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Step Two: Determine the Causal Relationships
strategies. Have faith in the process and, just like the jigsaw puzzle, with
a little patience and tenacity, the picture will become clearer each time
you repeat the steps.
When the Realitychart is finished, there is usually only one primary
effect left. If you have some causes left over, chances are they are part of
another problem, or you have chosen to separate different parts of the
event.
The more complicated the event, the greater the chance of
multiple primary effects. Remember, because of the cause-and-effect
principle, all causes are connected with all other causes in some way.
Trying to show these connections may make your understanding of
the problem too complicated. If the problem is as big as an elephant,
how should we eat the elephant One bite at a time, of course. Eating
it whole would be impossible, so we need to divide the problem into
smaller parts by focusing on separate primary effects. We call this
“chunking” and it allows each part of a problem to be assigned to
different teams.
As we learned in chapter one, in the Deepwater Horizon Oil Well
Incident, the investigators found eight key findings and four critical
factors. Each one of these would be a good place to start a Realitychart.
Figures 5.2 and 5.3 provide an example of this. As we continue to ask and
answer the why questions, we will find more and more causes and the
picture becomes clearer. Some of these Realitycharts will combine and
others may not.
Action
Nitrogen
Migrated
Primary Effect
Annulus
Cement Failed
Figure 5.2.
Caused
By
Condition
Cement
Strength Below
Requirement
First Causal Element for
Annulus Cement Failed
Figure 5.3 includes the critical factor of “Hydrocarbons Flowing” and
the key finding that the “Shoe Track Failed.” Instead of categorizing causes
into critical factors and key findings like BP did, with this perspective we
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