percent of the loss. If you investigate the 20 percent of the failures representing 80 percent of your losses, you will reap quantum benefits in a short period. I recently spoke with a manufacturing manager who had to scrap 300 parts. I asked him if they had identified the root cause. He said "no," the problem went away on its own. Problems never go away unless you clearly identify the fundamental root cause and remove it from the process. Successful organizations create a mindset that actively looks for change, for variability in a process. Within these organizations, every employee understands how to identify the warning signs of process deviation as part of their reality and part of their job. Their employers encourage them to raise a red flag early on so that it doesn't cost to fix errors at the end. Companies that thrive and compete will instill these values, creating a culture driven by change and fueled by energized people. Source Savo, P. (2007). Root Cause Analysis System for Problem Solving and Problem Avoidance. from www.genonow.com Savo, P. (2006). Root Cause Analysis System for Problem Solving and Problem Avoidance (1 ed.). Boston: Tradition Books.ISBN 978-1-4303-0068-7