Root Cause Analysis/ Incident Investigation/ Problem Solving

Root Cause Analysis/ Incident Investigation/ Problem Solving

Root Cause Analysis and Incident Investigation

Root Cause Analysis and Incident Investigation are different sides of the same coin. They both involve investigating the causes of unplanned incidents. Root Cause Analysis is usually associated with process breakdowns, failures and quality issues, where Incident Investigation is more often linked to accident investigations into occupational injury events and process safety losses. However, both benefit from the use of the same tools and techniques. The main difference will tend to be the mental models applied to understand the event.

Our approach is to split out the tools from the mental models. The tools include:

  • 5 Whys
  • FMEA
  • Fishbone/ Ishikawa/ Cause and Effect Diagrams
  • 4C
  • ABC Analysis

The mental models give insight into the mechanisms of failures or incidents, enabling the tools to be more effective and allowing investigators to ask better questions to illicit more inciteful and useful answers so drilling down to the true root causes. Mental models include:

  • Splitting root causes into Physical, Human and Latent (or to use the HSE's terminology of immediate causes, underlying causes and root causes)
  • Human Failure Types to categorise and understand the human failure or error and so the appropriate actions to prevent it in the future
  • Performance Influencing Factors that increase (or decrease) the probability of human error
  • Maintenance Theory to correctly diagnose the failure pattern type that occurred to implement actions that will improve reliability and not degrade it

They are both very powerful approaches, if rigorously applied, to drive continuous improvement in performance. They both provide good return on efforts, in that time is only expended on extant issues. Root Cause Analysis and Incident Investigation processes need to be integrated with other business systems, in particular SQCDP (see Lean Management Systems). When applied with a 4C structure that includes Contain and Confirm teams become focused on regaining stability as quickly as possible as well as preventing re-occurrences.

Root Cause Analysis can be applied to safety issues including process safety and near miss incidents, quality, production losses, breakdowns/ reliability issues.

Problem Solving

Both Root Cause Analysis and Incident Investigation are forms of problem solving activities, but are not the only forms or applications of problem solving. We have a wide range of problem solving tools and strategies to approach a huge range of different challenges to help you overcome obstacles and challenges.

We employ a wide variety of problem solving approaches in our facilitated Kaizen events and other workshop programmes. We can provide training on the full range of Lean and Six Sigma problem solving approaches, including A3 Thinking and DMAIC. We can work with you to develop problem solving systems so that your organisation has a structure and process to identify improvement opportunities, to prioritise and select the next most suitable opportunity to address, and to manage that activity through to a successful conclusion and close out when the next opportunity can be selected and targeted. We can tailor problem solving systems to your organisation so it fits with your culture and environment, and design in escalation methodologies to suit the size and urgency of the problem.

At the end of the day, you employ people for their problem solving ability. Invest in your workforce's core skill and you will see an ongoing return.