True Root Cause Research Articles

Wall and pillar drains in puddle clay embankment dams

Puddle clay core embankment dams were built prior to the use of rolled clay core dams and comprise a large proportion of UK dams, with the dams relying for their watertightness on the addition of water to (puddle) the clay until it has an undrained shear strength of around 10 kPa, and thus has increased ability to deform without cracking. Such dams sometimes had early forms of unfiltered drains, comprising coarse cobbles, in the downstream shoulder, either to assist construction and/or to lower the phreatic surface and improve the slope stability once the reservoir is in operation. These drains are separate from foundation drains dealing with springs encountered in the foundation excavation and drains to deal with surface runoff. This paper gives examples of such drains in dams constructed between 1863 and 1940. These drains were installed prior to the development of classic filter design rules and tools to analyse seepage. This is important as the drains have no filter, and are thus vulnerable to internal erosion which, if not detected, could lead to failure of the dam. These drains may also be the true root cause of historic incidents at these dams, due to embankment fill materials washing into the drain and creating sinkholes.

АНАЛІЗ ОСНОВНОЇ ПРИЧИНИ (RCA) ЯК ЕФЕКТИВНИЙ КОГНІТИВНИЙ МЕТОД В ПРЕДМЕТНО-МОВНОМУ ІНТЕГРОВАНОМУ НАВЧАННІ (CLIL)

This article considers Content and Language Integrated Learning (CLIL) as a dual-focused educational approach in which Maritime English is used for the learning and teaching of both content and language. In maritime business English is applied as a lingua franca because this field requires an English-language-proficient workforce. Authors' teaching experience with navigational students at the National University “Odessa Maritime Academy” shows that to achieve professional competence on operational and management levels using English as the main communicative tool, students have to be intellectually challenged in order to transform information and ideas, to solve problems based on their situational awareness. Effective content learning should be applied through creative thinking, problem-solving and cognitive challenge. A navigator must figure out the cause of the problem and the processes that will help him to survive and save the property and crew. The technique of Root Cause Analysis (RCA) is widely used in all spheres of life and science as an effective method of predicting, analyzing, and summarizing the facts and building a clear paradigm to solve professional tasks. RCA has proven to be a powerful loss-prevention tool and allows crewmembers to discover the true root cause of a casualty. The problem-solving approach focuses on the analytical and cognitive ability of navigators to find correct professionallygrounded solutions based on good seamanship on board the vessel. Keywords: Maritime English, situational awareness, content, cognition, problem-solving task, case-history, creative thinking, root cause, accident investigation.

A Unified Framework for Layout Pattern Analysis With Deep Causal Estimation

The decrease of feature size and the growing complexity of the fabrication process lead to more failures in manufacturing semiconductor devices. Therefore, identifying the root cause layout patterns of failures becomes increasingly crucial for yield improvement. In this article, a novel layout-aware diagnosis-based layout pattern analysis framework is proposed to identify the root cause efficiently. At the first stage of the framework, an encoder network trained using contrastive learning is used to extract representations of layout snippets that are invariant to trivial transformations, including shift, rotation, and mirroring, which are then clustered to form layout patterns. At the second stage, we model the causal relationship between any potential root cause layout patterns and the systematic defects by a structural causal model, which is then used to estimate the average causal effect (ACE) of candidate layout patterns on the systematic defect to identify the true root cause. Experimental results on real industrial cases demonstrate that our framework outperforms a commercial tool with higher accuracies and around <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$\times 8.4$ </tex-math></inline-formula> speedup on average.

