“If you can't describe what you are doing as a process, you don't know what you're doing.” ― W. Edwards Deming
In this webinar we reviewed the primary tools used for finding Root Cause, and how to use them effectively to converge on the Root Cause of a problem. We reviewed the philosophy of the 5 Whys and the Kepner-Tregoe principles of critical thinking. We also reviewed the most commonly used RCA tools including:
- Cause/Incident Mapping
- Fishbone or Ishikawa Diagrams
- Fault Tree Analysis
The webinar focused on using best practices to discover the answer to the question, “What did change”. We demonstrated how to move beyond the philosophy of the 5 whys and to continue investigating until we get past mechanical causes to address systemic and procedural causes that contributed to the choice which started the causal chain. Many iterations of RCA may be necessary to explain a series of true causes before we get to root cause.
Apollo 13 Cause Map (zoom in to read text)