Apollo Root Cause Analysis:
Effective Problem Solving Defined
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Introduction:
The term Problem Solving has different meanings for each of us.
For some, it may mean how to design a new house, and others see it as
resolving personal relationships. In industry, it often means preventing
an undesirable effect from recurring. For many people, problem solving
means critical or rational thinking. Ask a business executive what they
want most in an employee, and they will respond by asking for someone
who can think. "We can teach them everything they need to know
about the job, we just need someone who can think," is a common
refrain.
The typical education program, regardless of the level, does not teach problem solving as a subject. It is understood to be part of the subject matter, not a separate branch of knowledge, so it is no wonder our graduates and employees are not good problem solvers. My studies show only 20% of the general population are effective problem solvers. With this gap, many schools today are trying to teach problem solving, but with mixed results. After studying human problem solving efforts for the past 13 years, I have come to understand why we are ineffective problem solvers most of the time. With this understanding, I have developed a new and simple way of thinking, along with some simple tools that will significantly improve problem-solving skills for anyone with basic language skills.
Before we get into these simple tools, we first need to understand the common barriers to effective problem solving. Problem Solving for the purposes of this discussion refers to the search for a solution to an undesired consequence; something we don't want to recur. Effective problem solving means the prevention of the problem from occurring again. This last distinction is necessary because we often implement solutions and never confirm their effectiveness. Then, when the problem occurs again in a slightly different form, we don't recognize our failure to prevent recurrence in the first place and experience the same effects.
Interestingly, we begin our journey in life with very good problem solving skills but they rarely survive the cultural perils of childhood. We have a built-in experimental strategy with a basic inquisitiveness and questioning attitude. This natural inquisitiveness drives us to ask why until we find the limits of knowledge. Anyone who has raised children knows this as the terrible twos, or by the Why? Why? Why? of the three year old. While more predominant in the first six years, a fundamental human strategy is to develop a prototype or model of the world and test it against reality (Reference 1). Anecdotally we can observe this in children running into the walls, falling down (a lot), tasting really yucky things, and pushing their parents to the limit with selfish demands. The child doesn't want to go past the limit; they just want to know where the limit is so they can redefine their prototypical truth.
In the early years, the edge of our truth is primarily determined by physical pain, like discovering that those yellow and orange flickering things can burn us. Once we know the limit, we move on to understand more causal relationships, and their limits. Starting at about six years we learn about emotional pain (Reference 5). "Sticks and stones will break my bones, but names will never hurt me," was the tough-guy rhyme we used to help us deny the emotional pain we felt. The fact is, those names did hurt and they hurt a lot. Also about this time we learned about embarrassment and the emotional pain of being told that our questions are stupid. This is the beginning of the end of our enthusiasm for learning. The "why?" questions begin to subside and eventually die out because the questions get harder and there are fewer people who know the answers. Besides, many of the answers we get from adults don't make any sense. Children are very good at recognizing contradictions because they haven't learned the art of denial that adults have accomplished so well. "Because I said so," becomes a more frequent answer to their questions.
In our search for answers that do not come, our ignorance forces us to develop and adopt simple strategies for dealing with the ever-growing complexity of life. The seemingly infinite set of possibilities becomes too much to handle so we look for simple answers and adopt simple strategies. The strategies we adopt are primarily driven by our culture. They are learned from our elders and the conventional wisdom of the day. Unfortunately, conventional wisdom is nearly always proven wrong over time. If you study 5000 years of human knowledge (Reference 7), you will see that the most commonly held beliefs were always shown incorrect at some later point in time. Sometimes conventional wisdom held for 3000 years, but eventually it gave way to a better understanding of cause.
Because most of us have lost our questioning attitude by the age of 25, we learn to go along to get along (References 3 & 8). In our search for security, we welcome predictability by understanding life as a set of rules. In doing so we remove ourselves from the infinite set of possibilities that life has to offer and adopt a rule-based strategy. We adopt rules for as many situations as we can define and classify things as right or wrong so we can keep our decision making simple. Rule-based problem solving has its place in our toolbox, but it does not help us solve the event-based problems that dominate our daily life. Rule-based problems are like 2 + 2 = 4, or three strikes and you're out, or run the stop light and you break the law. Rule-based problems always have a right answer, but event-based problems, which are more common, do not. For example: How do you get to grandma's house? How can I make a living? How can we make the workplace safe? None of these problems have a single right answer. Rather, they can have many answers and they range from good, to better, to best. When we adopt a rule-based problem solving strategy, as most of us do, we try to force fit the event-based problem into our rule-based thinking and it doesn't work. Furthermore, rule-based thinking prevents learning and creativity.
