Bottoms Up!

There is a hierarchical structure to investigations. The key of any investigation is to get to the bottom of things, or rather, identify Root Cause. Until you get to the bottom of things, it is impossible to identify any real possibility to correct the issues causing the loss event and affect organizational improvement.

Key to identifying Root Cause and solving the problem is "cause of the cause" or "5 Why Analysis", both are very similar. Conceptually, you ask what the cause of the loss event was. Once you have a general idea, then you ask yourself what the cause of that was (cause of the cause) or why that happened (second layer in 5 Why Analysis), you continue to ask the same question, "Why did that happen?" until you can no longer go any further. Data suggests that you typically find Root Cause after asking "Why?" no more than 5 times.

Here are some hierarchical definitions that will help you in your investigations (it is important to note these are not original with me, and are generally considered standard in formal Root Cause Analysis):

1. Loss Event: This is the occurence of some event that caused a loss, of one sort or another, to the organization. e.g., machine failure, safety issue, suspect analytical result, etc.
2. Causal Factor: This is a generalization as to the cause of the loss event. Consider it the first "why" in 5 Why Analysis.
3. Root Cause Category: This is cause of the cause, or the second layer in 5 Why Analysis.
4. Near Root Cause: More cause of the cause and the third layer in 5 Why Analysis.
5. Root Cause: Cause of the cause and the fourth layer in 5 Why Analysis.

Fishbone diagrams and Fault Tree Analysis are good ways to get a graphical view of how things are shaping up. Build in a time line and you now have a two dimensional view of the loss event and all the factors impacting it.

Once you get to the BOTTOM of the loss event, you can finally serve UP some Corrective Actions that will drive organizational improvement.

Hence, Bottoms Up!