Hidden Fault lines In Your Organization. Find them FAST FIX them Forever Dr. Ted Spickler Quality and Business Services 412-777-2054 [email protected] Bayer Corporate and Business Services LLC. Why Are We Here?.
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Bill owns a company that manufactures and installs car-wash systems. Bill's company installed a car-wash system in Frederick, MD. These are complete systems, that include not only the car wash itself, but also the money-changing machines.
Lots of money turned up missing - was it the manager? Or had someone stolen the key from the manager to make a copy?
Bill just couldn't believe that his people would do that, so they set up a camera to catch the thief in action. Well, they caught him on film!
No matter what the circumstantial evidence may be, don’t jump to conclusions until you have all the facts. In this case, the new owner made the assumption that since:a) Money was missing on a regular basis.b) The machines were not being broke into (no damage).c) The only other keys would be the dealer or one of the dealer’s employees. that it must be theft by the dealer or a stolen key.
The Logic Tree
Each box contains a single item. Avoid statements like: “Driving his car at 35”.
Need to investigate why he was “Not aware that
speed limit was 25”
The root cause here might be attributed to “Inattention”. BUT: why the “Inattention”?
Take these eight statements and identify the symptom of the problem - then draw the events and conditions in a Logic Tree Chart.
Case of the Shredded Tire
“Present but not visible or Active”
The Case of Something That went Wrong?
“Warning labels and large instruction manuals are signs of failures, attempts to patch up problems that should have been avoided by proper design in the first place.”The Designof Everyday Things, by D. A. Norman, 1988, Doubleday.
“Procedures are the scar tissue of past mistakes”
Sherry Poriss, Performance Review Institute, Warrendale, PA
“Well, the preheater pressure is maxed out.”
“Why is the preheater pressure maxed out?”
“Because the polymer melt viscosity is too high.”
“So why is the polymer melt viscosity too high?
“Because the polymer melt temperature is low.”
“Why is the polymer melt temperature low?”
“The second-stage reactor temperature is low.”
Why is the second reactor temperature low?
“Because the process chemistry requires it to be low.”For Simple Problems, A “5 Why’s” Analysis May Work
“Hey ... if we go to this new catalyst we can run the second-stage reactor at a higher temperature.”
Just hit upon a corrective action!
BUT: Have we considered other factors?
This is really just one branch of a Fault Tree.Need Another Why
Use this tool when it is not clear what changed to lead to the undesired effect.
Compare “problem” cases to “no problem” cases.
IRACI Definitions (cont.)
Determine what’s needed, i.e.
resources, training. Remove
If root cause is determined to be
“human error” or simply a case of
people not doing what they are
supposed to do. Conduct a Root
Cause Analysis for Behavior.
Develop and communicate clear
and agreed-upon RACI.
Ensure the right things are being
reinforced, especially when there
are competing behaviors.
Need Mistake Proofing