Casual factor charting

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A Note About Continuous Assessment

The continuous assessment mark for this
course will be based on three components:
– Your journal entries
– Submission of a document in which you will
describe a group problem solving experiment
– A presentation which you will give in class
You don’t need to start working on the latter
two just yet
For now start thinking about groups and
possible problems to solve

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The M.Sc. Reading Group
On an M.Sc. course experience in
reviewing academic papers/
articles is extremely important
A reading group will be started to
help with this
This will help when you get to the case study
module on the course
Papers will be selected and discussions will
take place both on-line and in lectures
More will follow shortly…

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Brainstorming Ideas Review
Excellent Interesting Useless
• Discounts • Connect artists • Bring back vinyl
• Price material with different • TV ads in Iran
encouragingly markets • Kidnap bands
• Subscription service • Develop streaming- • Kidnap
for downloads only technology downloaders as an
• Cheaper in bulk • Distribute music for example
• Downloads give multiple cultures • Brain implants
concert discounts • Secondary sales • Subliminal
• Sell iPods with pre- • Competitions with messages on vinyl
loaded music downloads records
• Subscriptions to • Diversify into iPods • MUSIC SHOULD BE
charts while they are • Stop players sharing FREE
there music • Sabotage
• Sell broadcast • iPod Jukebox downloads with
concerts online white noise

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Brainstorming Ideas Review
Some interesting things to note:
– There was only one unanimous choice in both
the interesting and excellent categories
– The ideas that inspired most disagreement:
• Downloads don't last forever
• Free pint with ten songs
• Free download with X (beer, bananas, sandwiches)
• Convert politician’s speeches into rap songs
– We rejected the brain implants!
• In 2002 there was something of a
scandal over the falsified invention
of a tooth implant!

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Force Field/S.W.O.T. Analysis Feedback

Any comments questions about last week?

Problem Solving,
Communication
& Innovation:
Root Cause
Analysis

Course Website: http://www.comp.dit.ie/bmacnamee

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Contents
In today’s lecture we are going to look at
Root Cause Analysis
– What is root cause analysis?
– Origins of root cause analysis
– Is this important for software/knowledge
management?
– Major steps in root cause analysis
– Root cause analysis example
– When to use root cause analysis
– Impediments to root cause analysis

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Root Cause Analysis
Root Cause Analysis (RCA) is a process
deigned to help determine the causes of
events – typically bad events!
Root cause analysis gets us past what and
how to why
Only by knowing why an event happened
can we hope to prevent it happening in the
future
Treat the cause not the symptoms

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Root Cause Analysis Example
Scenario # 1: The Plant Manager walked into the
plant and found oil on the floor. He called the
Foreman over and told him to have maintenance
clean up the oil. The next day while the Plant
Manager was in the same area of the plant he
found oil on the floor again and he subsequently
raked the Foreman over the coals for not following
his directions from the day
before. His parting words were to
either get the oil cleaned up or
he'd find someone that would.

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Root Cause Analysis Example (cont…)

Scenario # 2: The Plant Manager walked into the
plant and found oil on the floor. He called the
Foreman over and asked him why there was oil on
the floor. The Foreman indicated that it was due to
a leaky gasket in the pipe joint above. The Plant
Manager then asked when the gasket had been
replaced and the Foreman responded that
Maintenance had installed 4 gaskets over the past
few weeks and they each one seemed to leak. The
Foreman also indicated that Maintenance had
been talking to Purchasing about the gaskets
because it seemed they were all bad.

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The Plant Manager then went to talk with
Purchasing about the situation with the gaskets.
The Purchasing Manager indicated that they had
in fact received a bad batch of
gaskets from the supplier. The
Purchasing Manager also
indicated that they had been
trying for the past 2 months to
try to get the supplier to make
good on the last order of 5,000 gaskets that all
seemed to be bad.

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The Plant Manager then asked the Purchasing
Manager why they had purchased from this
supplier if they were so disreputable and the
Purchasing Manager said because they were the
lowest bidder when quotes were
received from various suppliers.
The Plant Manager then asked
the Purchasing Manager why
they went with the lowest bidder
and he indicated that was the
direction he had received from the VP of Finance.

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The Plant Manager then went to talk to the VP of
Finance about the situation. When the Plant
Manager asked the VP of Finance why Purchasing
had been directed to always take the lowest bidder
the VP of Finance said, "Because you indicated
that we had to be as cost conscious as possible!"
and purchasing from the lowest bidder saves us
lots of money. The Plant Manger was horrified
when he realized that he was the reason there was
oil on the plant floor.

