This post is a guest entry written by Eric H., an electrical engineer living in Las Cruces NM. Hey, that’s where I live too. If that weren’t coincidental enough, I make his dinner (nearly) every night and he does all the grocery shopping; a fair trade in my estimation.
———–
Think of the last few times that you solved -or thought you solved- a production problem, only to have it rear its ugly head again. And again. Each time it crops up, you panic and pull team members together to come up with ideas for a quick fix to get the product out the door. Why didn’t the quick fix prevent the problem from cropping up again?
Root Cause Analysis is a tool for solving problems. Caution: there is a difference between “solving problems” and “applying quick fixes”! We tend to emphasize the latter because we are pressed for time even though, ironically, the former saves more time than it takes. Cognitive bias is playing a role here, so you need to learn to overcome your innate tendency to emphasize the immediate, the easy, the temporary. Properly done, Root Cause Analysis (RCA) addresses those cognitive biases, uncovers the underlying issues, and prevents problem recurrence.
- What is RCA?
- Why is it done?
- How is it done?
What is RCA?
Many different tools have been developed to try to solve problems systematically. A mass production line (Toyota) might use Taiichi Ohno’s “5 Whys”, the Fishbone (Ishikawa) diagram, or Pareto analysis. Engineers may use Failure Mode and Effects Analysis (FMEA). Safety specialists would use accident analysis and risk management. Any of these can be combined.
Why is it done?
When you are in the midst of dealing with a crisis, chances are that you are blinded or misled by a cognitive bias. Think again of that list of recurring problems: did you ever finally discover an underlying problem that -once that was solved- prevented the recurring problem from recurring? Why didn’t you see that the first time? Look at this list of cognitive biases and check off all the factors that were playing against you. The “recency effect” can be expressed as, “Generals always fight the last war”. The “clustering illusion” occurs when the observer believes they see a pattern that really does not exist. “Confirmation bias” is the tendency to pay attention to facts which support our theories and ignore those which don’t. The “deformation professionelle” or “professional bias” causes one to attribute errors from the point of view of one’s own profession. There’s nothing wrong with people making these mistakes; these are common biases hardwired into our genetic makeup. “Groupthink”, a problem where the group feels its way to a popular but incorrect consensus, is thought to have played a part in the Challenger shuttle disaster. RCA is a tool intended to systematically overcome bias.
A problem arises; you don’t have time for this right now. What do you do? You and your team quickly analyze the problem, spot the immediate cause, apply a band-aid, and move product out. You can’t afford the time to convene a formal investigation; time is money. However, if you were to objectively add up the amount of time that you and everyone around you spends on devising and implementing “quick” fixes, and don’t forget to add the lost materials and sales that result from the problems themselves, and then compare that with the actual amount of time spent on RCA, you would probably be astounded at how much such investigations save you in the long run.
Quick fixes are known in management literature as “first order problem solving”; root cause analysis and underlying source elimination is “second order problem solving” (Kathleen has written about this here, here and here). Many supervisors and managers will typically agree with both of the following statements:
- I should spend more time on second order problem-solving: it is more productive. It eliminates the time thieves that eat into my day.
- I don’t have time for second-order problem solving because I am too busy trying to do first order problem-solving.
See? We recognize the benefit, but still can’t force ourselves to invest our time into high-yield activities like RCA (the result of “hyperbolic discounting” bias!).
A quick fix is always reactive: you wait for the problem to appear, then you decide how to fix it. RCA is proactive: users believe that failure is an opportunity to find everything that led to it and then fix all of those problems. For every real problem, you will find several lesser problems, and dozens of potential problems. In the safety world, for every accident you have, there are a dozen incidents, and a hundred near-hits. By perceiving a problem as an opportunity to exercise your RCA method, you will possibly solve many more problems than just the one, so the payoff will be many times greater than the cost.
In my next entry, I’ll explain how to use simple techniques to solve any problem. In the meantime, we thought it would be fun if some of you could provide examples describing recurring situations you’ve had (via comments, e-mails, or the forum). What fixes did you use that turned out to be band-aids, i.e. didn’t really solve the problem? Feel free to describe problems you are currently having …for the third time! It will be fun to use those (with permission, of course) as demonstrations of the RCA technique.