Understanding Overlap in Automatic Root Cause Analysis in Manufacturing Using Causal Inference

Overlap has been identified in previous works as a significant obstacle to automated diagnosis using data mining algorithms, since it makes it impossible to discern how each machine influences product quality. Several solutions that handle overlap have been proposed, but the final result is a list of potential overlapped root causes. The goal of this paper is to develop a solution resilient to overlap that can determine the true root cause from a list of possible root causes, when possible, and determine the conditions in which it is possible to identify the root causes. This allows for a better understanding of overlap, and enables the development of a fully automatic root cause analysis for manufacturing. To do so, we propose an automatic root cause analysis approach that uses causal inference and <i>do</i> calculus to determine the true root cause. The proposed approach was validated on simulated and real case-study data, and allowed for an estimation of the effect of a product passing through a certain machine while disregarding the effect of overlap, in certain conditions. The results were on par with the state-of-the-art solutions capable of handling overlap. The contributions of this paper are a graphical definition of overlap, the identification of the conditions in which is possible to overcome the effect of overlap, and a solution that can present a single true root cause when such conditions are met.

Death in Mud Lick: A Coal Country Fight against the Drug Companies That Delivered the Opioid Epidemic by Eric Eyre

Reviewed by: Death in Mud Lick: A Coal Country Fight against the Drug Companies That Delivered the Opioid Epidemic by Eric Eyre Meghan Mayo Death in Mud Lick: A Coal Country Fight against the Drug Companies That Delivered the Opioid Epidemic. By Eric Eyre. (New York Scribner, 2020. Pp. 288.) While the opioid epidemic has raged across the nation, attentions lately have turned to Appalachia, where the people of the region have been hardest hit with the issue. Eric Eyre, the Pulitzer Prize winner for Investigating Reporting, weaves the tale of the battle those in southern West Virginia waged against the source of the epidemic itself. Death in Mud Lick, the culmination of nearly fifteen years of Eyre's reporting for the Charleston Gazette newspaper in Charleston, West Virginia, brings to light the full story of the state's battle against the pharmaceutical distributors of name brand drugs like Oxycontin, Lortab, and other potent opioid drugs that ravaged the people of the region. This battle, Eyre says, "set up a collision course with three of America's largest corporations" (xiv). In a journalistic-driven narrative, Eyre begins his work with the story of one victim of the opioid epidemic. When Debbie Preece finds her brother William "Bull" Preece's cause of death was actually side effects of opioids, [End Page 61] she sets out on a mission to bring to light the terrible truth of the reality concerning prescription drugs in southern West Virginia. From small-town lawyers to rural local judges to corrupt politicians, Death in Mud Lick elucidates the exact ways the wicked web of deceit allowed drug distributors to send millions of pills to small towns throughout the coalfields of West Virginia. Catching the attention of the national spotlight, Eyre's initial reporting highlighted the fact that distributors "shipped 20.8 million prescription opioids to two pharmacies four blocks apart in Williamson" located in Mingo County, which "had one of the highest overdose death rates in the nation" (xiii). Fighting corruption at the local level with a state attorney general too involved with drug companies and taking the issue to the federal level, the state of West Virginia ultimately won the battle. While not completely admitting fault in their role concerning the opioid epidemic, the drug distributors eventually settled the issue, making the state one of the first to win against such a powerful network of businesses. At a time when other narratives of Appalachia—those blaming the ravishes of the drug epidemic on the people or the region themselves—Eric Eyre's excellent work focuses the issue back to the true root causes. Historical narratives have illuminated the ways in which corrupt politics have been part of the equation, leading to Appalachia lagging behind the rest of the nation in several arenas. Eyre's tale adds to that history, elucidating ways in which political corruption is still active today, focusing on West Virginia attorney general Morrisey's office and their attempts to play it soft against the drug distributors, as well as the lack of oversight from state and federal agencies, which allowed the distributors to line their pockets with profits from the misery in southern West Virginia caused by these prescription pain killers. While other recent popular works expound the tired trope of lazy people from the region who would rather receive government handouts and continue destroying themselves with drugs, Eyre's story refutes this false narrative, showing the ways in which locals fought for addicts' rights while standing up for the state and region through the courts, hitting these Fortune 500 companies where it hurt most: their bottom line. While the history of this story is still to be written, Death in Mud Lick joins other journalistic works such as Dopesick, Dreamland, and American Pain, which work together to bring to light the true horrors the drug epidemic has reeked upon our nation and the Appalachian region especially. [End Page 62] Meghan Mayo West Virginia University Copyright © 2022 West Virginia University Press