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What About Ireland’s Woes?

Staunton Out!
What is the root cause of all of our problems?
Will sacking the manager do any good?
Will dropping the players do any good?
Is it all the fans fault?

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Origins Of Root Cause Analysis
Root cause analysis is not one well defined
technique, but rather a general philosophy
The origins of root cause analysis stem from
the following areas:
– Safety-based: accident investigation, health
& safety
– Production-based: quality control
– Process-based: business processes outside
of manufacturing
– Systems-based: organisational culture,
strategic management

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General Principles Of Root Cause
48 Analysis
The general principles of root cause analysis
are:
– Aiming corrective measures at root causes is
Based on “Root Cause Analysis Handbook”, ANS Consulting

more effective than merely treating the
symptoms of a problem
– To be effective, RCA must be performed
systematically, and conclusions must be
backed up by evidence
– There is usually more than one root cause for
any given problem

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What Is A Root Cause?
There is substantial debate on the definition
of root cause
The following is useful:

– Root causes are specific underlying causes
– Root causes are those that can reasonably
be identified
– Root causes are those we have control to fix
– Root causes are those for which effective
recommendations for preventing recurrences
can be generated

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Causes Of Problems
There are different kinds of causes can be
broken down as follows:
– Physical Causes are the tangible causes of
failures
– Human Causes almost always trigger a
physical cause of failure – these could be
errors of commission (we did something we
shouldn’t do) or omission (we didn’t do
something we should have done)
– Latent Causes (or Organisational Causes)
are the organisational systems that people
used to make their decisions

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But This All Just Sounds Like Common
48 Sense!
Common Sense is not particularly common
We all have a different notion of common
Based on Apollo Root Cause Analysis: A New Way Of Thinking, D Gano

sense because of:
– Our unique senses
– Our unique knowledge
– Our unique strategies
– Our unique conclusions
Number series experiment

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Root Cause Analysis &
48 Software/Computing?
This all sounds like something people in
factories should worry about – but we are
“History's Worst Software Bugs”, Simson Garfinkel

make software!
In 2002 Wired.com published an interesting
article on history’s worst software bugs
– July 28, 1962 Mariner I Space Probe: A bug in the
flight software for the Mariner 1 causes the rocket to
divert from its intended path on launch
– 1982 Soviet Gas Pipeline: Operatives working for the
Central Intelligence Agency allegedly plant a bug in a
Canadian computer system purchased to control the
trans-Siberian gas pipeline
– 1985-1987 Therac-25 medical accelerator. A
radiation therapy device malfunctions and delivers
lethal radiation doses at several medical facilities

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48 Software/Computing? (cont…)
– 1988 Buffer Overflow in Berkeley Unix Finger
Daemon: The first internet worm (the so-called Morris

Worm) infects between 2,000 and 6,000 computers in
less than a day by taking advantage of a buffer
overflow
– 1988-1996 Kerberos Random Number Generator:
The authors of the Kerberos security system neglect to
properly "seed" the program's random number
generator with a truly random seed
– January 15, 1990 AT&T Network Outage: A bug in a
new release of the software that controls AT&T's long
distance switches causes these mammoth computers
to crash when they receive a specific message from
one of their neighbouring machines

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– 1993 Intel Pentium Floating Point Divide: A silicon
error causes Intel's highly promoted Pentium chip to

make mistakes when dividing floating-point numbers
that occur within a specific range
– 1995/1996 The Ping of Death: A lack of sanity checks
and error handling in the IP fragmentation reassembly
code makes it possible to crash a wide variety of
operating systems by sending a malformed "ping"
packet from anywhere on the internet
– June 4, 1996 Ariane 5 Flight 501: Working code for
the Ariane 4 rocket is reused in the Ariane 5, but the
Ariane 5's faster engines trigger a bug in an arithmetic
routine inside the rocket's flight computer

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– November 2000 National Cancer Institute, Panama
City: In a series of accidents, therapy planning

software created by Multidata Systems International, a
U.S. firm, miscalculates the proper dosage of radiation
for patients undergoing radiation therapy
We should worry about this kind of thing in
software!

