October 3, 2012 | Barb Carr

Root Cause Tip: Root Causes Are the Absence of Best Practices …

Just a few quick best practice points today to use when analyzing a Causal Factor using the Root Cause Tree®, Root Cause Tree® Dictionary and your created SnapCharT® …

1. You are looking for Root Causes that contributed to the person’s, equipment’s or process’ inability to successfully perform a specific task (Causal Factor).  The Causal Factors led to an Incident or made the Incident worse.

For example, the investigator needs to find Root Causes for why the mechanic pushed the lift control up instead of down which then caused the load to become unbalanced with the Incident being a Damaged Product.

2. You must use the Root Cause Tree®, Root Cause Tree® Dictionary and SnapCharT® together. NO EXCEPTIONS. NO ASSUMPTIONS.

3. Treat the bullets in the Root Cause Tree® Dictionary as black and white. No reading between the lines. If there is failure to agree during the analysis, you must get further clarification of your Condition and Events on your SnapCharT®.  Clarify the facts, identify the bullets in the dictionary, and then verbally repeat the Causal Factor that you are analyzing. If the logic still does not match, then it is not a Root Cause.

4. Select the Root Cause if it is a fact.  DO NOT ignore a valid Root Cause and fail to select it because you think it can not or will not be changed. You can prioritize what does get fix or what does not get fixed during steps 5 and 6 of our 7-Step Process.

Help this helps settle some previous investigation discussions.

Root Cause Analysis
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