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so that the most effective solutions can be identified and implemented. It’s typically used
when something goes badly, but can also be used when something goes well. Within an
organization, problem solving, incident investigation, and root cause analysis are all
No special software required! Learn how to leverage root cause analysis across your organization
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Root cause
analysis is about digging beneath the surface of a problem. However, instead of looking
for a singular “root cause,” we shift your problem-solving paradigm to reveal a system of
causes. When using the Cause Mapping method, the word root in root cause
Most organizations mistakenly use the term “root cause” to identify one main cause.
Focusing on a single cause can limit the solutions set, resulting in the exclusion of
viable solutions. A Cause Map provides a simple visual explanation of all the causes
that contributed to the incident. The root is the system of causes that reveals all of the
different options for solutions. The result … multiple opportunities to mitigate risk and
prevent problems.
Define the issue by its impact to overall goals. People often disagree over how to define
the problem. You can get alignment when the problem is defined by the impact to the
goals.
Break the problem down into a visual map. Using a Cause Map provides a thorough
Prevent or mitigate any negative impact to the goals by selecting the best solutions.
Effective solutions should make a change to how people execute work process.
A Cause Map is
a simple diagram showing how and why a particular issue occurred. It begins with a few
Why questions (5 Whys), then expands into as much detail as necessary to (thoroughly)
explain even the most challenging issues (30+ Whys). The Cause Map creates a visual
dialogue, making it easier to communicate what’s known and what needs a little more
digging. People can see how all of the pieces fit together to produce a particular
incident.The better an organization gets at explaining its problems, the better it
Too many companies use generic buckets like human error and procedure not followed
to classify an entire incident. These are low-resolution investigations that result in weak
solving by deferring to the people in the organization who know how well current
processes actually work. A strong prevention culture makes it easier for people to share
what they know. Front-line personnel, management, and technical experts are all an
solving is a confusing maze of different tools, baffling terms, and puzzling categories.
An investigation should make a problem clearer, not more complicated. Cause Mapping
basics, that people find easy to learn and straightforward to apply. The Cause Mapping
method leverages fundamental principles to improve both the effectiveness and
Systems approach
Visual communication
clear problem statement, people can drift off course, waste valuable time, and miss
opportunities to solve the problem. The “problem” with defining problems is that
everyone has a different perspective on what the “real” problem is. The Cause Mapping
method uses a structured problem outline that reveals 3 key benefits to effective
problem solving. A well-defined problem at onset will help you avoid the common pitfalls
1. Problem alignment
No special software required! Learn how to leverage root cause analysis across your organization
A Cause Map can be very basic or it can be extremely detailed depending on the issue.
Investigating a problem begins with the problem and then backs into the causes by
asking Why questions. The questions begin, “Why did this effect happen?” The
response to this question provides a cause (or causes), which is written down to the
right.
The next question is again, “Why did this effect happen?” The cause that was written
down last becomes the effect for the next Whyquestion. Anyone who’s ever had a three-
year-old in their life will immediately recognize how Why questions change a cause into
an effect. This is fundamentally how causes and effects link together to create a chain
of events. Writing down 5 Whys, as shown below, is a great way to start an investigation
deviation from the ideal state. A Cause Map always begins with this deviation, which is
relationships, the Cause Mapping method also asks “What was required to produce this
effect?” Anything that is required to produce an effect is a cause of that effect. This
question, “What was required?,” allows you to build a detailed Cause Map that provides
problem on the right and builds the causes to the left. It was created by Kaoru Ishikawa
(1915-1989) in Japan. The fishbone diagram builds from right to left because the
Japanese language reads from right to left. The Cause Mapping method actually uses
Ishikawa’s convention by asking Why questions in the direction we read. The fishbone is
widely recognized as one of the standard quality tools. Ishikawa was a pioneer with his
approach. The fishbone cause-and-effect diagram is part of every Six Sigma program. A
Cause Map builds on the original lessons with the fishbone with some subtle but
important distinctions.
How does the Cause Map differ from the fishbone approach?
A fishbone starts
with just one, single problem, which doesn’t reflect the nature of real-world issues. It
reads right to left because the Japanese language reads that direction. It mixes causes
and possible causes without specifying evidence. And, it breaks apart the fundamental
categories.
as a journey of a thousand miles begins with the first step, every investigation,
regardless of size, begins with one Why question. The Why questions then continue,
passing through five, until enough Why questions have been asked (and answered) to
sufficiently explain the incident. The 5-Why approach, created by Sakichi Toyoda (1867
– 1930), the founder of Toyota, is a simple way to begin any investigation. A Cause Map
can start with just one Why question and then expand to accommodate as
many Why questions as necessary. Some refer to the Cause Mapping method as “5-
Whys on Steroids.”
required. When an effect has more than one cause, both causes are placed on the
Cause Map. Each cause is connected to the effect with AND placed in between. These
causes are independent of each other, but they are both required to produce that effect.