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Major Steps In Root Cause Analysis
There are four major steps in root cause
analysis:
– Data collection
Based on “Root Cause Analysis Handbook”, ABS Consulting

– Causal factor charting
– Root cause identification.
– Recommendation generation and
implementation

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Root Cause Analysis Steps:
48 Data Collection
The first step in root cause analysis is to
gather as much data as possible
Without complete information how can we

hope to find the root causes?
Data gathering consumes most of the time
in root cause analysis

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48 Causal Factor Charting
Causal factor charting provides a structure
for us to organise and analyse the data
gathered during the investigation

Preparing the chart begins as soon as we
start to gather data
The chart should show all of the information
that we know in a sequence diagram leading
up to the event we are investigating
Actors involved Actors involved Actors involved Actors involved Actors involved

Event Event Event Event Event
information information information information information
Timing info Timing info Timing info Timing info Timing info

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48 Causal Factor Charting (cont…)
The chart should begin as a skeleton
working backwards from the event we are
investigating

As more information arises it should be
added to the chart
Causal factors are those contributors that, if
eliminated, would have prevented the
occurrence
A causal factor chart can help us identify
gaps in our knowledge

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48 Root Cause Identification
After all factors have been identified, root
cause identification begins
Root causes are often identified by following

a chain of events to its beginning
Remember there will often be more than one
root cause
Tools such as the Root Cause Map (from
the “Root Cause Analysis Handbook”) can
be used to help identify root causes
for each cause factor follow the map to see
if this is a root cause

29 Start Here With Each Causal Factor
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Equipment
Difficulty

Equipment Equipment Installation/ Equipment
Design Problem Reliability Program Fabrication Misuse
Problem

Equipment
Design Equipment Reliability
Input/Output Records Program Procedures
Implementation

Equipment Administrative &
Reliability Management
Program Design Systems

30 Here With Each Causal Factor
Start
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Personnel Other
Difficulty Difficulty

Company Contract External Natural Sabotage/
Other
Employee Employee Events Phenomenon Horseplay

Human Factors
Engineering
Training Communications

Personal Immediate
Performance Supervision

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Following the identification of a root cause
recommendations for preventing its
recurrence should be made
The recommendations should be achievable
and must be implemented
If recommendations are not implemented
then the analysis is a waste of time and the
event should be expected to recur

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Example
“It was 5 p.m. I was frying chicken. My friend Jane
stopped by on her way home from the doctor, and
she was very upset. I invited her into the living
room so we could talk. After about 10 minutes, the
smoke detector near the kitchen came on. I ran
into the kitchen and found a fire on the stove. I
reached for the fire extinguisher and pulled the
plug. Nothing happened. The fire extinguisher was
not charged. In desperation, I threw water on the
fire. The fire spread throughout the kitchen. I called
the fire department, but the kitchen was destroyed.
The fire department arrived in time to save the rest
of the house.”

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Fire starts on
Mary Mary the stove Mary Mary Mary

Mary leaves Mary runs Mary tries to Fire extinguisher
Mary begins Smoke alarm
frying chicken into the use the fire does not operate
frying chicken Jane, Mary sounds
alone kitchen extinguisher when Mary tries it
17:00 Mary chats About 17:10
with Jane
10 minutes

Mary Kitchen, Mary Mary, FB FB

Mary throws Fire spreads Kitchen
Mary calls the Fire brigade Fire brigade
water on the throughout destroyed by
fire brigade arrives puts out fire
fire the kitchen fire
Time? Time? Time?

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What was
Did Mary
Jane
know this
doing
was
Did Mary during this
wrong?
do time?
Mary, pan
anything
else?
Fire was a How long Did the FB
Was grease fire did it take use the
Mary correct
the FB to
trying to techniques?
arrive?
do this?



Burner
35 Electric
of burner
shorts out
48
Pan

Arcing heats
bottom of
aluminium pan

Pan
Was it
Aluminium originally
Jane melts forming charged?
hole in pan
Jane comes Had it
to the door leaked?
What Had it
Conclusion exactly been
Grease ignites did she previously
see? used?
Jane when it hits the Assumption Mary Mary
How burner
Fire Fire
much Jane rings Mary sees
generates extinguisher
oil? How the doorbell fire on stove
much
smoke not charged
chicken?
Fire starts on

17:00 Mary chats About 17:10
with Jane
Mary Mary
10 minutes Does Mary
Mary uses Is plug Mary pulls the know how to
an aluminium the same plug on fire use an
pan as pin? extinguisher extinguisher?

