Root Cause Analysis Effective problem solving

1. Root Cause AnalysisEffective problem solving

2. While conventional root cause analysis tools provide some structure to the process of event problem solving, they are significantly limited and often work by chance not by design. Root Cause Analyses is becoming the standard for all event analysis because it is the only process that understands and follows the cause and effect principle. There are a number of methods that can be used to conduct RCA investigations; the preferred system we would recommend is the Apollo method.

3. The Apollo Method Introduced by Dean L Gano in the 1990,s, in his book, Apollo RCA Apollo Root Cause Analysis is about effective problem solving. It is truly a new way of thinking that will ensure effective solutions to almost any kind of problem. This method will enable people and organizations to effectively communicate and solve problems without the usual conflicts. This is a unique event-based problem solving method utilized by many Fortune 500 companies, Petro chemical companies, NASA, and the FAA. There is no other problem solving process like this.

5. Positives & Negatives • Benefits • The process is simple to follow allowing everyone in the organization to participate. • It creates a clear picture of what the causal relationships are, creating a situation where buy-in is easier to achieve. • Owing to the fact that each potential cause is reviewed, a thorough understanding of the problem is created to identify effective solutions. • The method is evidence-based meaning that opinions, bias and pre-conceived ideas are kept to a minimum • Shortcomings • Team • Time • Solution Follow-up • Problem Definition

6. The Apollo Methodology • Step 1: Define the Problem Statement. • Step 2: Create the Apollo Tree. • Step 3: Solution Development. • Step 4: Investigation Review.

7. Defining the Problem • What is defined as a “Problem”? • What event would warrant an RCA? • How should a problem be defined? • How would you describe the problem?

8. Required Preparation • RCA Participants For example. • System Operators • Company managers • Specialist • Process Control • HSE (Must be included in RCAs relating to injuries) • Facilitator It is his/ her responsibility to maintain the focus of the meeting on the RCA rather than other agendas regardless of how important they may be.

9. RCA Facilitation • Etiquette • Rule 1: RSVP • Rule 2: Preparation • Rule 3: Be on time • Facilitation

10. Creating the Apollo Tree • Starts with the Problem Definition • Causes – Action & Condition • Evidence – Timeline related, logical & factual • What, When. Where

11. A1 AA1 Evidence Evidence B1 No Evidence Root Cause 1 Evidence Caused by Caused by Problem Definition 2 A2 AA2 No Evidence Evidence Evidence 3 No Evidence

12. Interviews • Ask open ended questions • Don’t tape interviews • Don’t lead interviewee • Don’t try and answer question • Integrity of questions • Multiple interviews

13. Effective Solutions • Generating solutions • Identifying Effective Solutions • Assigning Action Items

14. Documentation

15. Questions

16. The 3 What's. 1,What could go wrong. 2,What could cause it to go wrong. 3,what can i/we do to prevent it from going wrong. 4, What contingencies can we make if it does go wrong