While the connection between process and cause-and-effect is obvious, organizations typically struggle to use this connection to their advantage during an investigation.  As a result, the investigations stop short of where some of the best solutions reside and typically focus only on what they call the human element of the problem.  For example, a common conclusion to a problem investigation is simply that a “procedure was not followed”.  The proposed solution: “reinforce the procedure” or “retrain on the procedure”.  Sound familiar?  If it does, then you can probably attest to the solutions’ ineffectiveness at actually solving the problem.

So why do we continually fall back into this trap?  We have a tendency to try and simplify the incident investigation which results in generalizing the causes.  If you have generic causes, you get generic solutions.   It’s at this point that the investigation should be taking the opposite approach and diving into the specific details of the process/procedure that was ineffective.  This is easier said than done, but there is a simple tool that can be extremely helpful… a process map.  Next week I will discuss how to use a process map to improve your investigations.

Reinforcing a procedure doesn’t do anything to address gaps within.  If someone doesn’t follow a procedure, it is important to identify “Why?” the procedure wasn’t followed.  Only then will you find that the details aren’t as straightforward as they seem.

I take many flights every year and so, getting to the plane on time is a fundamental requirement for getting my job done.  If I miss a flight, its important that I find out “why” and enact some sort of preventative measure to ensure that I don’t repeat that error.  So, when I missed a recent flight out of Chicago, it provided a perfect opportunity to do a self-investigation and a miniature Cause Map.

Here is the “Story”.

As I was leaving a client office I realized that there was time to get some Chicago Deep Dish Pizzas and take them home.  My family really loves it when I can bring something special back from a trip. I found a restaurant not far from the airport.  I was able to arrange preparation of the pizzas for transport.  Getting to the restaurant was more tricky than I had anticipated but I found a good parking spot so all was going smoothly.  I was actually rather proud of myself as I found I had arrived at the airport with time to spare.   As I approached the terminal I was confused by some of the signs and I turned into the airport departure and arrival area rather than rental car return area. Back-tracking required an extra 10 minutes to get to the rental car area.  Now, I would have to move quickly, but I would still make my flight.

I arrived at the rental car return area approximately 60 minutes prior to the scheduled flight departure. An item needed to be checked onto the aircraft and the requirement is 45 minute baggage check minimum.  Haste was needed to get from the rental car area (walking distance – no bus ride required) to the ticket counter.  Now, I was feeling rushed and, in my haste, I made an error.  I left my cell phone in the rental car.  Normally the cell phone would stay in my pocket or briefcase.  However the cell phone was left on the center console in the rental car. The console was black and the phone was black; I had scanned the area but hadn’t noticed it.  By the time I realized my error and worked with the rental car company to retrieve the car and the phone, only fifteen minutes remained before the scheduled flight departure and I still needed to get through security. 

Needless to say as I walked up to the gate the door had just closed.  The airline officials were more than accommodating and no additional airline costs were required; however, an overnight hotel stay was required.

After a failure of any kind, it is human nature to look for someone to blame.  My mind went through a list of “if only’s”:  if only the restaurant had been in a better location, if only the rental car company hadn’t taken fifteen minutes to retrieve my car, if only the signs in the airport had been more clear etc., etc. ad nauseum. 

But, when I got home I worked up a simple Cause Map that allowed me to escape my own private culture of blame and find a rather interesting action item to prevent this sort of failure in the future.

By following the same procedure that I would for a multi-million dollar issue, I was able to identify a simple solution that would prevent this particular incident from recurring.  I could not move the pizza place, I could not re-write the airport signs.  There were many things in the scenario that were clearly out of my control.  I could be more diligent about putting my cell phone back in my briefcase but that solution depended solely on “operator behavior” which is not completely reliable.  So, I, the management, decided to purchase a very distinctive case and lanyard for my cell phone.  This bright orange rubber case is a bit of an eye-sore according to my wife but, it certainly draws attention to itself.  It stands out against the dark console of a rental car and has helped me keep track of my cell phone on a daily basis.