An AND is needed when people provide different, yet valid, explanations of a cause.
line personnel learn how to thoroughly investigate complex problems, identify solutions,
All workshops can be presented at your site or online with a live instructor, so you can
choose the root cause investigation training format that works best for your
Need training that’s customized specifically for your organization? Contact us for a
quote
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CAUSE MAPPING™ ROOT CAUSE ANALYSIS
WORKSHOPS – FOR FACILITATION LEADS AND
PARTICIPANTS
These are our core workshops for becoming better at analyzing, documenting,
communicating and solving problems. People attend these workshops to improve their
skills in problem solving, incident investigation, root cause analysis and risk mitigation.
The following root cause investigation training options are delivered by a ThinkReliability
instructor at the client’s site, but can also be presented effectively, over the web, to
Geared towards managers and supervisors across all business functions, this one-day
workshop covers the concepts, lessons and steps of the Cause Mapping method,
including a focus on 5-Why Cause Mapping, while building in some case studies,
examples and exercises. Participants will establish a foundation for analyzing and
preventing problems using cause-and-effect thinking. Attendees will learn how to drive a
and will discover how a thorough problem explanation reveals better solution options to
This workshop covers the foundation of the Fundamentals workshop, and includes
start to finish. Attendees work through multiple exercises and case studies to apply the
lessons they’ve learned. Every attendee learns how to start a quick analysis that can
expand into a detailed explanation of exactly what happened. The course also covers
For Facilitation Leads and Root Cause Analysis Specialists – Includes Documentation
Skills
Attendees will learn all the tips, tricks and shortcuts for documenting an entire incident
within Microsoft Excel®. The workshop covers each element of the Cause Mapping
Template including how to add and edit diagrams, drawings and photos for a clearer
also provided. Each attendee will need to bring their laptop for the 3rd day.
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For Facilitation Leads and Root Cause Analysis Specialists – Includes Documentation
Skills
This is the online version of our Cause Mapping for Facilitators + Documentation
addition to the fundamentals of Cause Mapping and facilitating an investigation, all the
tips, tricks and shortcuts for documenting an entire incident within Microsoft Excel®.
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These workshops provide the people on the frontline with a quick and simple way to
start analyzing any problem. The frontline frequently sees problems at their earliest
stage, before they blow up into something major. Frontline people are an essential part
organization.
Craft
The 5-Why Cause Mapping Workshop explains root cause analysis, and dives into 5-
Why Cause Mapping benefits and concepts. Using examples and case studies,
attendees learn the DOs and DON’Ts of 5-Whys, the three steps to Cause Mapping, the
important role of evidence, the basics of critical thinking and how to develop useful
troubleshooting guides. Skills from this workshop give the frontline a better resource in
larger problem investigations and improves the way they explain an issue to
management.
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This course covers the material in the 5-Why Cause Mapping for Frontline in the
morning then allows time in the afternoon for attendees to apply what they’ve learned.
In order for participants to apply what they have learned to company-specific problems,
situations, incidents and issues, client case studies can be organized in advance of the
workshop with input from supervision and management or they can be identified during
the morning session. Working these examples during the training provides the group
with a head start on their current problems. This class develops problem lookouts within
the company.
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lessons and steps of Cause Mapping and how it aligns with the scientific method
expectations should be for people who attended the Cause Mapping and 5-Why
Performance & Work Process Reliability examples to explain how errors occur
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Please note: steps three, four and five are the most critical
part of the corrective measures because these have proved
to be successful in practice.
Change analysis
5 times why
In the Japanese analysis method 5 whys the question ‘why’ is
asked five times. The 5 whys technique was originally
developed by Sakichi Toyoda, and was used to trace the root
cause of the problems within the manufacturing process of
Toyota Motors.
Fishbone diagram
2. Keep the power off when working on the transformer. Make sure
there is zero electrical leakage or continuity between the current
source and the system.
7. Always keep your transformer and all of its components dry and free
from any kind of moisture or water. To protect unskilled onlookers,
set up caution signs that warn people to keep away from danger.