Tie RCA & 5 Whys Technique Triggers To Strategic Objectives

Tie RCA RCA & 5 Whys Technique Triggers To Strategic Objectives Ahmed Mustafa Ali Eltayef, October 6th. 2020 Normally, unplanned incident need to be investigated to find out the problem causing & to overcome / eliminate failures repeating.... 5 Whys technique is to resolve simple or moderately difficult problems. It is quick, timesaving & efficient technique... RCA or formal RCA is used for more complex or critical problems and it is time-consuming, costly, etc.. that’s why triggers mechanism are critical to the success of an RCA program. This article highlight RCA trigger mechanism + 5 Whys technique methodology. Tie RCA Triggers To Strategic Objectives RCA, normally triggered by an unplanned incident or event which falls into any of the safety, environment, production, quality, equipment failure or similar categories. When deciding on trigger events to initiate a root cause analysis (RCA), it is important to keep in mind your organization’s strategic objectives. Many organizations might have trigger events in place, but they are often poorly defined or infrequently reviewed for optimization. For example, consider an organization who has poorly defined RCA triggers in place leading to a high number of failure events that require an RCA study. There are two scenarios that can play out: either the organization drains its time, resources, and manpower to constantly problem solve and complete RCAs while ignoring other responsibilities. Or more realistically, commit to participating in a smaller number of RCA studies because there are other job functions needed to be performed. The latter would lead to a huge backlog of failure events to accumulate because there is not enough time and resources for the huge amount of problem solving required for the high number of failure events requiring RCA. This is why triggers are critical to the success of an RCA program. Page 1 Triggers should reflect your facilitation resources – the knowledge of your facilitators, the financial resources and time accessible to deliver the fixes, and the availability of stakeholders to join the RCA investigation. Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Triggers must match business objectives, and most organizations would typically include: 1- Production Loss/Downtime For production loss triggers, periodically review to evaluate the benefit of performing an RCA versus the costs associated. It is possible that some no longer makes financial sense to trigger analysis. 2- Health and Safety If it is OSHA recordable, high potential near miss or first aid is required, an RCA investigation is required by default. 3- Environment Non-compliance with applicable environmental requirements can have serious repercussions for any organization as it can lead to a license or permit suspension. 4- Repair Cost Similar to production loss triggers, you must identify the level of effort that is required to resolve the risk concerning repair costs. In other words, a Cost-Benefit Analysis. Every time an organization investigates a failure event, there is a cost to the organization in the form of man-power and corrective actions. These costs should not be greater than the monetary benefit gained from preventing future occurrences. 5- Frequency Often, smaller failure events can go unnoticed and unaddressed. Accurately tracking the frequency of specific equipment failure will ensure chronic issues are tackled and do not drain resources. 6- Product Quality/Customer Complaints Reputation and customer relationships are critical strategic objectives for practically any organization. Investigate events that lead to any sort of complaint or loss of a customer/contract. Page 2 ------------------------------------------------------------------------------------- Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Establish a Clear Trigger Mechanism Foundation There is no guarantee that any investigations will get done. This is where the definition of insanity applies – “doing the same thing over and over – and expecting different results” – so something must change. If there is no reason to perform an investigation, then things will continue to happen as they always have. This is where different way of thinking must truly come into play to counteract the status…. Time needs to be spent to develop a trigger system that will initiate the analysis, as well as a trigger a system of review and verification that the actions will be followed through. We need to establish Clear Trigger Mechanism… See below samples… A sample trigger system might look something like the example shown in Figure II below: Page 3 Figure II, General RCA trigger mechanism: Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Adjust Trigger Regularly It is important to realize that the above general RCA trigger mechanism is generic and encompasses many different issues that may plague a facility. The actual triggers should be adjusted to combat the items that are most significant to the facility. We must also be aware that spending a lot of time identifying what to work on may be counterproductive. People can spend weeks collecting data to identify where to apply their problem solving, but during that time, could have fixed multiple immediate problems. This immediate method is mostly applicable to an area, department, or plant that is in a reactive mode and is being bombarded with multiple repetitive problems. So be cautious about falling into “analysis paralysis” by getting bogged down with data collecting if the building is on fire!. A sample adjusted trigger mechanism for production loss analysis might look something like the example shown in Figure II below: Page 4 Figure II, Modified RCA trigger mechanism for PLA: Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 5 Whys technique methodology If based on RCA trigger mechanism, no formal RCA required, then 5Whys 5 Whys technique is to resolve simple or moderately difficult problems. It is quick, timesaving & efficient technique... Getting to the Root of a Problem Quickly Have you ever had a problem that refused to go away? No matter what you did, sooner or later it would return, perhaps in another form. Stubborn or recurrent