Root Cause Analysis

Duke Okes

Description

This best-seller can help anyone whose role is to try to find specific causes for failures.
It provides detailed steps for solving problems, focusing more heavily on the analytical process involved in finding the actual causes of problems. It does this using figures, diagrams, and tools useful for helping to make our thinking visible. This increases our ability to see what is truly significant and to better identify errors in our thinking.
In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; cautions for analyzing data; and what to do if one can’t find the causes. In its guidance on solution identification, biomimicry and TRIZ have been added as potential solution identification techniques. In addition, the appendices have been revised to include: an expanded breakdown of the 7 M’s, which includes more than 50 specific possible causes; forms for tracking causes and solutions, which can help maintain alignment of actions; techniques for how to enhance the interview process; and example responses to problem situations that the reader can analyze for appropriateness.

Sujets

• Risk Assessment
• Gestion et management
• Insurance
• Economics
• Business
• Management

Informations

• Publié par: ASQ Quality Press
• Date de parution: 06 février 2019
• Nombre de lectures: 0
• EAN13: 9781951058494
• Langue: English
• Poids de l'ouvrage: 3 Mo

Extrait

Root Cause
AnalysisAlso available from ASQ Quality Press:
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The Certifed Manager of Quality/Organizational Excellence Handbook,
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The ASQ Quality Improvement Pocket Guide: Basic History, Concepts,
Tools, and Relationships
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To request a complimentary catalog of ASQ Quality Press publications, call
800-248-1946, or visit our Web site at http://www.asq.org/quality-press.Root Cause
Analysis
The Core of Problem Solving
and Corrective Action
Second Edition
Duke Okes
ASQ Quality Press
Milwaukee, WisconsinAmerican Society for Quality, Quality Press, Milwaukee, WI 53203
© 2019 by Duke Okes.
All rights reserved. Published 2019.
Printed in the United States of America.
24 23 22 21 20 19 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Names: Okes, Duke, 1949- author.
Title: Root cause analysis: the core of problem solving and corrective action /
Duke Okes.
Description: Second edition. | Milwaukee, Wisconsin: ASQ Quality Press,
[2019] | Includes bibliographical references and index.
Identifers: LCCN 2018055702 | ISBN 9780873899826 (hardcover: alk. paper)
Subjects: LCSH: Problem solving. | Decision making. | Management. |
Root cause analysis.
Classifcation: LCC HD30.29 .O44 2019 | DDC 658.4/03—dc22
LC record available at https://lccn.loc.gov/2018055702
No part of this book may be reproduced in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
Director, Quality Press and Programs: Ray Zielke
Managing Editor: Paul Daniel O’Mara
Sr. Creative Services Specialist: Randy L. Benson
ASQ Mission: The American Society for Quality advances individual,
organizational, and community excellence worldwide through learning,
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Printed on acid-free paper

To Karl, a superb teacher.


Contents
List of Figures and Tables ........................................ xi
Preface to the Second Edition ..................................... xv
Preface to the First Edition ....................................... xvii
Chapter 1 Getting Better Root Cause Analysis 1
The Problem ............................................ 1
The Impact ............................................. 3
Approaches to Root Cause Analysis ....................... 3
Existing Problem-solving Models .......................... 5
A Proposed Model ....................................... 6
Chapter 2 Multiple Causes and Types of Action 13
Initial Problem Response ................................. 13
The Diagnosis .......................................... 14
Actions to Prevent Future Problems ........................ 18
The Need for Filters ..................................... 20
Chapter 3 Step 1: Defne the Problem 23
Selecting the Right Problem ............................... 24
Scoping the Problem Appropriately ........................ 28
The Problem Statement .................................. 30
Chapter 4 Step 2: Understand the Process 37
Setting Process Boundaries 37
Flowcharting the Process ................................. 38
Why Process is So Important .............................. 43
Additional Values of the Flowchart ........................ 46
vii





