Passion Rooted in Experience

In my last post I alluded to my passion for elevating the leadership and analytical skills of the labor force. My passion is rooted in experience.

I was late to the game. I spent my 20's chasing a fast buck. In my early thirties I came to realize that I was, for the most part, chasing a pot o' gold at the end of the rainbow. Once reality set in, I realized next that I needed to get grounded quickly. I needed to develop a solid income and solid marketable and transferable skills.

My quest began by getting the first job I could find. I lived by the adage to...

Call no work low that is honest. Honest toil never degrades.

The job I took was in the brine room of a plant that makes Swiss cheese. It was not enough to cover my expenses so I took assignments from a temporary agency, working in a process cheese plant when work was available and I could squeeze it in. Stability, although visible on the horizon, eluded me. Eventually, an opportunity on the production line of a fitness equipment manufacturer opened up and I was hired. The pay, supplemented by my temporary assignments, was enough to provide the beginnings of stability. I was now prepared for my next step and enrolled in the university located in the community.

At the time, among the best paying jobs in the community were permanent assignments at the cheese processing plant to which I was being temporarily assigned from time to time. Eventually, after nearly a year, I was able to get on permanently. I quit working at the fitness equipment manufacturer and also no longer had the need to accept temporary work assignments to supplement my income. Stability had been achieved.

As it turned out, working for the company owning the cheese processing plant was one of the best things that could have happened to me. As an operator, I was trained on root cause analysis, the basics of business, process variation, team dynamics and other forms of leadership and analytical thinking. We certified by taking a proficiency test, executing an approved project. I participated on a process improvement project that increased productivity by a significant amount.

This company realized the value of enabling shop floor resources (labor) through training. This company also realized the value of empowering their employees through the opportunity to validate the training they received and allowing them to execute projects using their new found skills. This company realized that this not only provided their employees with the satisfaction of being engaged and part of the business, but it also helped the bottom line.

I had an extraordinary experience as I participated in this culture as an operator. I found further value by integrating what I was doing on the shop floor with my education as an undergraduate majoring in production management.

It has now been over 20 years since those days. Over the years I've developed a deep sensitivity for the talent on the shop floor. It is from the shop floor that I come. I recognize that this is where the rubber meets the road. I realize that there is vast talent that if tapped into appropriately, can yield huge dividends to the company for which these resources are employed. The key is to enable, through training and empowerment, shop floor resources around the country.

I did it, by the wisdom of a company for which I worked. If I did it, I believe most others can do it as well.

My passion is rooted in experience.

Root Cause Investigation of the Month Winner

On my pager, I was just sent a page from a colleague (not more colleagues!?) to look at my email account at work. When I did, I was surprised to find that I had been selected, in my Corporate Division, as the Root Cause Investigation of the Month Winner. What I was even more gratified by, was that the things that I think are truly important to a good Root Cause Analysis, were all listed as components of the selection criteria.

The body of the text in the announcement included the following:

"Strong points include: 1) Performed thorough fault tree analysis of the situation and provided data for those paths both pursued and eliminated, even though confirmed root cause could not be identified, 2) Employed investigative tasks to obtain SME contributions, 3) Supplied solid data to support impact conclusions and final disposition, 4) Employed good technical writing practices, and 5) Demonstrated adherence to [appropriate] tools. In addition, the [investigative] team exhibited curiosity and open-mindedness."

My intent in sharing this is not to toot my horn, so much as to illustrate that development of this skill set is highly valued by organizations. There are not a great many individuals that are willing to do what it takes to seriously develop these skills. Doing so requires you to make yourself vulnerable by soliciting feedback, and credible, by acting on that feedback. Demonstrating these behaviors with each investigation will drive improvement of your skill set, as well as your capability within the organization.

The Root Cause Investigation of the Month Winner is...

[Insert your name here]

Just do it!

Years ago, before I had written my first book, I saw a movie entitled, "Throw Mama From The Train." The film starred Billy Crystal. Crystal's character was an instructor at a community college teaching creative writing. At the end of his classes, he would close the session with the line, "...and remember, a writer writes."

Not long ago, I had opportunity to read a book entitled, "How to Run Seminars & Workshops: Presentation Skills for Consultants, Trainers and Teachers." I read a comment in the book, that paraphrased, stated that outlining is not writing, talking about writing is not writing, only writing is writing. This holds true for investigators in two different ways.

First, an investigator cannot complete an investigation without the appropriate activity taking place. An investigator, investigates. It doesn't matter if you are a Six Sigma Green Belt or Black Belt, an investigator using Root Cause Analysis, or any other methodology. Nothing happens until you start investigating.

Second, an investigator writes. all the investigation in the world is meaningless for others to learn from, unless, the investigation, and the results of the investigation are documented. Furthermore, many organizations require approval of the investigation from many different functions, as well as different layers of management in the organizational structure, requiring a technical document describing the investigation and it's results. An investigator writes.

What does one do if they don't really like to write? An investigator, investigates. An investigator writes. To quote a Nike ad that will be easily remembered...

"Just do it!"

