CAUSAL ANALYSIS

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Causal Analysis
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What is Causal?

• Dictionaries tell you that
• causal káwz'l  
• 1. being or involving cause involving or being
  the cause of something else or the relationship
  of cause and effect.
• 2. grammar expressing cause expressing or
  indicating a cause or the relationship of cause
  and effect

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What is Analysis?

• Dictionaries tell you that
• analysis ? náll?ssiss (plural
  analyses) 
• 1. close examination the examination of
  something in detail in order to understand it
  better or draw conclusions from it.2. separation
  into components the separation of something into
  its constituents in order to find out what it
  contains, to examine individual parts, or to
  study the structure of the whole.3. assessment a
  n assessment, description, or explanation of
  something, usually based on careful consideration
  or investigation.

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What is a Cause?

• One of the reasons for a problem which, when
  identified and corrected, will minimize the
  potential for the problem occurring.

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What is Causal Analysis?

• Causal analysis is the process of breaking down
  an event so that each part and causal factor in
  the event can be considered, examined, tracked
  and evaluated.
• Analyzing lesser significant trends before they
  become major issues is a proactive process.
• Causal analysis, by its very nature, is a
  reactive process

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Causal Analysis is a tool.

• Causal Analysis, properly implemented, will
  reveal the real reasons for problems and help
  point out solutions.
• Causal Analysis is the building block for
  determining corrective action.
• The primary objective of Causal Analysis is to
  determine why problems occur, facilitate
  corrective actions, and prevent the recurrence of
  problems.

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What is an Apparent Cause?

• The most likely reason for a problem to have
  occurred based on a review of the relevant facts
  determined during the preliminary investigation.

Note We are not talking about an event we are
talking about a cause (problem) related to the
event. In addition, this is not considered to be
the last word until additional analysis has been
performed.
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The components of Causal Analysis
Identify the Problem
Problem
Analysis
Identify the Causes
Solutions
Identify the Corrective Actions
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The components of Causal Analysis
Problem
Identify the Problem
During this phase it is discovered that one of
the Goals, Standards or Requirements of the
organization has been violated.
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The components of Causal Analysis
Analysis
Identify the Causes
This is the actual analysis phase. This is the
stage where causes are identified and an outline
is developed which shows how the relevant causes
fit together.
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The components of Causal Analysis
Solutions
Identify the Corrective Actions
This is where the causes are evaluated for
possible solutions and where the best solutions
are chosen to implement. You cannot get here
until you have performed a thorough analysis. If
you rush to a solution phase prematurely you will
not prevent the problem from occurring again in
the long term or even the short term forecast.
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Finding Causes

• All of us are problem solvers . . .
• although many of us may tend to think of our
  problem solving process as something less fancy
  than "cause analysis.

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Analyzing Problems

• Analyzing our problems is an effort we make to
  control and prevent
• interruptions, production obstacles, and
  counter-quality occurrences.
• During this process we discover the causal
  factors that make up an unplanned event and
  recognize the possible causes for that event.
• Correcting such causes helps to prevent future
  reoccurrence.

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How do I know when I am at a real cause (Or, when
do I stop asking why?)

• You may have taken root cause classes that tell
  you to keep asking why until you get to the
  problem, or until the factors are out of your
  control.
• Where do you stop?

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How do I know when I am at a causal stopping
point? (Or, when do I stop asking why?)
No policy or process for pre-launch inspection
No pre-launch inspection performed
Drain plug not installed
Owner relied on memory to prepare for launch
Cost impacted
AND
Water entering through boats drain hole
Involved parties assumed plug to be in place
AND
Schedule Impacted
Bass-boat sunk at pier
Boat was launched into the water
AND
Boat not designed to operate when filled with
water

• Looking at a Causal Map, you should normally stop
  asking why when you reach a point in which the
  problem is eliminated by
• The use of a process.
• The improvement of a process.
• Writing a process.