Contingencies of Violent Radicalization: The Terror Contagion Simulation

This paper builds confidence in the terror contagion hypothesis that violent radicalization leading to predatory mass violence operates as a system. Within this system, the contingent values of key root causes create channels within which violent ideologies and terrorism emerge. We built a system dynamics simulation model capable of replicating historical reference modes and sophisticated enough to test the contingent values of these propositions. Of 16 propositions, we identified six root-cause propositions that must simultaneously exist, act in concert and explain the dynamics of their interaction which generate a terror contagion. Other propositions can strengthen or weaken an existing contagion but not eliminate it. We use an experiment to demonstrate how changing the contingent values of these propositions creates downward channels. This experiment helps reconcile the swarm vs. fishermen debate over the true root causes of violent radicalization. Within these channels, the contingent values can favor swarm or fishermen manifestations. The simulation and experimentation results enable the future development of the terror contagion hypothesis, provide a testing environment for research on violent radicalization, and provide a pathway to policy development in the combating of terrorism that arises from violent radicalization.

Development of a dynamics-based model for analyzing strategic water–environmental conflicts: systems thinking instead of linear thinking

Abstract A new evolution in graph modeling for conflict resolution (GMCR), a robust methodology for conflict resolution, is presented in this research to incorporate the systems thinking concept into the conventional paradigm of GMCR so that the dynamic nature of water–environmental conflicts can be modeled, and better outcomes obtained. To achieve this objective, a methodology is developed in three phases: static, dynamic, and outcome-based analyses. To develop the methodology, the Tigris–Euphrates basin conflict in the Middle East over the past 30 years, as a real-life case study, is used to show the robustness and capabilities of the proposed approach. Finally, a sustainable resolution to the current conflict is proposed, and the results are discussed. The proposed methodology benefits from improving the existing and often static-based conflict resolution developments by considering the dynamic nature so that the true root causes of complex conflicts are addressed, better strategic insights achieved, and comprehensive resolution provided.

A Hierarchical Approach to Improve the Interpretability of Causality Maps for Plant-Wide Fault Identification

Modern mineral processing plants utilise fault detection and diagnosis to minimise time spent under faulty conditions. However, a fault originating in one plant section (PS) can propagate throughout the entire plant, obscuring its root cause. Causality analysis identifies the cause–effect relationships between process variables and presents them in a causality map to inform root cause identification. This paper presents a novel hierarchical approach for plant-wide causality analysis that decreases the number of nodes in a causality map, improving interpretability and enabling causality analysis as a tool for plant-wide fault diagnosis. Two causality maps are constructed in subsequent stages: first, a dimensionally reduced, plant-wide causality map used to localise the fault to a PS; second, a causality map of the identified PS used to identify the root cause. The hierarchical approach accurately identified the true root cause in a well-understood case study; its plant-wide map consisted of only three nodes compared to 15 nodes in the standard causality map and its transitive reduction. The plant-wide map required less fault-state data, time series in the order of hours or days instead of weeks or months, further motivating its application in rapid root cause analysis.

Systemic Issues Influencing Technical Certainty in Social Housing Programmes in a Small Island Developing State

Underestimating costs in major public sector social infrastructure development projects is a highly contested and problematic issue. Several gaps exist in the identification of root causes of cost overruns. Behavioural science academics advocate political and psychological explanations as root causes for cost overruns against technical factors, such as errors and omissions by engineers, practitioners and scientists. Most studies in this field primarily concentrate on developed countries. Although some studies have been undertaken in developing countries, very little attention is given to the Small Island Developing States (SIDS). This paper presents a case study of public sector social housing construction programmes in a Caribbean SIDS to further understand the root causes of cost overruns. Primary and secondary data spanning across two different political cycles were collected to test the concepts of whether political influences or technical influences are the true root causes of cost overruns. It was found that political explanations based on the psycho-strategic concept are the leading sources of cost risks on the final estimated contract price. This study strengthens the argument and discusses how strategic decisions emanating from the political directorate outweigh and influence informed technical decisions formulated during the planning stages.

