Digging below the metaphorical surface

To help guide you in the quest for absolute truth, we’re going to take another leap into the morass we call the Web in search of practical, zero-cost, noncommercial, registration-free Web resources focused on root cause analysis. Remember, we search the Web so you don't have to.

By Russ Kratowicz

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Art Doyle probably said it best in his 1926 book, “The Blanched Soldier” — “When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.” While that line originally was used in a different context, it certainly represents the essential concept underlying the fine art and science of root cause analysis. While it might be easy to grasp on an intellectual level, the economic pressure a mechanical failure and the mandate for continuous improvement imposes have a tendency to foster unwarranted leaps in logic that can backfire on the plant professional. And that’s an outcome that won’t do anybody’s career a good turn.

When it comes to uncovering the roots of a problem, it pays to be a true detective who doggedly pursues the ultimate reason for the mishap under investigation. To help guide you in the quest for absolute truth, we’re going to take another leap into the morass we call the Web in search of practical, zero-cost, noncommercial, registration-free Web resources focused on root cause analysis. Remember, we search the Web so you don't have to.

No conclusion jumping allowed

Identifying the real root cause is a serious part of a continuous improvement process. If you get it wrong and then act on a mistaken belief, you might as well guess outright at the beginning and skip the entire analysis. To help you get pointed in the right direction, stand up, turn around twice and turn toward www.asq.org/pub/qualityprogress/past/0704/qp0704rooney.pdf. This effort will get you a copy of “Root Cause Analysis For Beginners,” a nine-page article that appeared in the July 2004 edition of Quality Progress magazine. The authors, James J. Rooney and Lee N. Vanden Heuvel at ABSG Consulting Inc.’s Risk Consulting Division in Knoxville, Tenn., propose four characteristics they believe should be present before you can consider anything to be even a mere candidate for induction in the Root Cause Hall of Fame. Also, they outline a four-step process that forms the roadmap for a rigorous root cause analysis. Following that map requires three tools — a causal factor chart, a root cause map and a root cause summary table — all of which they illustrate with an example analysis all worked out and waiting for your inspection.

Counting Geigers

Regardless of your views about nuclear energy, I think we can agree that our hired hands in Washington, D.C., had best do what they can to make the technology as safe as possible for us commoners. Those energetic neutrons and other subatomic detritus whizzing about in a reactor core are indiscriminate and they play for keeps. If ever there was a place where root cause analysis might prove a wise practice to adopt, a nuke plant is it. Rest easy, fellow citizens, your families are safe. The Office of Nuclear Safety Policy and Standards at the U.S. Department of Energy is on top of things. As evidence, I offer you a publication titled “Root cause analysis guidance document,” which your mutant mouse will find at www.eh.doe.gov/techstds/standard/nst1004/nst1004.pdf. This is a 69-page treatise that presents its content using the characteristic government-ese that we love and cherish for its ability to impart knowledge most efficiently and unambiguously. Here you can learn about the 32 subcategories of the seven causes, some of which are direct causes, others are contributing causes and one, the holy grail, the root cause. The worksheet templates in the appendix are generic enough to be used in your plant even if you don’t have a reactor out in the powerhouse. Check it out. You paid for it.

Sorta like six sigma

The chain is clear. Continuous paychecks depend on market dominance, which depends on continuous improvement, which leads to six-sigma performance, which depends on reliability, which depends on your root cause analysis to ferret out the truth about failures. Because of the connection between low failure rates and root cause, Michael Cyger of iSixSigma LLC in Ridgefield, Conn., posts quite a bit of root cause information at his Web site dedicated to the discipline of six sigma. Use a positional error of less than 1 part in 3.4 million to steer your mouse in the direction of www.isixsigma.com/library/content/c050516a.asp and you’ll find Cyger’s site. Then, use the search function in the upper right to scour the entire site for the phrase “root cause analysis.” Doing so returns more than 1,100 pages of material relevant to our topic. You’ll need to sort out what’s important to your operations on your own. Before you leave this Web site, return to Cyger’s home page to investigate “The Cox-Box” link on the left side of the screen.


Rigorous root cause analysis involves gathering data and evidence from multiple locations. Organizing this input is much easier if you have some sort of checklist to record your findings. We located a generic checklist in the most unlikely of places. Waltham-based MassPRO is a quality improvement consultant serving the medical industry in the Commonwealth of Massachusetts. You see, the medical business uses a form of root cause analysis to investigate something called a sentinel event. This is an unexpected, rare incident, related to system or process deficiencies, which leads to catastrophic outcomes such as patient death or major and enduring loss of function. You’re pretty lucky in that regard in the sense that machinery can’t sue you for malpractice if you make a serious maintenance mistake. You can get a sterile copy of the three-page document, “A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event,” if your trusty mouse checks the vital signs at www.masspro.org/publications/pubs/misc/HPMPAppT.pdf.

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