English 105 – Week 9!!

1. English 105 – Week 9!! Teri “of Doom” Tosspon

2. Grammar Review Part I – Revise/Edit • Read the student paper aloud to a partner. • Make sure each sentence is complete • NOT a Fragment or Run on. • Sentences have a subject, a verb, and a complete thought/idea. • Circle & correct the misused words (there, their, they’re) Part II - create an outline (separate paper)

3. Assignment • After break, gather in the commons for a demonstration. • You will need paper and writing utensil

4. Causal Analysis • Pg 274-286

5. What is Causal? Dictionaries tell you that – caus·al [ káwz'l ] 1. being or involving cause: involving or being the cause of something else or the relationship of cause and effect. 2. grammar expressing cause: expressing or indicating a cause or the relationship of cause and effect

6. What is Analysis? Dictionaries tell you that – a·nal·y·sis [ ə nálləssiss ](plurala·nal·y·ses) 1. close examination: the examination of something in detail in order to understand it better or draw conclusions from it.2. separation into components: the separation of something into its constituents in order to find out what it contains, to examine individual parts, or to study the structure of the whole.3. assessment: an assessment, description, or explanation of something, usually based on careful consideration or investigation.

7. What is a Cause? • One of the reasons for a problem which, when identified and corrected, will minimize the potential for the problem occurring.

8. What is Causal Analysis? • Causal analysis is the process of breaking down an event so that each part and causal factor in the event can be considered, examined, tracked and evaluated. • Analyzing lesser significant trends before they become major issues is a proactive process. • Causal analysis, by its very nature, is a reactive process

9. Causal Analysis is a tool. • Causal Analysis, properly implemented, will reveal thereal reasons for problems and help point out solutions. • Causal Analysisis the building block for determining corrective action. • The primary objective of Causal Analysis is to determine why problems occur, facilitate corrective actions, and prevent the recurrence of problems.

10. What is an Apparent Cause? • The most likely reason for a problem to have occurred based on a review of the relevant facts determined during the preliminary investigation. Note: We are not talking about an event; we are talking about a cause (problem) related to the event. In addition, this is not considered to be the last word until additional analysis has been performed.

11. The components of Causal Analysis Identify the Problem Problem Analysis Identify the Causes Solutions Identify the Corrective Actions

12. The components of Causal Analysis Problem Identify the Problem During this phase it is discovered that one of the Goals, Standards or Requirements of the organization has been violated. The balloon was popped

13. The components of Causal Analysis Analysis Identify the Causes This is the actual analysis phase. This is the stage where causes are identified and an outline is developed which shows how the relevant causes fit together. Because I had an education to get a job to get the money Because I had a pin Because I had a balloon Because I went to the store to get them Because I had the money to get them Because I had a job to get the money to get them

14. The components of Causal Analysis Solutions Identify the Corrective Actions This is where the causes are evaluated for possible solutions and where the best solutions are chosen to implement. You cannot get here until you have performed a thorough analysis. If you rush to a solution phase prematurely you will not prevent the problem from occurring again in the long term or even the short term forecast. Because I used a pin to pop the balloon Because I had an education to get a job to get the money Because I had a pin Because I had a balloon Because I went to the store to get them Because I had the money to get them Because I had a job to get the money to get them

15. Finding Causes All of us are problem solvers . . . although many of us may tend to think of our problem solving process as something less fancy than "cause analysis”.

16. Analyzing Problems Analyzing our problems is an effort we make to control and prevent: interruptions, production obstacles, and counter-quality occurrences. During this process we discover the causal factors that make up an unplanned event and recognize the possible causes for that event. Correcting such causes helps to prevent future reoccurrence.

17. How do I know when I am at a real cause(Or, when do I stop asking why?) • You may have taken root cause classes that tell you to keep asking “why” until you get to the problem, or until the factors are out of your control. • Where do you stop?

18. How do I know when I am at a causal stopping point? (Or, when do I stop asking why?) No policy or process for pre-launch inspection No pre-launch inspection performed Drain plug not installed Water entering through boat’s drain hole Cost impacted AND Bass-boat sunk at pier AND Owner relied on memory to prepare for launch Schedule Impacted Involved parties assumed plug to be in place AND Boat was launched into the water Looking at a Causal Map, you should normally stop asking “why” when you reach a point in which the problem is eliminated by: • The use of a process. • The improvement of a process. • Writing a process. Safety Impacted Boat not designed to operate when filled with water

19. Introduction to Cause and Effect Another method used for performing cause analysis is a method called Cause Mapping which involves investigating an event using the cause and effect approach. The following is some ideas and theory recommended for use when investigating an event.

20. Start Here Two Simple Problem Solving Tools Process Maps When a process doesn’t produce the desired results our first question should be “WHY?” These “WHY?” questions are the analysis of the problem. A map of the specific steps of a work process. The work process defines how the organization would like to conduct its business every day. The corrective actions after an investigation make specific changes to the work process. This is the cycle of Continuous Process Improvement. Cause Maps A map of the causes of a problem. The Cause Map is a visual explanation of why the organization didn’t get the desired results from their work process.