Root Causes of Violent Radicalization: Reconciling Fishermen V. Swarm Debate with a System Structure of a Terror Contagion

This paper broadens the search for causes of radicalization leading to predatory mass violence beyond the well-known fishermen-swarm debate. We begin by creating a system hierarchy of five levels within which we synthesize expert theories of radicalization to present a complete system structure in a causal-loop diagram (CLD). From this we identify potential root-causes operating simultaneously at different levels of the hierarchy. Leveraging complexity science we demonstrate that six root causes operating at the highest level of system structure work together create a dynamic we term a ‘terror contagion’. As these root causes influence downwards into a system they create channels favoring different violent ideologies as well as radicalizaiton dynamics such as fishermen or swarm. This analysis demonstrates that swarm and fishermen are the effects of true root-causes of radicalization, and not the cause of radicalization itself. We conclude by proposing several experiments to test the proposed terror contagion hypothesis through traditional analysis as well as computer modeling and simulation.

Restoring the natural functional capacity of coastal dune ecosystems: Utilising research records for New Zealand littoral refurbishment as a proxy for analogous global responses

Aggregated results from twenty years of community-engaged assiduous restoration of severely degraded coastal littoral systems in New Zealand (NZ) reveal numerous fundamental and substantive natural improvements to dune form, function, and storm resilience. This is accomplished by simple, low-cost exclusive utilisation of the variably threatened local indigenous dune plant species. These valuable and innovative enhancements succeed countless decades of cascading consequences from numerous impacts instigated by historic (and frequently continuing) damaging effects on those previously natural coastal dune ecosystems – impacts that subsequently induced problematic littoral retreat – the true root cause of prevailing coastal erosion. The durable reversals were often generated in less than two decades, contemporaneously with adverse storm surge and sea level rise conditions. Research reveals many global dune ecosystems are afflicted with analogous normalised degradation and erosion difficulties, with the earliest active circumvention recorded in sixteenth century Denmark (McKelvey 1999). Historic plus current pressures such as coastal settlement impacts and continuing agricultural use of dunelands similarly threaten numerous global littoral margins, alongside recent concerns regarding the compounding effects of climate change. Successful, affordable, diligent dune restoration work pioneered in NZ has extensive benefits for other nations experiencing similarly challenging attrition on degraded coastal zones. Persuasive data is presented to validate the numerous persistently accrued benefits of this cost-effective and enduring coastal adaptation response.

AN APPROACH TO IMPROVING CUSTOMER ON-TIME DELIVERY AGAINST THE ORIGINAL PROMISE DATE

One of the main challenges that a low-volume high-variety (LVHV) product manufacturing industry faces is to improve customer on-time delivery (OTD) against the original promised date (OPD) in a make-to-order (MTO) situation. A systematic root-cause analysis is carried out in the LVHV industry to find the true root cause and eliminate it. This paper proposes a methodology that incorporates the lean thinking methodology, a lean live tracking (LLT) tool, and cross-functional team (CFT) approaches to improve OTD. These are tested using real-time data from an industrial valve manufacturing LVHV firm, resulting in an average OTD improvement from 30 percent to 90 percent in about eight months.