Another way we seek to simplify our world is to classify things. If a situation fits a certain pre-defined pattern, it gets classified and one or two possible pre-defined solutions are resident within the classification. For example, if the problem is classified as human error we can know that punishment is a requisite solution - very simple, but very ineffective. Instead of taking the time to figure out why something does what it does, we classify it as good or bad, or right or wrong, or strong or weak. By adopting a pure classification or dualistic view of the world we make things simple, but we fail to understand what is really going on. For example: is it good that the lion eats the gazelle or is it bad? It is neither. It is simply the result of a set of causes that are knowable and understandable. But we have to take the time to study them, and there in lies the rub. We don't want to take the time to understand when it is much easier to classify. By classifying this situation as bad, we fail to understand the causes and hence fail to fully understand the world around us. By understanding causal relationships, we are able to know which causes we have control over and hence can solve our problems more effectively. The ineffective strategies presented above are only a few of the reasons we are such ineffective problem solvers. For more detailed information, read Reference 4. But in the mean time, come with me on an adventure in learning as we explore the cause and effect principle like you have never seen before.
The Cause and Effect Principle:
For at least 5000 years, mankind has used the notion of causation to express
happenings. Unfortunately we have failed to differentiate the immense
power of the Cause and Effect Principle from the simple notion of causation.
Causation tells us that everything that happens has a cause, while the
Cause and Effect Principle provides four basic characteristics that allow
us to develop effective problem solving tools. The four characteristics
are as follows:
Knowing that Cause and Effect are the same thing only viewed from a different perspective in time, helps us understand why people can look at the same situation and see different causal relationships. In an injury accident, I may see the cause as a fall, while the next person sees the fall as an effect that needs understanding. We are actually perceiving different time segments of the same thing, and we can put them together causally to achieve a better understanding.
Knowing that Causes and Effects are part of an infinite continuum of causes helps us understand that no matter where we start on our problem, we are always in the middle of a chain of causes. This helps us understand that there is no right place to start. Like the jigsaw puzzle, we can start the problem solving process anywhere and still end up with a complete picture. This avoids the usual arguments over who is right.
Probably the most profound characteristic of the Cause and Effect Principle is that each effect has at least two causes in the form of actions and conditions This teaches us that every time we ask "why," we should find at least two causes and for each of these causes we should find two more resulting in at least four causes, and from each of these four causes we may find two causes, resulting in at least 8, and on to 16, 32, etc. With this understanding, we see that there is an infinite set of causes for each effect, limited only by our lack of knowledge. It is this element of the cause and effect principle that is responsible for our pursuit of simpler strategies. We never knew how to deal with an infinite set of causes before now. This is what the Apollo problem solving method is all about.
Cause and Effect relationships exist with or without the human mind, but we perceive them relative to time and space. From observation, we see that an effect exists only if its causes exist at the same point in time and space. See Figure 1 below. An open fire exists because of three conditional causes: Oxygen, Oily Rags, a Match, and one momentary action cause: a Match Strike. If these four causes did not exist at the same time and space, the fire would not exist. For example, if the oily rags where stored in a closed can, or if the match was struck at a different time, a fire could not exist. Understanding this characteristic helps us determine the validity of causal relationships.
From these four characteristics we can see that everything that happens is built upon an elemental set of causes consisting of conditional and action causes coming together to cause an effect at a common place in time and space. By understanding causal relationships we can devise some simple tools that will enable us to tap the awesome power of the Cause and Effect Principle and break away from the ineffective strategies we use today.
Effective Problem Solving Tools:
For the past 13 years I have been working with many different industries
to develop a simple set of tools that everyone can use on any event-based
problem. This methodology, which is as much a philosophy as it is a set
of simple tools does not require forms or checklists. When fully implemented
it empowers everyone in the organization to be effective problem solvers.
It truly changes the way people think about the world around them and
improves their ability to effectively communicate what they know. People
begin to realize that things do not just happen, and that everything has
a cause. As a result, a proactive attitude begins to develop, and conditional
causes that set people up to fail are removed before they can cause a
loss. This methodology, called Apollo Root Cause Analysis (RCA), provides
a four step process based on the cause and effect principle.
Step 1: Define the problem by writing the:
Primary Effect (Noun Verb)
Relative Time of the Primary Effect
Relative Location in System,
Facility, or Component
Why you are working on
this problem?