Safety Impacted
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Introduction to Cause and Effect
Another method used for performing cause analysis
is a method called Cause Mapping which
involves investigating an event using the cause
and effect approach. The following is some ideas
and theory recommended for use when investigating
an event.
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Two Simple Problem Solving Tools
Process Maps
When a process doesnt produce the desired
results our first question should be WHY? These
WHY? questions are the analysis of the problem.
A map of the specific steps of a work process.
The work process defines how the organization
would like to conduct its business every day.
The corrective actions after an investigation
make specific changes to the work process. This
is the cycle of Continuous Process Improvement.
Cause Maps
A map of the causes of a problem.
The Cause Map is a visual explanation of why the
organization didnt get the desired results from
their work process.
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Introduction to Cause and Effect
What did it cause
What was it caused by
Effect
Cause
Time flows from right to left This analysis moves
backwards
Time
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Introduction to Cause and Effect
What did it cause
What was it caused by
Cause/Effect
Cause/Effect
Cause/Effect
Every effect is also a Cause Every Cause is also
an effect
Time
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Introduction to Cause and Effect
For every Effect there is a Cause
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Introduction to Cause and Effect
Was caused by
All Are True!
One point of view
Was caused by
Another point of view
Was caused by
Yet another point of view
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Right Answer vs.System Thinking

• 22 4
• The Capital of Virginia is Richmond
• The amount of inches in a foot 12

• The most important component of a car?
• How many ways are there to New York?
• What is the best car to buy?

There is one correct answer
There are many possible solutions
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Cause and Effect

• For everything that happens there is a cause that
  sets the condition for it to happen, or prevents
  it from happening.

Cause
Effect
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Cause and Effect
Cause
Effect
Was caused by?
Titanic Sank
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Cause and Effect
Why?
Was caused by?
Cause
Effect
Titanic Sank
Ship Hit Iceberg
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Cause and Effect
Why?
Was caused by?
Cause
Effect
Titanic Sank
Ship Hit Iceberg
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Cause and Effect
Why?
Was caused by?
Cause
Effect
Titanic Sank
Ship Hit Iceberg
Couldn't Turn Quickly Enough
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Cause and Effect
Why?
Was caused by?
Cause
Effect
Titanic Sank
Ship Hit Iceberg
Couldn't Turn Quickly Enough
Have we figured it out? Can we go back to work
now? Will our people be safer? Are our people
aware, smarter, better prepared? Will the cost
of the mistake be minimized in the future and
will the schedule interruption occur again?
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How Many Causes ?

• Normally there is more than one cause for a
  particular event.
• In most cases there are a number of conditional
  factors that have to be present for the event to
  take place.