Semiparametric PCA and bayesian network based process fault diagnosis technique

AbstractSemiparametric Principal Component Analysis has advantages over Principal Component Analysis (PCA), as it can deal with nonlinear and non‐monotonic correlation and non‐Gaussian distribution process data. In Semiparametric PCA the distance correlation coefficient matrix is used to replace the covariance matrix, and a semi‐parametric Gaussian transformation is used to allow variables to follow multivariate Gaussian distribution. To reduce the cost of monitoring and alarm flooding, a fault diagnosis technique, which combines Semiparametric PCA and Bayesian Network (BN), is proposed here. In the first stage, Semiparametric PCA is used to find the fault in monitored variables. Considering the interaction of process variables and historical process data, a Bayesian network is developed in the second stage. Considering Semiparametric PCA outcome as evidence, the Bayesian network applies deductive and abductive reasoning to update and analysis, which assist in determining the true root cause(s) and fault propagation pathway. The implementation and applicability of the proposed methodology are demonstrated using three process systems.

Root Cause Diagnosis of Process Fault Using KPCA and Bayesian Network

This paper develops a methodology to combine diagnostic information from various fault detection and isolation tools to diagnose the true root cause of an abnormal event in industrial processes. Limited diagnostic information from kernel principal component analysis, other online fault detection and diagnostic tools, and process knowledge were combined through Bayesian belief network. The proposed methodology will enable an operator to diagnose the root cause of the abnormality. Further, some challenges on application of Bayesian network on process fault diagnosis such as network connection determination, estimation of conditional probabilities, and cyclic loop handling were addressed. The proposed methodology was applied to Fluid Catalytic Cracking unit and Tennessee Eastman Chemical Process. In both cases, the proposed approach showed a good capability of diagnosing the root cause of abnormal conditions.

Systematic problem solving in production: The NAX approach

This paper outlines the NAX problem solving approach developed by a group of problem solving experts at a large Danish producer of medical equipment. The company is one of Denmark's leading companies when it comes to lean and it has developed a strong problem solving culture. The main steps of the approach are to extensively gather direct detailed process knowledge at the actual process, assemble a team that systematically builds on each other ideas, apply team thinking in a structured way to get a rapid and very deep understanding of the problem, and conducting a structured deselection of hypothetical causes to uncover the true root causes. What sets this approach apart from other is that it contains a guide of how to facilitate these steps. A case study was performed in a production department at Medicmeter to demonstrate its effectiveness and reproducibility. It resulted in a close to 60% reduction of the issue concerned.

Modified Independent Component Analysis and Bayesian Network-Based Two-Stage Fault Diagnosis of Process Operations

Statistical fault detection techniques are able to detect fault and diagnose root-cause(s) from the monitored process variables. For complex process operations, it is not feasible to screen all the process variables due to monitoring cost and flooding of alarms. Thus, if a fault is originated from a process variable that is not monitored, conventional statistical techniques are incapable of locating the true root-cause. To relax this limitation, a two-stage fault diagnosis technique is proposed for process operations. In the first-stage, the modified independent component analysis is used for fault detection and to identify the faulty monitored variable. In the second-stage, a Bayesian Network model is constructed considering the process variables and their dependence obtained from the process flow diagram. Evidence is then generated at the network node corresponding to the faulty variable identified in the first-stage. Subsequently, the network is updated and analyzed using deductive and abductive reasoning to identify the true root-cause. To verify the applicability of the proposed technique it is tested on two process models. The results of both case studies have demonstrated the effectiveness of the proposed technique to diagnose the true root-cause that originated from process variables that are not monitored. Once integrated with process loss functions, the proposed technique will serve as an important element of dynamic operational risk management framework.

