How often is the phrase “The ROOT Cause of the problem” used at your plant/mill? This phrase is a bit symptomatic of how Root Cause Analysis is thought of.
The phrase implies that there is only one “cause” to the problem. Rarely is there a single root cause to any given problem. Usually, there are multiple root causes; to be sure there are several “technical causes” that interact to create a breakdown/failure.
We often forget to uncover the deeper layers of a root cause investigation.
When we define “root cause(s),” we typically define it in several “layers” or multiple root causes
1. The technical causes – technical causes of the problem, often components and/or manufacturing process.
2. The human – The human causes of the problem
3. The system – The systematic causes of the root causes
For example, a technical root cause could be that a bearing failed due to misalignment, the human cause for the same problem could be that the person aligning the shafts because he/she didn’t have enough time to do it right, the system cause could be that we don’t plan and schedule our shutdowns well, particularly to allow time for alignment.
It’s important to uncover the human and systematic root causes and not only the technical root causes in an investigation.
In your next investigation, practice uncovering the human and systematic root causes.
Do you need to learn a method for uncovering these layers of Root Cause?
IDCON’s Root Cause Problem Elimination Training is a good place to start.