Step 2: Create an Apollo Cause & Effect Chart:
 |
For each Primary Effect ask why |
Step 3: Identify effective solutions:
Challenge the causes and offer solutions Identify the best solutions - they must:
Step 4: Implement the best solutions:
When completed, an Apollo Cause and Effect Chart may look something like Figure 2. Please note the branched causes connected by the words "Caused By." Using "Caused By" prevents story telling by forcing our mind to go from present to past. More on the importance of this later. An added feature unique to the Apollo method is the inclusion of evidenced-based causes. When you can't find evidence, or can't find the next cause, use a question mark. Evidence should be sensed data that supports the existence of the various causes. Without evidence, we are subject to our own prejudices and preconceived ideas. It helps to be humble when pursuing causes and evidence. When you don't know, admit it and use a question mark to signify this on the chart. If there is value in pursuing the unknown, then do so. If no value is perceived, you can make a conscious decision to stop, like we did after "Car Existed," or leave the uncertainty on the chart, like we did after "Narrow Road." If evidence is uncertain, use a question mark to express your doubts. Look closely at the chart below to see how the question marks have been used.
To better understand the four-step process, let's take a closer look at each step.
Problem Definition:
Let's first start by defining what a problem is. A
problem is the gap between actual and desired. If the goal is to
produce a product safely and efficiently and someone is injured in the
process, or the cost of production exceeds the sales price there is a
gap between actual and desired. Every problem can be defined in terms
of a gap. With this fundamental understanding of a problem being the gap
between the goal and the actual state, every problem should be defined
within the context of a goal. Therefore we must first know what the goals
are to define a problem. Likewise, we must know what our present state
is.
Sometimes the goals are not clear. Have you witnessed groups within an organization, such as Maintenance and Operations, which appear to have conflicting goals? Do they end up seeing different problems? Does it lead to miscommunications and conflict? Do different groups within an organization really have different or conflicting goals? It may seem like they do, but if the organization is to be effective, these goals must be aligned.
This perception of conflicting goals is often the result of misunderstanding the goals. As an example, consider a football team. The goal of a football team is to win the game. At the highest level, everyone's goal - players, coaches, and managers - is to win the game and everyone's actions are focused on that goal. But let's look at a different level. What is the goal of the offense? What is the goal of the defense? At this next level, the offense's goal is to score points. The defense's goal is to prevent their opponent from scoring points. The offense and the defense, at this next level, have completely different goals: score points and prevent points from being scored. Different goals at this level, same goal at the higher level. Is there a conflict? No. At the highest level they have the same goal: win the game. Work groups and individuals should always consider their individual, group or team goals within the context of the overall goals. If individual goals are not aligned to the overall goal conflict will occur during the problem solving process.
How do we overcome this apparent conflict in goals? By defining the organization's overall goals within the significance section of the problem definition. Every problem, incident, opportunity or project should be defined within the context of the organization's overall goals.
A clear problem definition helps to get everyone "on the same page" when an incident occurs. It improves the understanding of what is important to the organization - a crucial step toward improving the organization's overall effectiveness and ultimate success in preventing problems from occurring. The four elements of problem definition are:
Single point of view:
Minor leakage, No reportable spills, and $2,500 pump replacement
Expanded to reflect all company goals:
| Safety: | Near miss of flying pump impeller parts |
|
| Environmental: | Minor Leakage, No Reportable spills |
|
| Production: | 20% reduction in pulp processing line #2, cutback in throughput of 15,000 pounds per hour at $0.30/lbs for 6 hrs. equals $27,000 loss |
|
| Maintenance: | Materials - $1,250 pump replacement |
|
| Labor: | $1,250 |
|
| Frequency: | Second time this year, 3X in 1998, 5 similar pumps in the plant |
In the above example, the significance has been expanded into five areas that reflect the overall goals of the company. The single point of view of the maintenance group only saw the pump loss as the "problem" and the significance is only partially defined. When all the company goals are included the significance provides a much clearer understanding of the problem. It is important for everyone in the organization to define the problem within the context of the overall company goals. Properly stating the significance generates the primary effect for the cause and effect chart. For example, with this broader understanding, the primary effect could be changed to "Production Loss" which is eventually caused by the "Pump Loss." It is a subtle, but important distinction required to improve communications because the focus changes from one of operational or maintenance perspective to that of the company goals; produce product safely and efficiently.
