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Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Risk MitigationExample - Case StudyA Root Cause Analysis of the Titanic - Simple to DetailedInvestigating and preventing complex problems in your business.How a Simple 5-Whys can Turn Into a Complete and Thorough Analysisinfo@thinkreliability.comHouston, Texas 281.412.7766Root Cause Analysis - Cause Mapping MethodStep 1. Define the ProblemStep 2. Conduct a Cause-and-Effect Analysis (visual, simple to detailed)Step 3. Identify Solution Options to Mitigate Risk (select the best ones)Copyright 2015 ThinkReliability1
Root Cause Analysis - Cause Mapping MethodStep 1. Define the ProblemWhatProblem(s)Titanic sank, ship hit iceberg, people died, weak rivetsWhenDate, timeApril 14th, 1912, 11:40 pmDifferent, unusualMaiden voyage, five ice warnings, nighttimeGeographic locationNorth AtlanticCompanyWhite Star LineEquipment, unit, areaRMS Titanic, starboard bowTask (work process)Transporting passengers from UK to USWhereImpact to the Overall GoalsSafety1500 Fatalities (705 survivors)Customer ServiceMajor ?Operations, ScheduleMajor ?Property, Equip.Lost entire shipFrequency1xCopyright 2015 ThinkReliability 7,500,0002
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500lives3
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankShip hit iceberg4
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankShip hit iceberg5
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankShip hit iceberg6
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankWater filled hullShip hit iceberg7
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankWater filled hullOpening inhullShip hit iceberg8
Why?Step 2. AnalysisEffectTitanic SankCause MapCauseBasic Cause-and-Effect Relationship5-Whys is simply a Cause Map with 5-Why questions, but there are more.Why ?Impact toSafety GoalCopyright 2015 ThinkReliabilityWhy ?Loss of 1500livesWhy ?Titanic sankWhy ?Water filled hullWhy ?Opening inhullShip hit iceberg9
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankWater filled hullOpening inhullSteel platespulled apart onhullShip hit iceberg10
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankWater filled hullOpening inhullSteel platespulled apart onhullShip hit icebergShip didn't turnsufficiently11
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalCopyright 2015 ThinkReliabilityLoss of 1500livesTitanic sankWater filled hullOpening inhullSteel platespulled apart onhullShip hit icebergShip didn't turnsufficientlySaw iceberglateNighttime12
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapImpact toSafety GoalLoss of 1500livesTitanic sankImpact toProperty GoalWater filled hullOpening inhullSteel platespulled apart onhullShip hit icebergShip didn't turnsufficientlySaw iceberglateNighttimeLost entire shipCopyright 2015 ThinkReliability13
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipCause MapInsufficientlifeboatsImpact toSafety GoalLoss of 1500livesANDTitanic sankTitanic sankImpact toProperty GoalWater filled hullOpening inhullSteel platespulled apart onhullShip hit icebergShip didn't turnsufficientlySaw iceberglateNighttimeLost entire shipCopyright 2015 ThinkReliability14
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipStrength of HullCause MapStrength ofRivetsInsufficientlifeboatsImpact toSafety GoalLoss of 1500livesANDANDTitanic sankTitanic sankWater filled hullOpening inhullSteel platespulled apart onhullShip hit icebergImpact toProperty GoalShip didn't turnsufficientlySaw iceberglateNighttimeLost entire shipCopyright 2015 ThinkReliability15
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipStrength of HullCause MapStrength ofRivetsInsufficientlifeboatsImpact toSafety GoalLoss of 1500livesOpening inhullANDTitanic sankTitanic sankSteel platespulled apart onhullANDWater filled hullANDShip hit icebergImpact toProperty GoalShip didn't turnsufficientlySaw iceberglateNighttimeLost entire shipBulkheadsopen at topCopyright 2015 ThinkReliability16
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipStrength of HullCause MapStrength ofRivetsInsufficientlifeboatsImpact toSafety GoalLoss of 1500livesOpening inhullANDTitanic sankTitanic sankSteel platespulled apart onhullANDWater filled hullSaw iceberglateANDShip hit icebergImpact toProperty GoalLost entire shipNighttimeShip didn't turnsufficientlyANDBulkheadsopen at topSpeed of shipCopyright 2015 ThinkReliability17
Why?Step 2. AnalysisEffectTitanic SankCauseBasic Cause-and-Effect RelationshipSolution:Add 20 more lifeboats.Cause MapSolution:Change steel hulldesign, materials.Strength of HullStrength ofRivetsInsufficientlifeboatsImpact toSafety GoalLoss of 1500livesOpening inhullANDSteel platespulled apart onhullSolution:Add two more lookouts to thebow.ANDSolution:Improve bow watch hazardrecognition process.Titanic sankTitanic sankImpact toProperty GoalLost entire shipWater filled hullSaw iceberglateANDSolution:Run bulkheads to the topdeck.Bulkheadsopen at topShip hit icebergNighttimeShip didn't turnsufficientlyANDSolution:Slow down with knownicebergs in area.Speed of shipCopyright 2015 ThinkReliability18
Click here to get a Titanic Root Cause Analysis t 2015 ThinkReliability19
Work Process - A series of steps to produce an end.Titanic Cause Map with "Broken" Work Processes IdentifiedWork Processes the Broke DownLifeboat evacuationRescue communicationRivet design, manufactureRivet installation, inspectionRudder designShop port around maneuverNaviationIceberg-hazard identificationEvery task in an organization is part of a work process. An investigationidentifies the causes of an incident so that specific improvements can bemade within the work processes. Highly reliable organizations perform workprocesses effectively.again and again.ProcessSolution:Ensure each lookout hasbincoulars available.LookoutNo binocularsANDSolution:Change steel hulldesign, materials.Strength ofhullPropertyGoalImpactedLost entireshipOpenings oss of1500 livesShip filledwith waterBulkheadsnot sealedANDSolution:Add 20 more Solution:Add two more lookoutsto the bow.Iceberg inpathANDANDShip hiticebergBulkheadsImpact stresson hullANDCalifornianradio was offDark,nighttimeSolution:Improve bow watchprocess.ANDLookouts sawiceberg dle outside propellersinstead of reversing.RadiosRescue shipsarrived lateStrength ofrivetsSteel seamsopened onhullANDLookoutLookoutSolution:Run bulkheads to thetop deck.ANDNo splash onicebergHull designInsufficientturn of shipSolution:Slow down with knownicebergs in area.Speed(18-22 knots)SpeedANDSpeed(18-22 knots)Size ofRudderRudder designEvacuationProcessCrew LifeboatTrainingProcessNOTES- A Cause Map shows the causes that produced a particular incident (the Analysis).- Each causal path reveals specific work processes that broke down (Pinpoints Necessary Changes)- Solutions are implemented as changes within those particular work processes (Best Practices going Forward).- Every cause and every work proccess does not need to be solved (Lowest Acceptable Risk).Copyright 2015 ThinkReliability20
A Root Cause Analysis of the Titanic - Simple to Detailed Investigating and preventing complex problems in your business. Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Risk Mitigation info@thinkreliability.com Houston, Texas 281.412.7766 How a Simple 5-Whys can Tu