Related:
How to solve any problem (part one)
Problems in problem prevention
On becoming a lean manufacturer
The perils of D.I.Y.
My problem is not one of conflict, per se, or mistakes….Perhaps it doesn’t fit in this discussion topic. I am developing a few dresses to send to a boutique. From discussions with the enthusiastic retailer, I have a clear picture of her customer base, I understand her fashion mix and she and I have discussed the challenges of her required price points. Here is my “problem”, my brain keeps creating designs. I choose a design, I begin drafting the pattern, then I see several variations in my head. I quickly sketch them, feeling panicky about my choices, second guessing myself. I sew the sample and my mind is designing even more dresses. I try to focus on the task at hand, to follow through and I end up with so many choices and variations I feel like my brain is going to explode… How can I stay focused?, how can I let go the notion that there is an ultimate “perfect” design choice for this store? My brain just keeps desigining and designing. Everyone I show the designs to loves them. Since I am just beginning I imagine my subconcious is sabotaging me, how can I deal with this problem?
Andrea – I’ve had this happen all the time when designing things, even just for myself. In the end, you’ve got to pick a choice and go with it. Yeah, yeah, I know, easier said than done. :) Have you tried sketching all the designs en masses and making sure they play well off each other, and then making the patterns? This might alleviate some of the indecision. Also, leaving some time for you to put aside the drawings and look at them with a fresh eye would be good.
Also, drop the “perfect dress” notion. Just…drop it. It’s the root of much procrastination in my life. :) There’s no perfect dress. There are, however, many pretty, appropriate, and saleable dresses. Sometimes you’ve just got to leave well enough alone and allow yourself to make an “imperfect” product. I’ve been very guilty of Microsofting some designs, myself.
Oh, and Eric, good article. It’ll probably take some time for me to digest it, but for the moment, my sleep-deprived brain is coming up with a crazy example: coffee. If you don’t sleep and keep up an odd routine, you start feeling tired. So you have some coffee, and you feel some more energy. But you’re tired again, so you have more coffee! And then you crash. (Why yes, I do need some sleep!)
Eric, thanks so much… I am still reading and I love this article. Bur before I continue I have to quote a hilarious saying from some people I know in industy, “Pound it to fit, paint it to match and Ship it!”
Okay, back to my reading.
Eric: Thank you! RCA is an invaluable skill. I foresee many articles in this series. I had suggested to Kathleen, offline, that there are several ways to use the 5 Whys, namely: broadening the scope or diving deeply. I’m looking forward to watching you ground this puppy!
Andrea: you’ve got “monkey mind”, gurl! Don’t sweat it, we all go thru it. Oxanna’s advice is sound. But, I would tweak one thing: I don’t suggest you analyze the slew of sketches the same day as you draw them – that’s a whole ‘nother can of worms.
Instead, I’m going to recommend a moving meditation. When you get distracted from your project at-hand, do whatever you need to until your mind calms down. In this case, sketch. Just flow with the consciousness and ride out the wave. Return to the task at-hand feeling relieved. Continue to do this every time the inspiration swells. In time, you’ll train your mind to compartmentalize (herding the monkeys) by giving each facet its fair time.
Don’t worry about the quality of the sketch or wondering where it fits in, where you were going, etc. Just let it out. Sit down one consistent time each day or week to look over your sketches and then analyze. Filter off the things you know can be acted upon, first, leave the others sit in your “ideation” box until you can devote more time to refining them (steering the elephant).
I guess one of my recurring problems would be:
My fabric ends pile up and get sloppy and disorganized- they can’t be thrown away, you know– they could be and often are used for home sewing projects or one of a kind jobs that help keep us afloat
My band-aid is that I box them up and stack that box on top of the other boxes of fabric in my storage room.
The way my problem gets out of control is:
“Hummm… where’s that purple quilting fabric? The one with the tiny flowers. I need that for this little job…”
dig dig dig, toss, shuffle, slide box, throw pile, dig dig dig. “Ah ha! here it is! Gotta go sew this up real quick. She needs it by tomorrow!”
At this point you should see my storage room. It looks like a fabric bomb went off and the shelf under my cutting table is starting to pile up again. Oh dear. Time to get more boxes.
Eric, I think maybe I need shelves? Some type of system?
These are not exactly what imagined, but we’ll see where this goes. Please keep them coming.
