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Fault Tree Analysis: Conventional Wisdom Compared (Method) Fault tree analysis (FTA) is a quantitative causal diagram used to identify possible failures in a system. It is a common engineering tool used in the design stages of a project and works well to identify possible causal relationships. It requires the use of specific data regarding known failure rates of components. Causal relationships can be identified with “and” and “or” relationships or various combinations thereof. FTA does not function well as a root cause analysis method, but is often used to support an RCA. More about this later. Failure Modes and Effect Analysis: (Tool) Failure modes and effects analysis (FMEA) is similar to fault tree analysis in that it is primarily used in the design of engineered systems rather than root cause analysis. Like the name implies, it identifies a component, subjectively lists all the possible failures (modes) that could happen, and then makes an assessment of the consequences (effect) of each failure. Sometimes a relative score is given to how critical the failure mode is to the operability of the system or component. This is called FMECA, where C stands for criticality. <strong>RealityCharting</strong>: (Method) A simple causal process whereby one asks why of a defined problem, answers with at least two causes in the form of an action and condition, then asks why of each answer and continues asking why of each stated cause until there are no more answers. At that time, a search for the unknown is launched and the process is repeated several times until a complete cause-and-effect chart, called a Realitychart, is created, showing all the known causes and their interrelationships. Every cause on the chart has evidence to support its existence or a “” is used to reflect an unknown and thus a risk. All causes are then examined to find a way to change them with a solution that is within your control, prevents recurrence, meets your goals and objectives, and does not cause other problems. The result is clear causal connections between your solutions and the defined problem. Because all stakeholders can insert their causal relationships into the Realitychart, buy-in of the solutions is readily attained. 42
RCA Methods and Tools Compared Conventional Wisdom Compared Many purveyors of root cause analysis state the process is so complicated that you should use several of them for each problem or select them based on which type of problem you are experiencing. In researching the various proponents of this approach, I find that the reason some people think root cause analysis is so complicated is that they don’t understand the cause-and-effect principle. To quote Albert Einstein, “If you can’t say it simply, you probably don’t understand it.” Method/Tool Type Events & Causal Factors Method Yes Limited No No No No 1.5 Change Analysis Tool Yes No No No No No 1 Barrier Analysis Tool Yes No No No No No 1 Tree Diagrams Method Yes No No No No No 1 Why-Why Chart Method Yes No Yes No No No 2 Pareto Tool Yes No No No No No 1 Storytelling Method Limited No No No No No 0.5 Fault Tree Method Yes Yes Yes No Yes No 4 FMEA Tool Yes No Limited No Limited No 2 <strong>RealityCharting</strong> ® Method Yes Yes Yes Yes Yes Yes 6 Figure 2.2. Defines Problem Defines All Known Causes Provides A Causal Path To Root Causes Delineates Evidence Explains How Solutions Prevent Recurrence Easy To Follow Report Comparison of Selected RCA Methods and Tools Score Using the comparison criteria we established earlier, Figure 2.2. provides a summary of how each method or tool meets the criteria. One point is scored for each criterion that is met. “Limited” is scored as 0.5 points. While the comparison in Figure 2.2 serves to show how poorly these conventional tools and methods provide effective solutions, it does not tell the whole story, as explained below. Events and Causal Factor Charting can provide the time line to help discover the action causes, but is generally inefficient and ineffective because it mixes storytelling with conditional causes, thus it produces complicated relationships that are not necessarily causal and this only serves to add confusion rather than clarity. Instead of identifying the many causal relationships of a given event, events and causal factor charting resorts to categorizing the important causes as causal factors, 43
Page 1 and 2: Seven Steps To Effective Problem-So
Page 3 and 4: RealityCharting Seven Steps to Effe
Page 5 and 6: To all who value learning 3
Page 7 and 8: Table of Contents Fault Tree Ana
Page 9 and 10: Table of Contents Corrective Act
Page 11 and 12: Preface At the time of my first boo
Page 13 and 14: Acknowledgments This book is the pr
Page 15 and 16: Introduction Introduction If You Ha
Page 17 and 18: Personal Success Introduction Succe
Page 19 and 20: Paradigm Shift In his highly succes
Page 21 and 22: 19 Paradigm Shift incorporated into
Page 23 and 24: 3. Hydrocarbons ignited on Deepwate
Page 25 and 26: Paradigm Shift The following mainte
Page 27 and 28: Paradigm Shift Action Sealing Cemen
Page 29 and 30: Common Sense Paradigm Shift When th
Page 31 and 32: Paradigm Shift Synapse Nearby Neuro
Page 33 and 34: Paradigm Shift but are subject to c
Page 35 and 36: Paradigm Shift Why Cause/ Effect Wh
Page 37 and 38: 35 Paradigm Shift only our own arro
Page 39 and 40: 2 Conventional Wisdom Compared Igno
Page 41 and 42: Conventional Wisdom Compared Note:
Page 43: Conventional Wisdom Compared After
Page 47 and 48: Conventional Wisdom Compared causes
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Page 51 and 52: Conventional Wisdom Compared Conseq
Page 53 and 54: 3 Understanding the Cause-and-Effec
Page 55 and 56: Understanding the Cause-and-Effect
Page 65 and 66: Action Road Constructed Understandi
Page 73 and 74: Step One: Define the Problem The fi
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Page 81 and 82: Step Two: Determine the Causal Rela
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Step Three: Provide a Graphical Rep
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Step Three: Provide a Graphical Rep
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7 Step Four: Provide Evidence Don
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Step Four: Provide Evidence Conditi
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Step Four: Provide Evidence as such
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Step Four: Provide Evidence has abs
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Step Five: Determine if Causes Are
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Step Six: Identify Effective Soluti
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n n n n Step Six: Identify Effectiv
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Step Seven: Implement and Track Sol
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Step Seven: Implement and Track Sol
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Effective Problem-Solving Culture T
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Effective Problem-Solving Culture r
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Effective Problem-Solving Culture a
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Effective Problem-Solving Culture e
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Effective Problem-Solving Culture U
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Effective Problem-Solving Culture e
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Facilitation Skills Do not confuse
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Facilitation Skills broken parts an
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Facilitation Skills 1. Everyone sho
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Facilitation Skills investigation m
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Facilitation Skills forum works bes
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Facilitation Skills line of questio
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Facilitation Skills of interrogatio
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Facilitation Skills Review your not
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n n n n Used favorite indication in
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n n n n n n Facilitation Skills Rat
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Parochial Mindset Facilitation Skil
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Facilitation Skills a common proble
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Facilitation Skills For the person
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How do I prevent manipulation of th
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Facilitation Skills Let the storyte
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Success and Serendipity 13 Success
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Success and Serendipity If we look
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Success and Serendipity While “se
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Success and Serendipity To help us
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Success and Serendipity unknown. To
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Success and Serendipity provides ma
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187 Success and Serendipity path be
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and arrogance. To avoid this trap,
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14 A New Way of Thinking A New Way
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Like the evolution of mathematics,
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About the Author Dean L. Gano is pr
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