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Root Cause Analysis

TARGET AUDIENCE:  Any team with a problem to solve; primarily project teams (Superintendents, PMs, PEs, trade contractor foremen), but also Executive teams, Manager teams, Office teams.

Description
 “No problem can be solved from the same level of consciousness that created it.”
 – Albert Einstein

Problem solving requires a creative mind shift.  One barrier is that the team members who need to solve the problem may be caught up in the firefighting that occurs when a problem explodes.  This learn-to-do-by-doing session enables participants to distinguish between a problem that can be quickly resolved and one that requires deeper analysis.  Using the team’s real-life “problem”, participants will first learn and practice a method to clearly define and state “the problem”.
“It’s not that I’m so smart, it’s just that I stay with problems longer…. One should look for what is, and not for what one thinks should be.” – Albert Einstein

Then the session will coach participants to dig deeper beyond the problem’s symptoms to discover true causes, thus enabling the team to develop and test mitigation measures to solve them. Two methodologies (tools) will be explored:  5 Why and Root Cause Analysis.  At the end of the session the participants will have found the Root Cause of their real-life problem and learned how to apply these techniques again and again in shorter 30-60 minute bursts to solve future problems.
Session 1 Agenda

  1. OBJECTIVE:  The objective of this session is to learn how to:
    1. quickly identify a problem,
    2. quickly solve the problem using 5 Why, or
    3. immediately swarm it using Root Cause Analysis; and
    4. devise and test countermeasures to achieve a Target Condition.
  2. BASIC APPROACH:
    1. Find the problem
    2. Fix the problem, then
    3. Find the root cause
    4. Fix the process
        
  3. PROBLEM SOLVING TEMPLATES (based on Steven Spears, High Velocity Edge)
    1. Background
      1. Why are we concerned about this situation?
    2. Current Condition
      1. Seeing Problems (as used at Alcoa Aluminum and in Lean Construction)
        1. Visual Management, Weekly Work Planning
      2. Defining the Problem
    3. 5 Why
      1. Moving past symptoms and causes to the originating cause
      2. Risks/Deficiencies (eg. tendency to isolate a single root cause)
    4. Root-Cause Analysis (Diagnosis)
      1. Identify factors
      2. Use Fishbone Analysis
      3. Systematic investigation
      4. Documented evidence
      5. Team effort
      6. More than one root cause
      7. Sustained effort
    5. Countermeasure Treatments
    6. Describe the Target Condition
    7. Actual Outcomes
      1. Monitor and measure the countermeasures, changes and proposed solutions
    8. Gap Analysis
      1. Measure the metrics of the Target Condition against Actual Outcomes
      2. Is there a gap?  5 Whys
  4. BARRIERS TO PROBLEM SOLVING
    1. Simplistic thinking
    2. Stopping at symptoms
    3. Limits of investigator’s knowledge
    4. Push to hurry up
  5. THE PROCESS OF RCA – HANDS-ON LEARNING BY THE GROUP FINDING THE REAL ROOT CAUSE(S) OF A REAL PROBLEM
    1. Define the problem (describe the event)
    2. Gather data and evidence
    3. 5 Whys
    4. Classify causes into causal factors – HANDOUT:
      1. 7 Level 1 Causes (eg. Materials)
      2. 19 Level 2 Causes (eg. Design)
      3. 17 Level 3 Causes (eg. Ambiguous)
    5. Reveal multiple root causes
    6. Identify all harmful factors (might be causes)
    7. Identify corrective actions and solutions
    8. Implement them – PDCA
  6. FINAL THOUGHTS & TAKEAWAYS