We often see “Procedure not followed” as a finding in a Root Cause Analysis Investigation.  It is not uncommon that the investigation will stop at that point and the corrective action becomes; “Follow the Procedure”.  Taking the process to the next step is crucial.  Why was the procedure not followed?  How can we make it more likely that the procedure will be followed in the future?  Sometimes a very small adjustment can be the key to prevention.

Companies often reach very general causes in their investigations.  For example, the identified cause may be “Not paying attention”.

Just like the proverb, the devil is in the details, and the solutions are there too. Root cause analysis is an investigation approach for digging into what’s beneath the surface.

We provide free Excel templates and reference information on our website. If you are interested in learning more please go to our website at http://www.thinkreliability.com.  View the Cause Map I’ve worked up for this issue by clicking on “Download PDF” above.

Cheers, 

Loyd

Recognition of a hazard is the first step toward mitigation. At a recent workshop we spread out the cords on the floor for the projector and PC and once again I was faced with tripping concerns. As our workshop attendees are aware, the “Tripped on Barrier” is one of our core learning exercises. As I was presenting “Tripped on Barrier” I couldn’t help but form a “Instructor Tripped on Cords” cause map in my mind.

It looked a little bit like this:

If the barrier is observed it is less likely that the person will trip on the barrier. If the person takes a different path, it is also possible to avoid the barrier (tripping hazard). One possible solution is removing the electrical cords. This is not always the “Best Solution”; it is a possible solution. In the case of most workshops ‘removing the cords’ is not an option. However some rooms have a hard wired ceiling projector and a lectern.

Another possible solution is avoiding the electrical cords. As an instructor at the front of the room I am constantly moving around to field questions from one side of the room or the other and may step on cords or other obstructions.

In one particular case, I recall, I did not see the electrical cords because I became distracted answering questions. In this particular case the Cause Map would have looked like…

We can go even further by asking Why the person was distracted? The person who tripped is often the only person who can answer that question. It is also possible that an observer can witness the event and state the person was distracted. The Cause Map with more information added may look like…

A clever solution may be to remove the exposed electrical cords. Often times I see gray duct tape used. That is a possible solution but some clients are reluctant to use the sticky stuff on the floor or the duct tape may not be available. At a recent workshop at FMC Technologies in Houston, our workshop coordinator brought in a very clever Velcro Cover. It attached to the carpet AND it was colored Yellow!

(By the way, we also relocated the position of the cord to take advantage of a floor outlet located just in front of the table.) If it’s difficult to visually show the room orientation with a photo no problem; Excel has excellent drawing tools!

Now that these causes were addressed I presented “Tripped on Barrier” without the fear of tripping on the cords!

Cheers,

Loyd.

Of course, it would be easy to focus the blame on the previous mechanic, who at best was grossly negligent and at worst was committing outright fraud.  But what interests me more than fixing the blame is preventing a similar breakdown from happening again.  I certainly won’t use that particular mechanic again, but what prevents the same problem from occurring with a different mechanic?  Even the best mechanic could forget to do part of a job on a particularly bad day.

What I would like is to verify that the work was done, but that is difficult in the case of a timing belt change, since the affected parts are behind a cover and not visible.  Besides, I probably don’t have the experience to tell by sight whether the job was done.  I have a lot more confidence that the second mechanic replaced all of the parts, because he showed me the old parts.  An effective solution for future repairs might be to always ask for the old parts, just so that I can know whether they remembered to perform the entire job.

An effective facilitator should begin collecting information as soon as they become aware an incident occurred. Answers to the following questions can typically be captured immediately after an incident occurs: what do people see as the problem, when did it happen, was anything being done differently, where did it happen, which equipment did it involve, which work process was being performed, was anyone injured, were there any environmental issues, any customer issues, any impact to production or schedule, any damaged property or materials, any additional labor costs because of this issue and has it happened before.

These questions, with appropriate space for responses, are part of the Problem Outline within the Cause Mapping method. The Problem Outline, within our Excel Cause Mapping template, can be carried as a hardcopy to wherever the information is located. This gives the facilitator the ability and direction to collect details right away. Notice the list of questions doesn’t even address the causes.