The Importance of Effective Root Cause Analysis of Failures in High Reliability Microelectronics Applications: A Case Study

The screening and detection of failures in high reliability electronics is crucial to mission success. The governing standards for microelectronic components prescribe effective screens to address known failure modes during the manufacture of the components. When failures are detected outside of the normal component screening process such as in the next higher assemblies, the analysis of such failures to root cause is even more crucial. Effective root cause analysis requires collaboration among personnel having expertise in many areas, both technical and organizational. Too often, the analysis stops at the ‘how’ a part failed, rather than the ‘why’ and true root cause determination. Failures may not only represent defects in the technical aspects of the design, materials or application of the hardware, but may also be related to human organizational factors such as the competing interests of time, quality and cost. The analysis must extend beyond the forensic data into the human organization and the interaction between people, process and hardware. In this paper, the author illustrates an effective root cause corrective action (RCCA) analysis process through the discussion of a microelectronics packaging case study. The case involved failure of high reliability hybrid microelectronic components at the next higher assembly level. The case study provides insights into the root cause analysis process as well as awareness that component level high reliability screening is not impervious. It is critical for the next level user to have the expertise in their organization to understand both the how and the why of such failures. The case study describes a failure related to loose metal particles inside a hermetically sealed multilayer ceramic package which had passed Particle Impact Noise Detection (PIND) screening at the supplier. Root cause analysis determined the cause for the screening escape as well as the cause of the metal particles, and effective corrective actions were implemented at both the component supplier and Honeywell. Technical causes include improper package design, weld schedule and screening methods. Organizational causes include inadequate documentation, lack of training and failure to react to prior failures. The root cause investigation team was a multi-discipline group from Honeywell, our customer, and the component supplier, with additional consulting input from other suppliers, equipment manufacturers and industry experts.

Analysis of causation of loss of communication with marine autonomous systems: A probability tree approach

The last decade has seen the eagerly anticipated introduction of marine autonomous systems as a pragmatic tool for ocean observation. However, outstanding reliability problems means that these vehicles are not yet fulfilling their true potential. Of the classes of problems, loss of communication with a marine autonomous system is both fundamental and difficult to diagnose. In our view, this is due to two reasons: first in many cases users are not technologists and secondly if a vehicle is lost the task of diagnosing the root cause is subject to epistemic uncertainty that users are often reluctant to quantify in a formal manner. As a result users may accept the first hypothesis considered as the main root cause for loss of communication. We show that this approach can result in an increased unreliability of marine autonomous systems through failure to ascertain and then address the true root causes. Consequently, we propose a probability tree approach to help diagnose root cause(s) for loss of communication with a marine autonomous system (MAS). The model was developed based on the results of two detailed investigations and a body of failure data collected from 205 undersea glider operations.

Risk Identification Biases and Their Impact to Space System Development Project Performance

:Risk identification during the design and development phases of complex systems is commonly implemented, but often fails to result in the identification of events and circumstances that truly challenge project performance. Inefficiencies in cost and schedule estimation are usually held accountable for cost and schedule overruns, but the true root cause is often the realization of programmatic and technical risks. This research explores risk identification trends and biases pervasive during space system development that limit the awareness of such risks. The findings and results provide insight into how future engineering and risk managers can potentially avoid these shortfalls.

Root Cause Analysis of Failed Diesel Engine Aluminum Pistons

Root cause analysis was performed to determine the cause of failure of numerous cast aluminum pistons used in high speed diesel engines over ~7 months. The analysis consisted of metallurgical and engine systems evaluations. The metallurgical evaluation of two of the initial failed pistons showed failure by exposure to incompletely atomized and combusted fuel droplets that melted and eroded the piston crown outer diameters. The initial suspected root cause of the uncombusted fuel droplets was the presence of fuel-tank biological growth. The tanks were cleaned and the engines restored to service, but there were additional piston failures after only a short time back on-line, including piston seizures that fractured the pistons and cylinder liners. A subsequent, much more detailed engine system evaluation showed that the true root cause explaining all the failures was incorrect fuel injection timing. Two key points to be taken from this analysis are: (1) determination of the true root cause in this case required continuous and close interaction among metallurgical and engine systems personnel throughout an extended analysis process; (2) getting to the true root cause may require tenacious ‘detective’ work to track down and eliminate all other potential causes.