Wednesday, March 14, 2012
Root Cause Analysis: Getting the Maximum Return On Investment from RCA
Follow multiple causal chains to provide multiple solutions for review
Look for all of the ways it could be prevented or mitigated including both the actions and conditions that led to the event. If you just using 5 Whys you may miss one or the other.
Evaluate all the solutions
Sometimes we tend to recommend our “pet solutions” meaning that we use the solutions that have worked in the past without understanding the cost and benefits and comparing that to other possible solutions. We need to look at all of the ways to lower risk to an acceptable level at an acceptable cost. The logic below can help with that goal.
Be Logical: Remember “and and or”
When looking at the fault tree use logic symbols to see where you need to only tackle one item to prevent or mitigate the failure in the case of “and” or where you may need to attack multiple causes in the case of “or” branches. If either this “or” this can cause the failure then you must address both to mitigate the risk whereas with the “and” eliminating the lowest cost cause in the branch will prevent the re-occurrence of the failure.
Remember latent and systemic level roots have the best savings potential but can also have the highest cost of implementation because in many cases you must change culture and human behavior. Because of this you should understand problems to the latent level and address problems at the cost effective level.
In the end RCA is not about developing pretty reports it is about developing a business case for the best solution from a cost and risk standpoint then ensuring that those recommendations both get implemented and get the results we expected at the lowest cost. Or to say it another way:
Have fun… understand causes… evaluate solutions… implement… verify… succeed!