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

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.

From the Ivory Tower

One can’t use a random approach if the objective is effective root cause analysis. Over the years, various structured approaches have been offered as the best way to identify the most basic underlying problems and each approach has its proponents as well as detractors. It’s a rare plant that has the resources to select the best by first becoming proficient at each. What you need is some much less expensive secondary research. And, wouldn’t you know, the Web has what you need to help pick the RCA methodology that’s best for your site. “A Statistical Comparison of Three Root Cause Analysis Tools,” by Dr. Anthony Mark Doggett, appeared in the February/April 2004 issue of the Journal of Industrial Technology. This is a nine-page peer-reviewed article, so it should have substantial credibility. The three tools at issue here are the cause-and-effect diagram, the interrelationship diagram and the current reality tree. An explanation of each is a bit beyond the scope of this column, but Doggett indicates that there’s plenty of literature around to explain the details and uses (your own Web search can track it down). Doggett researches these tools with regard to causality, factor relationships, usability and participation. His guinea pigs were first- and second-year undergrads in a general education course studying team problem-solving and leadership. Much of the middle of his article is devoted to a presentation of the statistics that he used to evaluate the tools. But, you can skip to the bottom of page 6 for his conclusions and a list of practical implications. Now, skip that desk rodent to www.nait.org/jit/Articles/doggett010504.pdf.

Testing, testing, 1-2-3

When something goes wrong, everyone has an opinion about the cause. And you know what they say about opinions. In too many cases, it’s all an exercise in finger-pointing seeking to deflect blame in the general direction of someone else, perhaps lower on the totem pole. You’ll never get continuous improvement that way. Instead, point your trusty mousie at www.schneiderman.com/The_Art_of_PM/root_cause/why_do_root_cause_analysis.htm to see why Arthur M. Schneiderman, an independent consultant on process management in Boxford, Mass., says a more introspective approach is better. His article, “Why Do Root Cause Analysis?” argues that getting your team to sit around a conference table to brainstorm possible candidate causes isn’t the best way to ensure that you’ll ever identify the true root cause. Instead, he advocates analyzing the data and evidence you collected and conducting a few experiments that will help you develop a concentrated short list of causes that has a much higher probability of including the true root cause. This suggests that you should know something about design of experiments, a discipline that can make your sleuthing more efficient. Included in the list of reference Web sites at the end of this column is an Internet column that discusses that very topic. Enjoy.

Killing the contradictions

TRIZ is the Russian acronym for the English phrase, “Theory of Inventive Problem Solving.” Genrich Altshuller developed this theory in the USSR back in 1946. The general definition of TRIZ revolves around the idea that technical systems evolve towards increasing ideality by overcoming contradictions, mostly with minimal introduction of resources. A perfect example of such a contradiction is using a baking oven to dry painted parts. Higher temperature is good because the parts dry faster and production can be increased, but higher temperature is bad because it can blister the paint. TRIZ seeks to circumvent the contradictions with two tools. It scatters its 40 inventive principles around a matrix of worsening features listed on one axis and improving features on the other. Find the relevant features, use the principles at the intersection, and your problem is on its way to being solved. Like every other topic under the sun, TRIZ has its magazine, [i]The TRIZ Journal[i], published by The TRIZ Institute, which is associated with The PQR Group, Upland, Calif. The magazine weighs in with commentary on our topic of the month in “Analysis Paralysis: When Root Cause Analysis Isn’t the Way,” by Darrell Mann. It argues that you might be wasting your time with RCA because there are problems for which it’s impossible or too costly to determine the true root cause. Instead, Mann says, use root contradiction analysis, which recognizes the existence of physical limits, beyond which no amount of effort will produce acceptable results. Anyway, there’s no contradiction evident if you visit www.triz-journal.com/archives/2002/05/b/ to read the article.

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