Workshop: 4 half-days Remote

Instructor: Loyd Hamilton

Loyd.Hamilton@thinkreliability.com

Main office email info@thinkreliability.com

phone 281.412.7766
fax 281.412.7761
website www.thinkreliability.com (or www.causemapping.com)

Physical address ThinkReliability

2225 CR 90 Suite 223
Pearland, TX 77584

Mailing address ThinkReliability

P.O. Box 301252
Houston, TX 77230

Summary PDF
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All rights reserved. This material may not be copied, reproduced, or translated in whole or in part without the written
permission of ThinkReliability. Contact us at the address above.
Version 17.2S PDF
Microsoft, Excel, NetMeeting and Visio are registered trademarks of Microsoft Corporation.
Post-it Notes is a registered trademark of 3M Corporation.
Cause Mapping and ThinkReliability are registered trademarks of Novem, Inc. dba ThinkReliability

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 Cause Mapping

Root Cause Analysis – The Concept

A weed provides a good analogy for problem solving. If you don’t get to the root, the weed grows back.
Root cause analysis digs into the details beneath the surface to provide a thorough explanation and find
better solutions.

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Analysis

Definition of Analysis ____________________________________

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Problem Solving – Three Steps

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ThinkReliability Approach - Two Views

Any negative occurrence within a process is a problem. A problem investigation pinpoints which
steps, within which process need to be done differently.

Workshop Objectives
Find the best solutions to meet your organization’s overall goals

This is done by being able to:

Break any problem into its causes - to identify different solution options
Break any work process into its steps – to identify where solutions apply
Clearly document and communicate both problems and processes

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Cause Mapping Method

These are three fundamental steps that can be applied effectively to any type of issue.

1. What’s the problem?

A problem is any negative deviation from the ideal state of the organization (the goals). There are four
questions that are used to define every problem.

2. Why did it happen?

The analysis begins by asking why the overall goals were negatively impacted. A thorough analysis breaks
an issue down, into specific cause-and-effect relationships supported with evidence, to a sufficient level of
detail.

3. What will be done?

The best solutions (one or more) are chosen from the possible solutions that are proposed for individual
causes.

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Timeframe – A specified period of time in which something occurs.

An incident in the past happened __________________, but it has _______________________.

Cause Mapping Definitions

Cause ___________________________________

Effect ___________________________________

Prevent – Keep something from happening. __________________________________

__________________________________

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 Cause Mapping

Cause-and-Effect Relationships - Chain of Events

Series - A straight line where each cause-and-effect relationship links together.

Why? Simple – Easy to get started

Why did this effect happen? Builds to the right.

How? Adding more detail

How specifically did this cause produce this effect?
Builds in between a cause and an effect.

Parallel - More than one cause for the same effect (splits). A thorough cause-and-effect
relationship identifies what is both necessary and sufficient.

Required? A thorough analysis

What was required to produce this effect?
Builds in parallel – more than one cause needed to
produce the same effect. Necessary and sufficient.

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Cause Mapping Conventions

Evidence – Validates that a cause occurred. It’s placed just beneath the cause it supports. It answers the
question, “How do we know this cause occurred?” Evidence boxes can be used for any additional
information that clarifies the cause.

Solutions – Controls a cause to change effects. A solution is placed just above the cause it controls.

The arrows always connect from the left side of the cause to the right side of the effect. The connector
arrows should not connect to the top or bottom of the causes and effects. The objective is to provide a
clear explanation of the cause-and-effect relationships for the reader.

AND
AND

AND

AND

Causes of an Effect - When more than one Possible Causes are labeled with a “?” to indicate
cause is required to produce a particular that evidence is presently missing – at this point
effect they are related with an “AND” “we don’t know for certain, we’re speculating.”
between them. They are related with an “OR” between them.

? ? ? ?

AND
= AND
= AND AND OR
= OR
= OR OR

? ? ? ?

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 Cause Mapping

Titanic
Read the following paragraph and write down answers to the questions.
th
On April 14 , 1912 at approximately 11:40pm the passenger ship Titanic, steaming from UK to New
York, struck an iceberg and began filling with water. Within about two and a half hours, the ship
was completely underwater and over 1500 people had lost their lives.

1. Problem Outline

2. Analysis (Cause Map)

3. Solutions
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ion
The purpose of an investigation is to thoroughly understand and explain an issue so that specific solutions
can be identified to prevent similar issues.

FACILITATE: to make easier

______________________________________________________________________________

Facilitator’s Role - Lead the Investigation Process

The participants in the investigation provide the causes, evidence and solutions. The facilitator coordinates
the investigation process.

• Collect all relevant information

- Gather Evidence, Facts, Observations
- Involve the People “Closest to the Work”

• Organize the information

- Use the Cause Map to drive the investigation
- Use Investigation tools: Timeline, Process Maps, Diagrams / Photos

• Document the information

Pen & Paper, Post-it Notes, Chart Paper, Dry-Erase, Microsoft Excel

• Manage the Dialogue

- Use visual tools to minimize disagreements
- More specific, evidence-based communication

• Drive to an appropriate level of detail to reveal specific solutions

- Use the impact and risk to the Goals to expand the analysis.
______________________________________________________________________________

Magnitude of the Incident

The analysis begins with 3 to 5 Why questions regardless of the magnitude of the incident. Mid-size
investigations will add more detail and major investigations will add even more detail

Analysis is iterative
Begins basic then builds into
as much detail as needed.

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 Cause Mapping

Root Cause Analysis & Failure Modes Effects Analysis

The important connection between RCA and FMEA

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Information from a specific failure (CM-Did) can be used to build collective know-how over a
period of time (Cumulative CM-Could), which can then be used to troubleshoot a specific failure.

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