ROOT CAUSE GUIDANCE 根本原因指南
KEY POINTS 關(guān)鍵點
? Root Cause Analysis is a useful process for understanding and solving a problem.
? Figure out what negative events are occurring. Then, look at the complex systems around those problems,and identify key points of failure. Finally, determine solutions to address those key points, or root causes.
? you can use many tools to support your Root Cause Analysis process. Cause and Effect Diagrams and 5 Whys are integral to the process itself.
? As an analytical tool, Root Cause Analysis is an essential way to perform a comprehensive, system- wide review of significant problems as well as the events and factors leading to them.
PERFORMAING THE INVESTIGATION 進行調(diào)查
DEFINE THE PROBLEM AND COLLECT DATA
Define the problem by developing a clear, complete and concise Problem Statement which includes what the problem is, who was involved (not attributing blame), where it occurred or was identified, when it occurred or was identified and the magnitude (e g , frequency, impact) operating conditions or precursor information which may provide additional details for consideration might also be required.
This problem statement will become more refined and detailed as the analysis is conducted to define the problem we will have to collect data, such as the ones listed in the following table, through interviews, review of documents, observation, statistical data sources, surveys, or other sources always remember that during an investigation, people can forget, overlook, or misinterpret information therefore the more thorough we can be, the better
DESCRIPTIVE FACTS ABOUT A PROBLEM
| CATEGORY | QUESTIONS |
| What | What is happening? What undesirable behavior or situation is occurring? What is NOT the problem?
|
| Who | Who is involved? Who does it affect? Who is not involved? Who does it not affect?
|
| Where | Where is it happening? What unit area, department...? Where is it not happening?
|
| When | When is it happening? When is it not happening? With what frequency? How long does it last? When is it a problem? When is it not a problem?
|
| How | How does the situation manifest itself? How does it affect the “what” and the “who” or other working situation, relationships, etc.? What other elements are derived from it?
|
How much/ How many | What are the costs associated with the situation? Intangibles? How much is it costing?
|