21. Tripped on Barrier Sprained Ankle Cause and Effect What did it cause What was it caused by Effect Cause Time flows from right to left This analysis moves backwards Time

22. Tripped on Barrier Did Not see Barrier Sprained Ankle Introduction to Cause and Effect What did it cause What was it caused by Cause/Effect Cause/Effect Cause/Effect Every effect is also a Cause Every Cause is also an effect Time

23. Stepping over Barrier Going to Station #4 Tripped on Barrier Did Not see Barrier Sprained Ankle Carrying Boxes Barrier in Path Introduction to Cause and Effect For every Effect there is a Cause

24. Stepping over Barrier Sprained Ankle Sprained Ankle Sprained Ankle Carrying Boxes Barrier in Path Introduction to Cause and Effect Was caused by All Are True! One point of view Was caused by Another point of view Was caused by Yet another point of view

25. 2+2 = 4 The Capital of Virginia is Richmond The amount of inches in a foot = 12 The most important component of a car? How many ways are there to New York? What is the best car to buy? Right Answer vs.System Thinking There is one correct answer There are many possible solutions

26. Cause and Effect For everything that happens there is a cause that sets the condition for it to happen, or prevents it from happening. Cause Effect

27. Cause and Effect Was caused by? Effect Cause Titanic Sank

28. Cause and Effect Why? Was caused by? Effect Cause Titanic Sank Ship Hit Iceberg

29. Cause Cause and Effect Why? Was caused by? Effect Cause Titanic Sank Ship Hit Iceberg

30. Cause and Effect Cause Why? Was caused by? Effect Cause Titanic Sank Ship Hit Iceberg Couldn't Turn Quickly Enough

31. Cause and Effect Cause Why? Was caused by? Effect Cause Titanic Sank Ship Hit Iceberg Couldn't Turn Quickly Enough Have we figured it out? Can we go back to work now? Will our people be safer? Are our people aware, smarter, better prepared? Will the cost of the mistake be minimized in the future and will the schedule interruption occur again?

32. How Many Causes ? Normally there is more than one cause for a particular event. In most cases there are a number of conditional factors that have to be present for the event to take place. Cause effect Cause Cause

33. The fire triangle (revisited) Effect Fire The fire triangle is a good example that demonstrates multiple causes for each effect (causal factor).

34. The fire triangle (revisited) Cause Effect Ignition source It illustrates the normal propensity toward multiple causes for a single effect. Fire

35. The fire triangle (revisited) Cause Effect Cause Ignition source Fire Fuel source Ask “What causes the effect to happen or occur?”

36. The fire triangle (revisited) Fuel source Cause Effect Cause Ignition source Cause Fire Ensure all apparent related causes are considered. Oxygen

37. The fire triangle (revisited) Fuel source Cause Effect Cause Ignition source Cause Fire Notice if you take one cause away…….., Oxygen

38. The fire triangle (revisited) Cause Effect Cause Ignition source Cause Fire Notice if you take one cause away, the effect cannot occur. Oxygen

39. The fire triangle (revisited) Fuel source Ignition source Fire Look for this recurring pattern in all cause and effect models. Oxygen

40. The fire triangle (revisited) Cause Effect Cause Ignition source Cause Fire Fuel source You will also notice causes you want to address and those that you may choose not to address. Oxygen

41. The fire triangle (revisited) Cause Effect Cause Ignition source Cause Fire Fuel source In this case, although oxygen is a cause, you may not choose to address it in your corrective actions Oxygen

42. The fire triangle (revisited) Cause Effect Cause Ignition source Cause Fire Fuel source However, the other two causes are items you will want to control, remove, fix or limit. Oxygen

43. The fire triangle (revisited) Cause Effect Cause Ignition source Cause Fire Fuel source Investigating and analyzing factors in such a manner allows us to uncover all relevant causes Oxygen

44. The fire triangle (revisited) Cause Was caused by? Effect Cause Was caused by? Ignition source Cause Fire Fuel source Insure you uncover all causes relevant to the problem you are analyzing. Oxygen

45. Cause and Effect Exercise Try to see if your thought process aligns with the logic of this exercise. Titanic Sank If the effect was the Titanic sinking, what was the cause?

46. Cause and Effect Exercise Titanic Sank Water Filled Hull If the effect was the hull filling with water, what was the cause?

47. Cause and Effect Exercise Titanic Sank Water Filled Hull Continue to follow the logic Ship in Water

48. Cause and Effect Exercise Why? Titanic Sank Water Filled Hull Ship in Water

49. Cause and Effect Exercise Opening in Hull Titanic Sank Water Filled Hull AND Ship in Water

50. Cause and Effect Exercise Why? Opening in Hull Titanic Sank Water Filled Hull AND Ship in Water