As the facilitator is collecting information for the Problem Outline, people will most likely explain some of the cause-and-effect relationships. The facilitator writes down all the causes and all the evidence people provide. Even though there may be limited information, what is known and what is unknown should be written on the Cause Map. The unknowns and uncertainties are designated with questions marks. Creating a visual map of the cause-and-effect relationships structures and organizes the entire analysis. As more information is collected, it’s added to the same Cause Map.

Many investigations begin fairly basic and a little blurry. As details are collected, the incident comes into focus. The ease of documentation using the Cause Mapping method, whether it’s with paper or in Excel, changes the rate at which an organization can investigate problems. Check the problem solving velocity of your organization and let us show you how to improve it.

This is the way the relationship between motivation and success is usually represented.  Motivated individuals succeed.  Managers need to focus on motivation first in order to lead their team to success.  I can think of multiple examples of teams working on a Safety Improvement Program, Reliability Effort, or Maintenance Turnaround/Shutdown plan and it always seemed that we were looking for a way to motivate our groups.

Motivation is, at best, elusive and difficult to conjure.  Think of a pep rally – lots of excitement sure, but focus? Not so much.  Motivation without a clear objective can lead a team to wander off scope.  As a leader or supervisor this was a constant challenge that I experienced.

Here is another interesting thought:

Success influences or can cause Motivation.  Teams that have a success can use that success as a catalyst for motivation.  The initial success serves as a compass or a “map” if you will toward team cohesion, focus and motivation.  At a very fundamental level I believe that everyone wants to be successful… some individuals may put more effort in than others.  Even the most negative of the “Grumblers” will embrace success.

How can we provide a catalyst?  One idea is success in solving problems.  Root Cause Analysis and more specifically Cause Mapping can provide a simple method to jump start a team.

Another key element is Positive Recognition of success.  And that means acknowledgement of the team!  As a Root Cause Analysis facilitator you must be sensitive to the fact that management may look to you as  the “Problem Solver”.  It is essential that you keep management focused on the team.  A simple e-mail posted in a common area can be “good enough”.  Prizes or rewards can actually trivialize the effort.

As a starting place or jumping off point pick an issue that is reoccurring and has attention.  The chronic issues can often times be more of a challenge for the Root Cause Analysis Facilitator.  Success in solving a problem that was widely thought to be a “necessary evil” or, “something we just have to work around” can be a huge catalyst for team motivation.

If you tackle a Chronic Issue and need assistance contact ThinkReliability.  We will help you and provide support.  For workshop attendees this is free of charge.  If you are just being introduced to Cause Mapping contact us anyway; we’ll give advice and get you started.

“Success precedes motivation, and once children see they can be successful, they will participate; thus, teachers must engineer success.”  from Classrooms that Work by Patricia Cunningham & Richard Allington (geared to 4^th & 5^th grade English reading).

Don’t forget some of the basic lessons we learned in grade school!

Cheers,

Loyd.

As you can see both causes are required to cause the overload. Google’s response was to increase capacity by adding additional request servers. Now that the crisis has been contained and email access has returned to normal, the next step is to conduct a more thorough root cause analysis to make sure this type of event doesn’t happen again. Stay tuned for a more detailed analysis of the incident.

A group of about 20 high school students were travelling across the U.S. by air for a school-sponsored activity.  The students had been split between two different flights, with 10 students on each flight.  Since there was only one adult in the group, the 10 youngest students were put on the flight with the adult, because the younger students seemed more at risk if their flight were delayed or diverted.

As it happened, the flight for the older students was cancelled, so those students were left to fend for themselves until the next available flight the next day.

Someone who is concerned with risk and reliability will ask, why were the students split into two groups, resulting in half of the students being stranded without an adult?  Did the airline only have enough seats for half of the group on each flight?  It was suggested to me that, as a matter of school policy, large groups were often split in two, so that if one of the planes crashed, then the number of students lost in the tragedy would be reduced.

Would such a policy make sense from a risk management perspective?  The following Cause Map shows the basic root cause analysis for losing all of the students in a plane crash, and how separating the students into two groups prevents (that is, reduces the risk of) losing all of the students.

However, splitting the students into two groups greatly increases the possibility of some students being stranded without an adult, as shown in the Cause Map below.

