Understanding Cause Analysis in Problem Solving
Cause analysis, or CA, is a vital tool for investigating incidents, identifying underlying causes, and implementing corrective actions to prevent recurrence. By delving deep into the root causes of problems, CA enables organizations to make effective recommendations and address issues at their source. Various methodologies like FMEA, Fishbone diagrams, and the Five Whys can be employed to uncover multiple causes and create comprehensive solutions.
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CAUSE ANALYSIS CA www.ioas.org
What do you know about CA? A tool for systematic investigation and analysis Reactive analysis Incident investigation may apply to losses, failure, inefficiencies What went wrong? What were the causes? What changes should be made? Cause analysis helps identify what, how and why something happened, thus preventing recurrence. Diving deep to find the source of the problem - to avoid addressing just the symptom. Causes are underlying factors, are reasonably identifiable, can be controlled and allow for generation of recommendations. Various techniques may be used.www.ioas.org
Causes are those that can reasonably be identified. those management has control to fix. those for which effective recommendations for preventing recurrences can be generated. www.ioas.org
Inspector uses wrong version of the inspection form The typical investigation would probably conclude inspector error was the cause, inform the inspector and give him the right form. But if the analysis stops here, it has not probed deeply enough to understand the reasons for the mistake. Not enough is known to prevent it from occurring again or to be sure it is not a widespread problem. www.ioas.org
There may be more than 1 cause of a problem www.ioas.org
Many methodologies are employed in CA Complex Failure Modes and Effects Analysis (FMEA) Causal factor charting Statistical data analysis Fishbone or Ishikawa diagram Simple Five Whys May incorporate simple techniques from complex analysis simple cause and effect maps fishbone diagrams www.ioas.org
5 Whys Cause(s) Analysis Corrective actions Problem www.ioas.org
Why did the inspector use the wrong form? It was the only form he had. He has always used that form, no one ever commented. Why did he have only that form? The inspector manager did not provide inspectors with the revised versions. Why did the inspector manager not provide inspectors with revised versions? She doesn t make the revisions. She doesn t see reports. She didn t know it was necessary. She never thought about it. Why did she not think about it? Not part of her training, job description, work instructions or procedures. www.ioas.org
The inspector has been using the wrong form for years. Why was this not caught? The review team did not know it was important. Why did they not know it was important? Use of current forms is not part of their training, was never mentioned before and they have no control over what the inspector does anyway. Why? Why? Why? www.ioas.org
In addition to asking why - writing it down may help the analysis. Didn t know it was important Not noticed by reviewers Didn t have authority Wrong form Inspector has old forms Manager did not know www.ioas.org
Fishbone diagram Had only old forms No one noticed Reviewers not trained Unaware of changes No one responsible Unable to access current formats Inspector uses wrong form www.ioas.org Cause4 Cause 3
5 Whys rules of thumb State the problem clearly. 5 is the number at which most causes are clearly identified. Do not worry about not meeting or exceeding 5 Whys. Follow your thought process to decide how many Why s you need to get to the point where the cause is evident. This is an investigative process. You don t need to answer all Whys at once. The outcome of 5 Whys (or other analysis) is a cause analysis, not the resolution. Corrective actions and effectiveness verification follow. www.ioas.org