problems are often symptoms of deeper issues. "Quick fixes" may seem convenient, but they often solve only the surface issues and waste resources that could otherwise be used to tackle the real cause. In this article, we look at the 5 Whys technique (sometimes known as 5Y). This is a simple but powerful tool for cutting quickly through the outward symptoms of a problem to reveal its underlying causes, so that you can deal with it once and for all. Origins of the 5 Whys Technique Sakichi Toyoda, the Japanese industrialist, inventor, and founder of Toyota Industries, developed the 5 Whys technique in the 1930s. It became popular in the 1970s, and Toyota still uses it to solve problems today. Toyota has a "go and see" philosophy. This means that its decision making is based on an indepth understanding of what's actually happening on the shop floor, rather than on what someone in a boardroom thinks might be happening. The 5 Whys technique is true to this tradition, and it is most effective when the answers come from people who have hands-on experience of the process or problem in question. The method is remarkably simple: when a problem occurs, you drill down to its root cause by asking "Why?" five times. Then, when a counter-measure becomes apparent, you follow it through to prevent the issue from recurring. Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Page The 5 Whys uses "counter-measures," rather than "solutions." A counter-measure is an action or set of actions that seeks to prevent the problem from arising again, while a solution may just seek to deal with the symptom. As such, counter-measures are more robust, and will more likely prevent the problem from recurring. 5 Note: When to Use a 5 Whys Analysis You can use 5 Whys for troubleshooting, quality improvement, and problem solving, but it is most effective when used to resolve simple or moderately difficult problems. It may not be suitable if you need to tackle a complex or critical problem. This is because 5 Whys can lead you to pursue a single track, or a limited number of tracks, of inquiry when, in fact, there could be multiple causes. In cases like these, a wider-ranging method such as Cause and Effect Analysis or Failure Mode and Effects Analysis may be more effective. This simple technique, however, can often direct you quickly to the root cause of a problem. So, whenever a system or process isn't working properly, give it a try before you embark on a more in-depth approach – and certainly before you attempt to develop a solution. The tool's simplicity gives it great flexibility, too, and 5 Whys combines well with other methods and techniques, such as Root Cause Analysis . It is often associated with Lean Manufacturing , where it is used to identify and eliminate wasteful practices. It is also used in the analysis phase of the Six Sigma quality improvement methodology. How to Use the 5 Whys 5 Whys Technique follows a very simple seven-step process: 1. Assemble a Team Gather together people who are familiar with the specifics of the problem, and with the process that you're trying to fix. Include someone to act as a facilitator, who can keep the team focused on identifying effective counter-measures. 2. Define the Problem If you can, observe the problem in action. Discuss it with your team and write a brief, clear problem statement that you all agree on. For example, "Team A isn't meeting its response time targets" or "Software release B resulted in too many rollback failures." Page 6 Then, write your statement on a whiteboard or sticky note, leaving enough space around it to add your answers to the repeated question, "Why?" Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 3. Ask the First "Why?" Ask your team why the problem is occurring. (For example, "Why isn't Team A meeting its response time targets?") Asking "Why?" sounds simple, but answering it requires serious thought. Search for answers that are grounded in fact: they must be accounts of things that have actually happened, not guesses at what might have happened. This prevents 5 Whys from becoming just a process of deductive reasoning, which can generate a large number of possible causes and, sometimes, create more confusion as you chase down hypothetical problems. Your team members may come up with one obvious reason why, or several plausible ones. Record their answers as succinct phrases, rather than as single words or lengthy statements, and write them below (or beside) your problem statement. For example, saying "volume of calls is too high" is better than a vague "overloaded." 4. Ask "Why?" Four More Times For each of the answers that you generated in Step 3, ask four further "whys" in succession. Each time, frame the question in response to the answer you've just recorded. Tip: Try to move quickly from one question to the next, so that you have the full picture before you jump to any conclusions. Page 7 In figure, 1, the diagram, below, shows an example of 5 Whys in action, following a single lane of inquiry. Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Page 8 Figure 1 Whys Example (Single Lane) Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 The 5 Whys method also allows you to follow multiple lanes of inquiry. An example of this is shown in Figure 2, below. In our example, asking "Why was the delivery late?" produces a second answer (Reason 2). Asking "Why?" for that answer reveals a single reason (Reason 1), which you can address with a counter-measure. Similarly, asking "Why did the job take longer than expected?" has a second answer (Reason 2), and asking "Why?" at this point reveals a single reason (Reason 1). Another "Why?" here identifies two possibilities (Reasons 1 and 2) before a possible counter-measure becomes evident. There is also a second reason for "Why we ran out of printer ink" (Reason 2), and a single answer for the next "Why?" (Reason 1), which can then be addressed with a counter-measure. Page 9 Figure 2, Whys Example (Multiple Lanes) Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Step 5. Know When to Stop You'll know that you've revealed the root cause of the problem when asking "why" produces no more useful responses, and you can go no further. An appropriate counter-measure or