I guess what I had in mind was a little more like production errors, “Oh, shoot, we forgot the buttons (again)” or “That’s the wrong color! (again)” or “Why does this thread keep breaking” or “We misplaced the order (again)” or “somebody just got shocked by their machine (again)”. But other types of problems might make for an interesting exercies. The claim was *any* problem, right? And the real point is to develop skills for problem solving, not just to arrive at easy answers.
Dear JC and Oxanna, Thanks so much for your comments I will try them out…I have always liked monkeys, “herding” them is a happy visual for me; and Dear Eric, I too am looking forward to the rest of your info on problem solving. I am intrigued to look at things in a new/better way. Thanks!!
For Andrea:
This is a quote I have on my bulletin board –
“But Michelangelo always dreamed on a scale utterly disproportionate to the foolish little span of life allotted to us, and the San Lorenzo facade was never even begun.”
From: A Wanderer in Florence by B.V. Lucas, 1912; discarded by the Cornell University Library and rescued by my husband 30 years ago.
Ahh…..,,,,,
There are Engineers and there are Others….
a fact known primarily by Engineers and the women who love them.
Wheat
Okay, I’ll give it another shot. I have one stacked pocket in my diaperbag design. All the others are just single pockets sewn to the bag.
I all the time forget to sew the top (smaller)pocket onto the bottom (bigger) pocket before I sew the bottom pocket onto the front of the bag. At that point, it is too late to sew the top pocket onto the other. The only way to fix it is to rip it out. It is an easy step to forget because it’s the only pocket that is like this.
Further compounding the issue is that the top pocket is tacked onto bottom pocket with little dabs of fabric adhesive. The machine I use to sew the pockets on is not a walking foot so to prevent shifting of this pocket while sewing, I have started doing the glue thing. It works great for me. It’s fast, cheap, and easy, and the pockets are consistantly lined up well. The reason why this compounds the issue is because the pockets are already stacked together while I’m sewing it on the bag so you have to actually look for stitches to see if the top pocket was sewn on yet. Sometimes I take for granted that it has been sewn on when it’s only tacked on with glue.
Should I be doing a list of the sewing steps (sewing order p 127, yes I have read the book!) and manually checking them off after each step is sewn?
Gee- this is like having to hold up a stupid sign. The internet is private, right?
Oh, Carissa, now this is a great problem/project to work on. I’m totally serious when I say that you should look at every failure as an opportunity. Extra points to Carissa for demonstrating courage.
Can nobody else find opportunities like this? I find that hard to believe.
Interesting post, Eric. Root cause analysis would be a wonderful technique if you could find somebody besides managers to do it. I’ve worked at a couple of hospitals where middle management committees did what they called “root cause analysis,” and their finding was usually that the problem resulted from nursing staff not being micromanaged enough. The solution? A new form and a lip-service (er, in-service) meeting to tell us how to fill it out!
This is so interesting! My problem is losing stock. I sell on the Web, and once something is up for sale I wrap it in plastic and it goes into a plastic tub of similar things. Sometimes things stay in the virtual store for a long time before selling, and then they are long buried and I sometimes (almost once a week) can’t find a garment that has sold, so I have to apologize to the customer and refund their money. I have worked on keeping more detailed records, which works for things I have multiples of. I have purchased transparent bins so that I can see what is inside better. I am going to think about root cause here and see what I think is the root of this. Besides my own absentmindedness. Because I am sure every time I fail to deliver, I lose a potential repeat customer. And it could get me tossed off my selling platform (i.e. eBay). I will be reading further posts on this subject with great interest.
Kevin – I agree that everyone should and anyone can use it. The problem with floor workers is their authority/ability to recruit the helpers needed (see next post). Also, as Kathleen has pointed out (add link here?), some pay systems popular in the apparel industry (even among workers) bode poorly for these activities, and that is a problem for management to solve. These are beyond the scope of this post, though they remain an interest to our gracious hostess.
dosfashionistas – That could be interesting. Before even getting into the rest of the RCA method though, my first impression is that you might get something out of Hirano, Hiroyuki (1995); 5 Pillars of the Visual Workplace: The Sourcebook for 5S Implementation. One thing you will get out of the next post is a systematic method for thinking about the root cause.