The missing piece of this risk management puzzle is the probabilities that the causes in the Cause Maps occur.  Risk can be quantified by multiplying the consequence of a failure times its probability.  Over the past year, 1.63% of U.S. plane flights have been cancelled, so if the students are split into two groups, the unescorted group will become stranded at least 1 time in 100.  On the other hand, the probability that a plane flight will crash is on the order of 1 in 10,000,000 and, contrary to what you may think, it is rare that more than a quarter of the passengers die in a crash.

Creating a policy to split up the students is a possible solution to the problem of losing all students in a single crash, but now that the risks are better understood, is it a very effective solution for reducing the overall risk to the students?

Checklists are wonderful tools when used effectively.  The checklist must be clear and simple to use.  AND the checklist must be used diligently.  Shortcutting the checklist invalidates the philosophy and effectiveness.

Pilots are an excellent example of the effectiveness of checklists.  There are more than four checklists that the cockpit crew goes through before any flight on a Boeing 737.  Ask any pilot if they use their checklist…  There is a saying;  “There are old pilots, and bold pilots.  But there are no old/bold pilots”. 

So here’s Loyd’s checklist issue.  My packing checklist for a workshop has over 108 items.  Some things range from putting a fresh package of post-it notes in my bag, pre-printing my boarding pass, or checking that I have aspirin. 

On a recent workshop that also involved my Scuba gear I left my wallet at home.  Between my two packing lists there are over 200 checklist items.  So here’s what did not go so well…  I left my wallet at home.  My wallet is not on my checklist…  It’s just too simple right?

The last time I remember leaving my wallet at home was in 2000 when my wife was 9 months pregnant.  Assuming I put my wallet in my pocket once per day that is approx. 3,000 tasks.  Failure rate of 1/3000 is not so bad, right?

In Root Cause Analysis we must also think about the impact to the goals.  In this particular case it almost impacted the diving portion of my trip…  (I was flying in a day before the workshop – going diving with decompression and air travel considerations can be tricky). 

The Cause Map outline would look something like this:

…not the end of the world.

Divers must be patient people and getting in a hurry or stressing out about a dive is not a good starting place.  The potential impact of missing a workshop was significantly reduced as the morning dive was scheduled for the day before the workshop.

This event did make me think about consequence of missing a workshop, including the hassle of rescheduling a workshop or adjusting the schedule from the client’s perspective.  The Customer Service impact could be significant.

Someone might look at the Cause Map above or hear me discuss this and say, “You were not paying attention… “ I would suggest that you NOT say this.

Such a statement will probably put people on the defensive.  Instead, identify the things that may have affected the person’s attention.  Then corrective actions can be explored.

So here’s the dilemma: do I add another item to the checklist for my wallet?

P.S.  This was a happy ending.  My system for traveling is to get to the airport well in advance of the flight.  My wife was able to bring my wallet and Loyd plus gear got onto the airplane.  …and the Dive was GREAT!  And all my gear had been packed correctly… 

Cheers,

Loyd

If customers choose to participate, the electrical utility will text page them to warn that the grid is reaching a peak capacity. The message will request that the customer please turn off all possible devices and turn up the thermostat 3 degrees.

The pitch from the local utility is that they can prevent building a new power plant over the next 5 years with cooperation from the customers. Now imagine the statement from the electrical utility. They are not promising to lower rates… they are merely asking for help in improving the environment. The Austin market is very sensitive to environmental concerns.

The participants will receive a text page when the plant is overloaded and are asked to reduce their electricity usage between 3 p.m. and 7 p.m. Delay running dishwashers and washers/dryers until outside of this four hour window.

In addition, the utility would send voluntary text pages to interested customers with a specific request to turn up thermostat on the air-conditioner 3 degrees on a maximum electrical load day. On this specific day in Austin the ambient temperature was 100F with the heat index at 108F. This is a true commitment from the customers! …and an indirect pay back in the form of less capital costs from the Electrical Provider.

This commercial and some discussion with my wife on our road trip (side note – not so economically friendly) resulted in me thinking about efficiency and shaving the tops off the peak loads.

 Cheers,

Loyd