Problem Outline |
The outline of the issues is just that, an outline. Root Cause Analysis investigation basics consists of four simple questions with specific information required within each question. Organizations typically write a problem description in paragraph form, which can take too long and provide too little information. It's futile trying to find "the right" problem description. No one will ever agree because people see things differently (ref. 5). Five people can observe the same event yet when they're asked to write down what the problem is different points of view will become apparent. It is important for people to have different areas of expertise and see things differently as long as they can communicate what they know effectively. This is where outline and Cause Map improve problem solving within an organization. The outline captures the setting and value of the problem to the organization by asking four simple questions. The four questions are What?, When?, Where? and Impact to the Goals? - What's the problem? When did it happen? Where did it happen? (ref. 6) and How did it impact the overall Goals of the organization?
Asking a group of people "What is the problem?" will yield different points of view. We can anticipate that people will disagree. Don't try to find the right answer simply document what people see as the problem and move on to the next question.quickly. Write one or two of them down and move on to the When. In the When it's standard to capture the date and time an incident occurred. There is also another important part of the timing - the relative timing. Relative timing captures the relative time and what was different during this particular incident. If it was a piece of equipment the relative timing might be during increases in load, for a late delivery we might have the relative timing as the first time we made this new route. For a car accident we might say while it was raining. The relative timing may or may not be causally related to the incident, but we will determine that during the analysis. We are only outlining the issue at this point. The Where of an issue has several elements. There is the physical location where the incident occurred, there is the stage of whatever process it's in and there is the relative location, for example, next to the operating fan. The relative location is analogous to the relative timing mentioned above.
The last part of the problem outline that we need to capture is how this incident impacts the overall goals of the organization (ref. 7) - goals plural. It is important to recognize that what happens in one part of an organization can effect what happens in another. Remember an organization is a system. The better people recognize the interconnectedness within an organization the better we become at working together to prevent incidents that impact the overall goals (ref. 1). Every incident regardless of how small should be framed within the context of the organizations overall goals (ref. 2, 5). Outlining incidents in terms of the goals will cause the technician in the field to frame the problem the same way as the business unit manager. The technician and the manger will see a different "What" in the beginning of the outline, but the impact to the overall goals will be the same regardless of where they are in the organization. For this reason the "Impact to the Overall Goals" question gives us the starting point for our Cause Map - not the "What." Starting the Cause Map with the "Impact to the Goals" gives us effective alignment and significantly improves communication at the beginning of an analysis.
The goals not only dictate what a problem is in the first place, but they prioritize all incidents and remind everyone to focus their efforts on what is important overall. There are many incidents that require immediate action in the field. Please don't think that anytime an issue occurs we need to get everyone together and first build a Cause Map. The goals overall will dictate how we proceed - is this issue routine or is it an emergency? For most industrial companies the overall goals include safety, environmental, customer service, production, maintenance and the frequency of occurrence. The outline of the issue should take no more than five to ten minutes and it's done consistently for every issue. Some of the information may not be available at that particular time, like the total maintenance cost, so mark it down with a question mark and add it in later. The outline of the problem is a simple checklist (reminder) of the important information that should be captured and questions that should be asked for any incident.
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