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The fire triangle (revisited)
Effect
Fire
The fire triangle is a good example that
demonstrates multiple causes for each effect
(causal factor).
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The fire triangle (revisited)
Cause
Effect
Ignition source
Fire
It illustrates the normal propensity toward
multiple causes for a single effect.
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Fire
Fuel source
Ask What causes the effect to happen or occur?
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Ensure all apparent related causes are
considered.
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Notice if you take one cause away..,
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Notice if you take one cause away, the effect
cannot occur.
Oxygen
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The fire triangle (revisited)
Ignition source
Fire
Look for this recurring pattern in all cause and
effect models.
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Fuel source
You will also notice causes you want to address
and those that you may choose not to address.
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Fuel source
In this case, although oxygen is a cause, you may
not choose to address it in your corrective
actions
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Fuel source
However, the other two causes are items you will
want to control, remove, fix or limit.
Oxygen
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The fire triangle (revisited)
Cause
Effect
Cause
Ignition source
Cause
Fire
Fuel source
Investigating and analyzing factors in such a
manner allows us to uncover all relevant causes
Oxygen
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The fire triangle (revisited)
Cause
Was caused by?
Effect
Cause
Was caused by?
Ignition source
Cause
Fire
Fuel source
Insure you uncover all causes relevant to the
problem you are analyzing.
Oxygen
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Cause and Effect Exercise
Try to see if your thought process aligns with
the logic of this exercise.
Titanic Sank
If the effect was the Titanic sinking, what was
the cause?
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Cause and Effect Exercise
Water Filled Hull
Titanic Sank
If the effect was the hull filling with water,
what was the cause?
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Cause and Effect Exercise
Water Filled Hull
Titanic Sank
Continue to follow the logic
Ship in Water
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Cause and Effect Exercise
Why?
Water Filled Hull
Titanic Sank
Ship in Water
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Cause and Effect Exercise
Opening in Hull
Water Filled Hull
Titanic Sank
AND
Ship in Water
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Cause and Effect Exercise
Why?
Opening in Hull
Water Filled Hull
Titanic Sank
AND
Ship in Water
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Cause and Effect Exercise
Why?
Opening in Hull
Water Filled Hull
Titanic Sank
AND
Why?
Ship in Water
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Cause and Effect Exercise
Steel Plates Buckled on Hull
Opening in Hull
Water Filled Hull
Titanic Sank
AND
Why?
Ship in Water
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Cause and Effect Exercise
Steel Plates Buckled on Hull
Opening in Hull
Water Filled Hull
Titanic Sank
AND
Ship in Water
Atlantic crossing
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Cause and Effect Exercise
Steel Plates Buckled on Hull
Opening in Hull
Ship Hit Iceberg
Water Filled Hull
Titanic Sank
AND
Ship in Water
Atlantic crossing
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Cause and Effect Exercise
Iceberg Present
Steel Plates Buckled on Hull
Opening in Hull
Ship Hit Iceberg
Water Filled Hull
Titanic Sank
AND
Ship in Water
Atlantic crossing
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Cause and Effect Exercise
Iceberg Present
Steel Plates Buckled on Hull
Opening in Hull
Ship Hit Iceberg
AND
Water Filled Hull
Titanic Sank
Couldn't Turn Quickly Enough
AND
Ship in Water
Atlantic crossing
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Cause and Effect Exercise
Iceberg Present
Steel Plates Buckled on Hull
Opening in Hull
Ship Hit Iceberg
AND
Water Filled Hull
Titanic Sank
Couldn't Turn Quickly Enough
Ship's undersized Rudder
AND
Ship in Water
Atlantic crossing
Can you see where additional causes would fit
into the map?
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Cause and Effect Exercise
Iceberg Present
Ship Hit Iceberg
AND
Steel Plates Buckled on Hull
Opening in Hull
Couldn't Turn Quickly Enough
Ship's undersized Rudder
Water Filled Hull
Titanic Sank
Material problem with hull
AND
Ship in Water
Atlantic crossing
Can you see which causes could be corrected or
eliminated? Can you see the causes that you would
not want wish to address
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Cause and Effect Exercise
Iceberg Present
Ship Hit Iceberg
AND
Steel Plates Buckled on Hull
Opening in Hull
Couldn't Turn Quickly Enough
Ship's undersized Rudder
Water Filled Hull
Titanic Sank
Material problem with hull
AND
Ship in Water
Atlantic crossing
Lets take the Couldn't Turn Quickly Enough
cause and expand on it
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Cause and Effect Exercise
Couldn't turn Quickly Enough
Ship's undersized Rudder
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Cause and Effect Exercise
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
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Cause and Effect Exercise
Excessive Speed (18 knots)
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
AND
Late response to the Iceberg
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
AND
Late response to the Iceberg
Lookouts saw iceberg late
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
AND
Binoculars not in crows nest
Late response to the Iceberg
Lookouts saw iceberg late
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
AND
Binoculars not in crows nest
Late response to the Iceberg
Lookouts saw iceberg late
AND
Difficult to see iceberg in calm waters
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Cause and Effect Exercise
Excessive Speed (18 knots)
Potential record crossing
AND
Couldn't turn Quickly Enough
Ship's undersized Rudder
Ship's Rudder design
Binoculars not in crows nest
Late response to the Iceberg
Lookouts saw iceberg late
AND
Difficult to see iceberg in calm waters
No water splashing on iceberg
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Cause and Effect Examples
800 Calls come in per hour
Knife slipped
Knife Contacted Finger
Call center response is slow ( x minutes)
6 People are available to answer
Cut finger
Holding tomato
Finger present
Average call takes 3 minutes
Object Fell
500 was taken out
Object slipped off of hook
Object struck person
Overdrew Checking Acct
Insufficient Funds in Acct
Performing work operations
Person Present
400 was the balance
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Switch Theory

• This theory is based on the principle that when
  all the switches are open, the system, work or
  process is running optimal.
• Each switch represents a causal factor in the
  chain.
• In order for the problem-event to occur all of
  the switches have to close.

Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
Inspection does not question the use of
non-level material data entry within a
mechanical system.
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
Shop personnel questioned the installation of a
non-level component but accepted a verbal answer
without documenting the problem for technical
resolution. The component installation is
completed.
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
A related problem was documented on a similar job
however the link between the two is not
recognized. This problem is written up on that
job but, Engineering does not recognize or
tie in the similar material errors.
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
Engineering did not recognize the non-level
component error during review of the Procedure.
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
During the initial planning of the job the
appropriate technical reviews were not
accomplished.
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Switch Theory
Installation of incorrect material in a
mechanical system
Prob 1 Prob 2 Prob 3 Prob 4
Prob 5
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Switch Theory

• The easiest switch to open is the last switch
  (personnel or QA oversight).
• The hardest switches to find are process or
  engineering related.
• Switches tied to personnel error always lead to
  bigger and deeper rooted causes .
• Associate switches can be related to the
• Interactive Work Model.
• High Performance Organizations - once they find a
  problem, they work to open all RELEVANT switches.

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Questions That Uncover Problems
?

• Open ended.
• Requires fill-in of missing information.
• Makes the responder do the talking.
• Uncovers opinions as well as facts.

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Typical Interactive Work Model for High
Performance Organizations- the right mix for the
job!
This philosophy depicts a balance of Training,
Supervision and Procedure
PROCEDURE
TRAINING
SUPERVISION
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Questions For Procedure Issues
PROCEDURE

• Was the procedure format confusing?
• Many drawings or procedures were used when the
  information could have been placed in a single
  procedural step?
• Did the personnel understand the procedure?
• Did the procedure reflect the actual work
  practice?
• Was the procedure technically accurate?
• Were there to many actions required in the step?

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Questions For Training Issues
TRAINING

• What qualifications were required to perform this
  work?
• Did the worker have these qualifications?
• Did the job have the right skill mix?
• Was there a change in work practices from the
  mock-up to the shipboard application?
• Was there a difference in the classroom training
  and shipboard application?

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Questions For Supervisory issues
SUPERVISION

• Was there a lack of coordination with all trades?
  
• Was an interactive brief used? What questions
  were asked at the briefing? Did the supervisor
  effectively communicate his/her expectations?
• What oversight did the supervisor provide on the
  deckplate?
• Were the instructions unclear or inadequate?
• Did we provide individuals the tools (training,
  instructions, guidance, etc.) needed to succeed?

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Data types use both flavors
Hard Data Facts, requirements, statistics,
goals, procedures, metrics, trends, deviations,
time factors, productivity, quality performance
levels.
Soft Data Feelings, opinions, human factors -
frictions, attitudes, satisfaction levels,
frustrations, personality conflicts, behaviors,
hearsay, intuition, gut reactions, mental
blocks.
Many times soft data will lead you to discover
additional facts
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Other Tools We Can Use

• Use non-adversarial questioning techniques.
• Keep asking The effect was caused by?
• Look for the Process weakness.
• Brainstorming.
• Listing unknowns.
• Analyze time-lines.

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This is your Captain speaking... er...sorry for
the little bump... its probably just a passing
whale.

Do not assume you know what the problem
is without performing a proper investigation .
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Dont get caught up in the false security of
Apparent Causes

• Remember to always review any previous similar
  corrective actions. This is the test to ensure
  that you are not doing the same corrective action
  and expecting different results.

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Dont get caught in the nomenclature bait and
switch trap

• Make sure all agree on the name of a particular
  item (component) and that it is referred to as
  same throughout a written report. Calling the
  same item different names distracts from an
  events clarity and leads to confusion within a
  given investigation.

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Dont move to a solution phase until you have
performed thorough causal analysis

• Review your causes against Previous Actions.
• Look deeper than just the last switch.
• Ensure you identify and open all relevant
  switches.
• Make sure they are logical.
• Relate them to the work model.

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Missed Opportunities

• Without a systematic approach to problem solving
• You allow your actions to be set by opinion and
  conjecture rather than a process that keys to the
  actual causal circumstances of an event.
• This will put you back into the grab bag
  analysis game.

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Remembering our Purpose
Cause Analysis is the building block for
determining corrective action. Finding the real
reasons that problems occur, facilitating
corrective action, and preventing the recurrence
of problems is the primary objective of Cause
Analysis.
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Preventing Recurrence

• Determine best preventive measure.
• Implement and monitor.

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In Summary

• Causal analysis should be the systematic process
  of gathering all relevant data.
• Breaking an event apart to look at all of its
  pieces.
• Identify the causes that have generated or
  allowed the problem.
• Identify the possible solutions.
• Provide to the decision-makers, options so the
  best solutions (Corrective Actions) can be
  implemented.

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END OF PRESENTATION