viii Contents
Chapter 5 Step 3: Identify Possible Causes 49
Using the Flowchart for Causes ........................... 50
Using a Logic Tree for Causes ............................. 51
Using Brainstorming and the Cause-and-Efect
Diagram for Causes ................................... 58
Using Barrier Analysis for Causes ......................... 60
Using Change 61
Eliminating Possible Causes .............................. 62
Sources for Possible Causes ............................... 64
Chapter 6 Step 4: Collect the Data 67
A Basic Concept ......................................... 68
Types of Data ........................................... 69
Using Existing versus New Data .......................... 70
Where to Collect Data .................................... 71
Special Tests ............................................ 72
Sample Size and Time Frame .............................. 75
Data Collection Tools for Both Low- and
High-frequency Problems .............................. 76
Additional Tools for High-frequency Problems .............. 80
Enhancing Data Collection Value .......................... 82
Organizing the Data Collection Process .................... 84
Chapter 7 Step 5: Analyze the Data 87
Tools for Low-frequency Data ............................. 88
Additional Tools for High-frequency Data .................. 90
Questioning the Data .................................... 100
Data Analyses Summaries ................................ 100
Analyzing Variation ..................................... 102
Cautions on Data Analysis 102
Where to Go Next? ...................................... 104
Can’t Find the Cause? 105
Chapter 8 Identify and Select Solutions 107
Step 6: Identify Possible Solutions ......................... 107
Step 7: Select Solutions to be Implemented .................. 117




Contents ix
Chapter 9 Implement, Evaluate, and Institutionalize 123
Step 8: Implement the Solution(s) .......................... 123
Step 9: Evaluate the Efect(s) .............................. 125
Step 10: Institutionalize the Change ........................ 127
Chapter 10 Organizational Issues 129
Cognitive Biases ........................................ 129
Emotional Barriers ...................................... 131
Resistance to Change .................................... 132
Organizational Culture ................................... 135
Project Ownership ....................................... 136
Coaching/Facilitation Skills .............................. 137
Other Issues ............................................ 141
Chapter 11 Human Error and Incident Analysis 145
Human Error ........................................... 145
Incident Analysis ........................................ 151
Chapter 12 Improving Corrective Action 155
Critical Thinking 157
Buddhism .............................................. 158
Stoic Philosophy 158
Summary of Root Cause Analysis ......................... 159
Appendix A Example Projects 161
A Need for Focus ........................................ 161
How Would They Know? ................................. 163
How Profcient is That? .................................. 164
Getting the Shaft Back ................................... 166
Got It in the Bag ......................................... 169
Appendix B Root Cause Analysis Process Guides 173
Generic Process Thinking 173
SIPOC Analysis Form .................................... 175
Data Collection and Analysis Tools ........................ 175
2Do-It Root Cause Analysis Guide ......................... 178
2Do-It Problem Solving Worksheet 180
Checklist for Reviewing the Corrective Action Process ....... 181
Expanded List of Seven Ms ............................... 183
Forms for Tracking Causes and Solutions ................... 185



x Contents
Appendix C Enhancing the Interview 187
Basic Interview Problems and Process ...................... 187
Types of Interviews and Questions ........................ 188
Leveraging How Memory Works .......................... 190
The Importance of Time and Refection ..................... 191
Appendix D Analyzing Problem Responses 193
Appendix E Additional Resources 199
Books .................................................. 199
Websites ............................................... 200
References .................................................... 201
Index ........................................................ 207


List of Figures and Tables
2Figure 1.1 The DO IT problem-solving model ......................... 7
Table 1.1 Problem solving model comparison ........................ 7
Figure 1.2 Visual depiction of the model .............................. 8
Figure 1.3 Corrective action, root cause analysis, and problem solving .... 9
Figure 2.1 Diferentiating between symptoms and causes
(physical and system) ..................................... 14
Figure 2.2 Levels of causes for machine p