Johnny Appleseed and Fault Tree Analysis

As a child in the sixties (as opposed to a child of the sixties, if you know what I mean), I learned about an American folk hero, part legend, part reality, named Johnny Appleseed. He would travel the frontier, what we now call the Midwest, planting apple trees. Little did I know, that later in my adult life, I would venture to and settle down in, the literal stomping ground of this icon of American folk lore.

Born John Chapman, Johnny Appleseed was an American pioneer nurseryman who introduced apple trees to large parts of Ohio, Indiana, and Illinois. He became an American legend while still alive, largely because of his kind and generous ways, his great leadership in conservation, and the symbolic importance of apples.

What does Johnny Appleseed have to do with Fault Tree Analysis? Well, I thought you would never ask. And if you didn't, I'm going to tell you anyway! Johnny planted apple seeds and they grew up into trees. As investigators, we get loss events planted on us, but that's OK, cause that's what we do. Our Fault Trees grow down into trees, much like a root system.

1. You start with the Loss Event.
2. From the Loss Event, you identify Causal Factors. These may be locations in a value chain, or activities on a time line. Either way, Causal Factors are high level hypotheses as to the occurrence of the Loss Event.
3. From the Causal Factors, you identify the Root Cause Categories. These are hypotheses subordinate to each of the Causal Factors. You can begin to see how this tree grows.
4. From Root Cause Categories, you then have your Near Root Cause(s), which are further hypotheses as to the Loss Event, subordinate to the Root Cause Categories. Now you're really drilling down.
5. Finally, from the Near Root Cause(s), you derive Root Cause(s). These are subordinate, still, to the Near Root Cause(s). They are still hypothetical, until validated otherwise through qualitative and/or quantitative data. (This process is the Verification Log, which I will discuss in another post.)

As you can see, the Fault Tree has now grown and you have the makings of a robust investigation on your hands. (For an example of a simple Fault Tree, you can click on the image below.)




Hmmm....

Perhaps Johnny Appleseed could have benefited from using Fault Tree Analysis to determine why apple trees and conservation were lacking in the Midwest at the time, rather than plodding around the country side.

Just a thought.

Ooops!! I could have had a...

I enjoy doing meaningful, robust investigations that really get to the root of the matter. They allow me to be involved in improving whatever process is impacted. This is something I find a great deal of satisfaction in.

The other day, I asked for feedback on a presentation I was giving for approval of an investigation I am working on. The investigation was not one of the type I had done before, was exceptionally high profile and had a very compressed time line for the level of effort and detail that would be required. I was given some reference numbers, in our database, of similar investigations I could review, and perhaps use as a template for my investigation.

Well, I did just that and started digging in. However, I was so zoned on completing the investigation, that I missed one of the key fundamentals I usually adhere to; I failed to utilize Fault Tree Analysis as a means of getting to Root Cause. I am not a disciple of Fault Tree Analysis. I AM A ZEALOT!! And yet, I failed to do what I am normally quite disciplined about doing.

Back to my feedback on the presentation: I was asked, "Where is your Fault Tree Analysis?" After trying to justify myself, I gave up and capitulated to what I knew was the truth; I had buried my nose so deep in the template, that I failed to do a thorough investigation.

I was forced (by my own behaviors) to rework my work (terribly painful on a personal level) and build my Fault Tree. The end result of the investigation was no different, but the Fault Tree provided substance to what I had done with the template and made it easy for the approvers to see my conclusion and how I had gotten there. In the end, I was glad I had to rework my work. (That's kind of a catchy phrase!)

I've now put together a little checklist for me to follow, so that when I am steeped in a big investigation, I won't slap my forehead with the heel of my palm and say, "Oooops!! I could have had a...

...Fault Tree!

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!

Time Lines & Tootsie Rolls

You ask yourself, "Tootsie Rolls?" A fair question indeed. Tootsie Rolls have nothing to do with time lines. However, time lines are not exciting and I needed to grab your attention as a result. Because time lines are not exciting many investigators either ignore or avoid them. The fact of the matter is that a time line is critical to the successful investigation of any loss event. Here is why:

1. A time line can help you identify all the activities that lead to the loss event. As you build the time line, you find gaps that you fill and you continue to build.
   
2. A time line can help you identify all the activities that transpired after the loss event. As you continue to build the time line, you find issues that obscured the loss event after it happened. These issues are important, as they also may represent gaps that need to be addressed.
3. Once your time line is constructed, you have an outline for your investigation.
4. A time line is extremely useful if your investigation requires approval, as it helps draw an organized picture of what activities or circumstances transpired around the loss event. (The key to approval is making it easy for the approver(s) to understand what happened.)
   

Nearly all investigations can be structured on a time line. Think for a moment of the press reporting an aircraft investigation. They are delivering news information about the aircraft accident, usually from a time line that the investigators have provided. This helps the press understand what happened. It also makes it easy for the press to convey to the public what happened. If your investigation has a time line outlined around the loss event, your written analysis will be smoother and make more sense.

So think about it; consider the value of a time line. If you've built them in your investigations in the past, continue building them. If not, start using them and see if they don't help your investigations immensely.

If you're not buying into the whole time line idea, it's time for you to get up and go get a Tootsie Roll!