Problem definition is not only the first step, it is critical to effective problem solving because it causes us to understand the problem from all perspectives, thus improving the communications of the organization.
Create an Apollo Cause and Effect Chart:
For each Primary Effect (the WHAT in your problem definition) begin asking
why. Use yellow stickies on a vertical board to document your progress.
As answers come, connect the causes with the words "Caused By."
This will go a long way to ensure a good chart because the words "caused
by" force the mind to go from the present to the past, and thus
minimize story telling. When you reach the end of a line of causes, go
back to the beginning and start over. Each time you ask "why?"
try to find two or more reasons. Look for condition and action causes.
If you have identified an action cause like operator pushed button, identify
the conditional causes that had to be present at that same point in time
and space to allow the effect to occur, like button existed, operator
at panel, etc. After going through the cause chart 4 or 5 times, begin
to write down the evidence that explains how you know each cause exists.
Once you have done this several times it gets very easy and natural, but
it may be difficult at first if you are used to thinking and communicating
by story telling.
Story telling is a significant barrier to effective problem solving because it violates the cause and effect principle. Stories express a linear sequence of events from past to present and conflict with the cause and effect principle in three ways:
Let's examine a simple little story to see how detrimental these conflicts are.
The little crippled boy lost control of the run-down wagon and it took off down the hill on a wild ride until it hit the little blind girl next to the drinking fountain by Mrs. Goodwin. The little boy was in the wagon the whole way, but was not injured. The boy's mother should never have left him unsupervised. The root cause of the girl's injury was human error.
Stories start in the Past:
As you can see, the story starts in the past at the top of the hill and
progresses through time from the past to the present, from the beginning
of the ride to the end; from the safe condition to the stated problem
of injury. The conflict this creates is that by going from past to present
we do not see the branched causal relationships of actions and conditions.
If we could know every cause of this injury example, we would see a diagram
of cause and effect relationships similar to Figure 2. That is, we would
see a set of ever-expanding causes starting with the injury and proceeding
into the past. To express what we know causally in story format, we would
first need to express all the causes on the right side of the diagram,
i.e.: starting from the past. Our language and the rules of storytelling
simply do not allow for this. We can not express 16 causes and then tell
what they caused and so on. No one would sit still for a story told this
way, because stories are about people, places and things as a linear function
of time.
Stories are Linear:
As we look at this simple story or any story we find our language restricts
us to a linear path through time and space. Stories go from A to B to
C, linearly through time without regard for the order of causal relationships.
We are told of the little boy loosing control of the wagon as it goes
down the hill and strikes the little blind girl. There is no ever-expanding
set of branched causes expressed like those in Figure 2.
We have the ability to escape this linearity and express branches if we use the words "and' and "or," but the rules of grammar tell us not to use these connecting words excessively. The best we can accomplish is one or two branches for each sentence. The conflict arises because the cause and effect principle theoretically dictates an infinite set of causes for everything that happens while stories are created and expressed linearly.
Stories Use Inference to Communicate Causes:
Since good stories seem to provide us with a valid perception of what
happened, we need to question how this can occur in light of the above
two conflicts. The key word here is perception. When we read or hear a
story our mind provides most of the information. As we read the words
we are busy creating images in our mind's eye. These images are created
from past experience and assembled into a sequence of events. We don't
necessarily need causal information to create the image; our mind fills
in with it's own causes. Because stories or the pictures we create do
not express the branched causes of the infinite set, we must make-up for
it somehow and we do this by inference. We infer causes within the story
that are not stated. For example, we read that the little crippled boy
lost control of the wagon. Since no cause is stated for how he lost control
we can infer anything our mind will provide, and we do just that if questioned
about it.
Furthermore, stories infer cause by the use of prepositions like in, on, with, etc. Prepositions and conjunctions by definition infer a relationship between words, and the relationship is left to the reader. The word "and" is often used to mean "caused." In this story we read that the boy lost control of the wagon and it took off down the hill, meaning the loss of control caused the wagon to take off down the hill. Within this "and" is the potential for many causal relationships and they are left for the reader to interpret. For me, the "and" between lost control and took-off down the hill is obviously a broken steering mechanism. You may have inferred that crippled means a paraplegic and this condition was the cause. The next person sees the wagon wheel strike a rock, which causes the wagon to veer sharply, while another person is so shocked by the politically incorrect usage of "crippled" and "blind children," they have lost the ability to think about the problem altogether. Because we do not express what is happening causally, each word in the story provides the reader with the opportunity to think they know more about the event than is stated. We interpret the situation from our own biased mind, which is not necessarily what happened or what the storyteller meant.