36 Pan
Pan Burner
Aluminium Arcing heats
of Jane melts forming bottom of
Electric
burner
hole in pan
48 Jane comes aluminium pan shorts out
to the door CF
Conclusion

Grease ignites
Jane when it hits the Assumption Mary Mary
burner
Fire Fire
Jane rings Mary sees
generates extinguisher
the doorbell fire on stove
smoke not charged

Fire starts on

17:00 CF Mary chats About 17:10
CF
with Jane
Mary Mary
10 minutes
Mary uses Mary pulls the
an aluminium plug on fire
pan Mary, pan extinguisher
Fire was a
grease fire


CF

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Root Cause Summary Table
Causal Factor 1 Recommendations
Description: Mary leaves the frying • Implement a policy that hot oil is never left
chicken unattended unattended on the cooker
• Determine whether policies are required for
other types of hazards

Description: Electric burner element • Replace all burners on cookers
fails (burns out) • Develop a preventative maintenance
strategy to periodically replace burner
elements
• Consider alternative, less hazardous
methods for preparing chicken

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Root Cause Summary Table (cont…)
Description: Fire extinguisher does • Refill fire extinguisher
not operate when Mary tries to use it • Inspect all fire extinguishers in the building
to make sure they are full
• Ensure a safety equipment audit is properly
in place

Description: Mary throws water on • Provide practical training on the use of fire
fire extinguishers
• Review overall training plan

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Root Cause Analysis Exercise
“This week DIT suffered a massive e-mail
failure. The hard-drive on our mail server
crashed and the contents of all mail boxes
were lost. Furthermore all e-mails arriving
over the following days were lost with no
indication given to senders that they were not
received. When back-ups were sought the last
back-up had been made 5 months before”
Let’s do a root cause analysis of this event
For this exercise I will have to act as an oracle
for our investigation – sorry!

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Impediments To Root Cause Analysis

There are a number of reasons why people
don’t like root cause analysis:
– This is great, but I don’t have time for this….
– Inability or unwillingness to tackle the bigger
issues
– Fear of being “blamed” for making an error

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This Is Great, But I Don’t Have Time For
48 This….
There is not one of us that does not have
more things to do than we have time to
perform
“If you haven’t got time to stop these
failures from recurring, how are you going
to find the time to keep fixing them?”

If you have ever tried test-driven-development
it offers the same value proposition

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Inability Or Unwillingness To Tackle The
48 Bigger Issues
The most effective solutions are those that
address the latent (or organisational) causes
of problems
These solutions typically require changes to
underlying organisational systems,
processes and beliefs and so require more
time, effort, and management clout to
implement
Often small root cause analysis teams are
reluctant or unable to identify these issues
as potential causes

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Fear Of Being Blamed For Errors
Root cause analysis often involves
identifying errors committed by individuals -
this can be terrifying
Bad use of root cause analysis can quickly
devolve into the blame game
It is worth thinking briefly about whether
blaming people is of any use to us

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Regarding human error many of us believe:
– Human error is infrequent
“Getting Root Cause Analysis to Work for You”, Alexander (Sandy) Dunn

– Human error is intrinsically bad
– A few people are responsible for most of the
human errors
– The most effective way of preventing human
error is through disciplinary actions
So, we allocate blame and then seek to
prevent recurrence through disciplinary
actions

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However many behavioural psychologists
are now showing:

– Human error is inevitable
– Human error is not intrinsically bad
– Everybody commits errors
– Blame and punishment is almost always
inappropriate
So we shouldn’t blame individuals but rather
seek to find the latent causes – using root
cause analysis?

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Teams And Root Cause Analysis
Advantages of team-based problem-solving:
– Those closest to the work know best how to

perform and improve their jobs
– Application of a broader range of knowledge
from multiple disciplines
– Broader, more creative solutions
– Greater chance of risk-taking
– Teams tend to be more successful in
implementing complex plans
– Higher level of ownership of results
This is all true for root cause analysis

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Root Cause Analysis Summary
Root cause analysis is a problem solving
technique which can be used to find the
reasons why an event occurred
There are four major steps:
– Data collection
– Causal factor charting
– Root cause identification.
– Recommendation generation and
implementation

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Exercise
Into your problem solving journals, write a ½
page – full page on your thoughts about
force field analysis, SWOT analysis and root
cause analysis
In particular focus on how useful you feel the
techniques are – does the formalism help, or
is it just “common sense” dressed up in a
fancy coat?

Casual factor charting

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