Data mining root cause analysis findings

Abstract

Clients often associate Root Cause Analysis (RCA) with troubleshooting equipment failures. But it encompasses more than simple troubleshooting or identifying component failure causal factors. RCA investigators systematically drill deep into an organization's standards, policies and administrative controls to determine how those elements failed to prevent or eliminate causal factors associated with an incident. Accordingly, repairing these deficiencies prevents not only further occurrences of the trigger incident but any potential incident that shared the same root causes. Failing to address these so-called root causes, conversely, increases the potential that other related incidents would occur. Tracking investigation findings is crucial in assessing the value of these investments. ABS Consulting (A subsidiary of American Bureau of Shipping) utilizes root cause mapping in order to categorize investigation findings and to facilitate assessing the impact of client remedial actions. The map provides consistent naming and enumeration of root causes across different investigations. This aspect of an investigation allows ABS to evaluate the type of root causes a client experiences and to curate effective client recommendations. Over time, these records can be used to assess whether the client has addressed the root causes. Identifying and resolving major root causes as determined in RCA investigations prevents recurrence of the trigger incident as well as potential related incidents. Conversely, as demonstrated in this paper, failure to address the major root causes allows the trigger incident to recur as well as other incidents that share the same causal factors. The client failed to address identified major root causes. The records demonstrated that even though the failure modes were different, the same root causes were identified indicating that the client did not address organization standards, policies and administrative controls that would eliminate these performance gaps. This review used a table of the client's investigation findings that were comprised of approximately 70 investigations spanning eight years. To simplify this example, only a narrow segment of investigations regarding marine diesel engines were included. The failure modes for these incidents were different but the investigations revealed virtually identical root causes. The investigators uncovered numerous front line personnel performance gaps regarding operation of marine diesel engines. In all of these investigations the recommendations included reviewing training requirements, qualifications for each position and training program effectiveness. The review determined that the client had failed to address the root causes identified in each of the investigations. The finding that personnel continued to make operational errors over the span of several years indicated that the client had failed to address the major root causes.