June 1, 2012 | Ken Reed

How To Test the Accuracy of Your “Why” Root Cause Analysis

I recently received an inquiry asking me, “What is the test to assure true root cause is found?  We use the “Why-Why” Analysis.”

    Using one of the “why” methods (“Why-Why”, 5-Why’s, etc) unfortunately leads many investigators to question their methodology.  That’s because, after using it once or twice, it becomes pretty obvious that these methods are 100% dependent on the experience and biases of the investigator.  If you’re a training person, amazingly enough, your “why” analysis leads you to training problems.  If you’re a quality person, you end up with quality-related issues.

    That’s because these methods do not give you any expert guidance to get beyond the investigator’s current level of knowledge.  For example, if you don’t know anything about “human engineering” (what color should an alarm light be? what shape valve hand wheel should be used?), you will never look for these problems.  You will only find problems you’re already familiar with, and therefore you will only put corrective actions in place that you have probably already tried in the past.

    The question posed is exactly the right question.  “How do I know I’ve found the real root cause?”  The bad news is that only a highly-trained human performance expert can answer that without some type of expert guidance.  The good news is, TapRooT® was designed to give you exactly that expert guidance.

    TapRooT® was designed by human performance experts to guide the normal investigator toward the true root causes that a highly-trained expert would find.  It does this by supplying a series of simple “yes/no” questions that you answer in the course of your investigation.  The answers to those question will quickly narrow you down to the true root causes of human performance or equipment failures that actually led to the accident.  Once you have these root causes, you can then apply effective corrective actions to eliminate them, preventing similar human performance mistakes in the future.

    Now, instead of ending up with corrective actions like, “Counseled the operator on the importance of opening the correct valve” (like he doesn’t already know that!), you can now find out why he opened the wrong valve.  You can be confident that the root causes you have found are real, proven root causes… the real reasons good people make mistakes.

     To directly answer the question, “why” methodologies will not consistently get you to true root causes.  There is no test built into those methods to verify root causes are found.  There’s no electronic “magic bullet” that can work around the weaknesses in those systems.  You’ll have to go outside those methodologies to get there.  Give TapRooT® a try!  We guarantee you’ll be satisfied with the results.

Root Cause Analysis
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