In the end, each one of us thinks we know what happened but we really don't because stories can not express the full set of causal relationships. Our linear language and the linear thinking behind it, prevents us from knowing and expressing what really happens in any given situation. And when we get together to discuss our problems, we usually end up arguing and making presumptuous statements like: "It's obvious why this happened," or "the solution is clear." By breaking away from storytelling and creating an Apollo Cause & Effect Chart we are able to include all possible causes without the usual arguing and politics.
Identify Effective Solutions:
Once we have an Apollo cause and effect chart, we can look at the causes
and propose solutions to remove or control them in a way that will prevent
recurrence of the primary effect. This is a two step process. First the
creation stage, where we challenge each cause and offer solutions. Next,
we evaluate each proposed solution against the three solution criteria:
prevents recurrence, is within our control, and meets our goals and objectives.
Looking at Figure 2, we can see several opportunities for prevention,
such as not parking on the shoulder of the road, or not listening to annoying
radio personalities while driving. Each cause provides the potential for
effective solutions and the more causes we can put on the chart, the greater
the chance of finding a creative solution.
Every solution is a function of our goals and objectives. It matters not what someone outside our organization thinks of our solutions because we are the ones who are going to be responsible for the success or failure. Accepting responsibility for our actions is what makes any decision to act "right" for us or our organization. If we can show that our solutions are supported by clear evidence-based cause and effect relationships and they meet the three solution criteria, then our solutions will be effective. We need to be careful during the solution stage because we have a tendency to transfer responsibility for the solution to others. For example: "My room would be clean if my mother would just pick up the mess." By doing this, we put the solution outside our control, and thus it violates one of the solution criteria.
If along the way to our solution, another stakeholder does not agree with our analysis or solutions, they are enthusiastically asked to share their evidenced based causes. If they are able to improve our understanding then we are obliged to add them to the chart and modify our conclusions as necessary. A common occurrence for people who use Apollo RCA is to take the problem analysis with its causes and recommended solution all the way to the President of the Corporation and rarely encounter opposition. Why? Because there are no opinionated stories, just evidence based causes. The chart provides a clear picture for anyone to see how effective the solution will be.
During a visit to a manufacturing plant where Apollo RCA has been in use for almost a year, the plant manager confided in me, "It is a little scary letting go, but if I can successfully apply the solution criteria to the corrective actions, then I let it go - regardless of my gut feelings or opinions. I have not been disappointed yet, and this process has truly empowered our workforce. They love it because it really works."
Competitive Advantage:
The Apollo problem-solving methodology empowers every person with the
ability to understand problems like they have never been able to do before.
Following institutionalization of this process, I have visited our client's
facilities and found employees working on a problem. The wall is covered
with yellow stickies and the employees are all working the problem by
placing evidence-based causes on the chart as they discover new information.
These are not serious problems required by some formal investigation,
but daily problems that are precursors to potentially larger problems
in quality or service. By observing and documenting the causes of the
problem over time, every stakeholder can be involved such that the solutions
are arrived at with everyone fully understanding their effectiveness.
There is no arguing and complaining about some outsiders pushing a dumb
solution down their throats.
In today's global marketplace, everyone can work harder, longer, or faster, but only a few will chose to work smarter. Working smarter means better communications and better problem solving, which translates to a more productive and safer work place. Using the ineffective methods of story telling and classification may have been good enough for our predecessors, but they won't take us into the future. Effective problem solving is a definite competitive advantage both from a production standpoint and a safety perspective. We have seen how using the Apollo cause and effect chart can help us communicate better and thus become more effective problem solvers and decision-makers. By first defining the problem with the What, When, Where, and Significance and then preparing an Apollo Cause and Effect Chart a common reality is created such that everyone in the organization can provide creative solutions that meet the three solution criteria.
As more personnel within an organization learn this simple structured
approach to event-based problem solving and effective communications,
a questioning attitude begins to permeate the work culture. With this
new attitude comes the understanding that things do not just happen and
if we look more closely at causes and effects, we can prevent problems
from occurring in the first place. With these simple communication tools
employees are able to communicate their ideas like never before. Likewise,
the time and money saved not having to resolve repeat events and emerging
issues can be used for positive business activities such as increasing
productivity or upgrading equipment. Can you afford not to improve your
communications and problem solving skills? For detailed information call
1-800-375-0414 or visit www.apolloRCA.com.
References: