What do you know about CA A tool for systematic investigation and analysis Reactive analysis Incident investigation may apply to losses failure inefficiencies What went wrong What were the causes What changes should be made ID: 935873
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Slide1
CAUSE ANALYSIS
CA
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Slide2What do you know about CA?
A tool for systematic investigation and analysisReactive analysisIncident investigation – may apply to losses, failure, inefficiencies
What went wrong? What were the causes? What changes should be made? Cause analysis helps identify what, how and why something happened, thus preventing recurrence.Diving deep to find the source of the problem - to avoid addressing just the symptom.
Causes are underlying factors, are reasonably identifiable, can be controlled and allow for generation of recommendations.
Various techniques may be used.
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Slide3Causes are
those that can reasonably be identified.those management has control to fix.
those for which effective recommendations for preventing recurrences can be generated.
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Slide4Inspector uses wrong version of the inspection form…
The typical investigation would probably conclude “inspector error” was the cause, inform the inspector and give him the right form.But if the analysis stops here, it has not probed deeply enough to understand the reasons for the mistake.
Not enough is known to prevent it from occurring again or to be sure it is not a widespread problem.
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Slide5There may be more than 1 cause of a problem…
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Slide6Many methodologies are employed in CA
Complex
Failure Modes and Effects Analysis (FMEA)Causal factor chartingStatistical data analysisFishbone or Ishikawa diagram
Simple
Five Whys
May incorporate simple techniques from complex analysis
simple cause and effect maps
fishbone diagrams
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Slide75 Whys
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Slide8Why did the inspector use the wrong form?
It was the only form he had. He has always used that form, no one ever commented.
Why did he have only that form?The inspector manager did not provide inspectors with the revised versions.Why did the inspector manager not provide inspectors with revised versions?
She doesn’t make the revisions. She doesn’t see reports. She didn’t know it was necessary. She never thought about it.
Why
did she not think about it?
Not part of her training, job description, work instructions or procedures.
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Slide9The inspector has been using the wrong form for years. Why was this not caught?
The review team did not know it was important.
Why did they not know it was important?Use of current forms is not part of their training, was never mentioned before and they have no control over what the inspector does anyway.
Why? Why? Why?
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Slide10In addition to asking why - writing it down may help the analysis.
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Slide11Fishbone diagram
Inspector uses wrong form
Had only old forms
No one noticed
Cause 3
Cause
4
Unaware of changes
Unable to access current formats
Reviewers not trained
No one responsible
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Slide125 Whys rules of thumb
State the problem clearly.
5 is the number at which most causes are clearly identified.
Do not worry about not meeting or exceeding 5 Whys.
Follow your thought process to decide how many Why’s you need to get to the point where the cause is evident.
This is an investigative process.
You don’t need to answer all Whys at once.
The outcome of 5 Whys (or other analysis) is a cause analysis,
not the resolution.
Corrective actions and effectiveness verification follow.
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