process change should then become evident. (As we said earlier, if you're not sure that you've uncovered the real root cause, consider using a more in-depth problem-solving technique like Cause and Effect Analysis, Root Cause Analysis, or FMEA) If you identified more than one reason in Step 3, repeat this process for each of the different branches of your analysis until you reach a root cause for each one. Tip 1: The "5" in 5 Whys is really just a "rule of thumb" In some cases, you may need to ask "Why?" a few more times before you get to the root of the problem. In other cases, you may reach this point before you ask your fifth "Why?" If you do, make sure that you haven't stopped too soon, and that you're not simply accepting "knee-jerk" responses. The important point is to stop asking "Why?" when you stop producing useful responses. Tip 2: As you work through your chain of questions, you may find that someone has failed to take a necessary action. The great thing about 5 Whys is that it prompts you to go further than just assigning blame, and to ask why that happened. This often points to organizational issues or areas where processes need to be improved. 6. Address the Root Cause(s) Now that you've identified at least one root cause, you need to discuss and agree on the counter-measures that will prevent the problem from recurring. 7. Monitor Your Measures Page 10 Keep a close watch on how effectively your counter-measures eliminate or minimize the initial problem. You may need to amend them, or replace them entirely. If this happens, it's a good idea to repeat the 5 Whys process to ensure that you've identified the correct root cause. Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Key Points The 5 Whys strategy is a simple, effective tool for uncovering the root of a problem. You can use it in troubleshooting, problem-solving, and quality-improvement initiatives. Start with a problem and ask why it is occurring. Make sure that your answer is grounded in fact, and then ask the question again. Continue the process until you reach the root cause of the problem, and you can identify a counter-measure that will prevent it from recurring. Bear in mind that this questioning process is best suited to simple or moderately difficult problems. Complex problems may benefit from a more detailed approach, although using 5 Whys will still give you useful insights. Page 11 Figure 3, below, show 5Whys brainstorming board: Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 5 Causal Questions Problem Solving Tool: Guide & Tips The 5 Causal Questions Problem Solving Tool is an every-day tool that applies Causal Reasoning fundamentals to a problem. This ensures that we are clear about what problem we are solving, have evidence about the causes of the problem, and develop solutions that address the causes of the problem. What is Casual Reasoning? There are three types of reasoning:  Defensive Reasoning • Determining what failed, was missed, or was wrong. • Ex. “The wrong piping was installed.”, “The operator skipped the step in the procedure” • Clue words: no, wrong, incorrect, missing, not (didn’t, couldn’t, wasn’t, etc.)  Solution Reasoning • Determining what action to take to fix or prevent the problem. • Ex. “We need to use stainless steel piping for this service.”, “Operators should initial the checklist after each step of the procedure” • Clue words: need to, should, could  Causal Reasoning • Determining what actually happened to cause a problem • Ex. “Carbon steel piping was installed”, “The operator closed Valve A while the pump was running” Remember to use Causal Reasoning while using the 5 Causal Questions Tool. Tip: Do you see any of the clue words from defensive or solution reasoning in the first three questions of your 5 Causal Questions? If so, revisit that section of the tool and apply Causal Reasoning instead. Page 12 Tip: Always use past tense when using Causal Reasoning. Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020 Use the 5 Causal Questions Tool by answering the questions below. 1. What is the Problem? A problem is something undesirable that happened that was different than what we expected to happen. The answer should include a description of what actually happened and what we expected to happen in that situation. Use causal reasoning! 2. What do we think caused the problem? List the causes of the problem. Use the 5 Why’s Method to dive deeper into the causes. Remember to use causal reasoning. Tip: Stuck on this section? Consider creating a high level Cause Tree Tip: What if you have multiple theories about what happened? Record them each here and use question 3 to examine the strength of the evidence for each theory. 3. What evidence do we have about the causes? Assess how certain you are that you know the causes of the problem. Before considering solutions, make sure that we have good quality data and have done enough analysis to verify the causes. Remember to use causal reasoning. Tip: Consider using the Data Quality Ladder to assess your evidence. If you find that your evidence is mostly low on the ladder, consider other causal theories before creating solutions. 4. What solution(s) do we have in mind? Only answer this question once you feel the first three questions have been satisfactorily answered. Be clear about what solutions or actions we have in mind. The solution should be sustainable and consider other areas on site that may have similar risk in place. Tip: Consider using the Systems of Safety to help determine strong solutions. Tip: Stuck on this section? Use the Recommendation Tool to brainstorm solutions. Page It’s important to test whether the proposed solution would be corrective. Does the solution actually eliminate the cause of the problem and prevent the problem from happening again? Does the solution introduce any new potential problems? Tip: A good way to check whether the solution is corrective is to imagine that the solution had already been in place before the problem occurred. Ask yourself exactly how the event would have played out instead. 13 5. How will the solution(s) eliminate the causes of the problem? Tie RCA & 5 Whys Technique Triggers To Strategic Objectives, Ahmed Mustafa Ali Eltayef, October 6th. 2020