In Search of the Root Cause.docVIP

In Search of the Root Cause By Dr. John Robert Dew An Operator in a steam plant shuts off a critical valve, causing a system malfunction and a million-dollar plant shutdown. The captain of an oil tanker fails to turn his vessel at the proper time, causing it to run aground and spill its cargo. The cockpit crew of an airplane does not realize the wing flaps are not properly set before takeoff, leading to a crash and tragic loss of life. These scenarios sound like stories on the evening news. In every case, there would be an investigation into the cause of the incident. Some people would study the situation to find out what actually happened. Others might be primarily concerned with who was to blame for the problem and who is liable for the damages. A few might suggest finding the root cause of the incident to ensure that it doesn’t happen again. Defining a problem In root-cause analysis, a problem is defined as a situation where the performance of a system does not meet expectations. For instance, you might your washing machine to run through all its cycles, but instead you find that it frequently goes out of balance in the spin-dry setting. Finding the Immediate cause When you have a problem, it is important to identify the immediate cause. The immediate cause will be the action, or series of actions, that directly creates the difference between expected and actual performance. In some cases, the immediate cause will be simple to identify. If a valve on a water system is left open and an operator freely admits that he is mistakenly left the valve open, we know the immediate cause of the problem. In other cases, the immediate cause of a problem might be hidden and require some investigation. In an airplane crash, there might not be an obvious cause. Investigators will need a questioning process to help them gather the important facts about the accident before they develop theories of possible causes. Effective questioning defines the probl