Apollo Root Cause Analysis DOCX

Title	Apollo Root Cause Analysis
Author	Nishant G
Pages	7
File Size	23.7 KB
File Type	DOCX
Total Downloads	58
Total Views	125

Summary

Apollo Root Cause Analysis Story telling is natural. People tell stories to describe an incident. Do not take the stories for granted for there could be misleading information Stories start in the past while causal relationship start with present. Stories are linear while causal relationship follow ...

Description

Apollo Root Cause Analysis Story telling is natural. People tell stories to describe an incident. Do not take the stories for granted for there could be misleading informaton Stories start in the past while causal relatonship start with present. Stories are linear while causal relatonship follow the branches of infnite set. Stories use inference to communicate meaning while problems are found using causal relatonships. E.g.: The operator ran into this breaker and the breaker exploded. The word "and" here is equivalent to the word "caused". In storytelling, "and" is not really a logical "and". Also, notce that it was linear in tme startng from past to present. In reality operator could have fallen due to a bad foor, or bad shoes or whatever... but we aren't looking at the causes. The basis of the problem solving process is the cause and efect principle, which simply states, everything has a cause. An efect in one cause is the cause in the next essentally making cause and efect relatonship an infnite contnuum of causes. Each efect has two causes - actons and conditons. Actons are the causes we most easily recognize, while conditons are causes ofen ignored. E.g.: Why free Acton - someone lit matches, conditons - fuel source, oxygen, and igniton source. All these causes and efects should happen in same tme and space ("when" and "where"). Whenever we categorize something, we bring our own belief system into the discussion and cloud rather than clarify the issue. A primary efect is an efect we aspire to prevent from happening. This is typically what triggers the root cause analysis. We may choose to change the primary efect as we perform the root case. Not only that the cause and efect is an infnite contnuum of causes, there are more causes between any two causes. When you take baby steps you realize that there are more missing links. For instance, broken wrist was caused by a fall. But the baby step in between is that the broken wrist is caused by an excess force which was caused by a fall. Appreciatve understanding: A skill to develop where we should be appreciatve of everyone's perspectves regardless of how silly their point sounds like. In all reality, a 'child like' behavior is what helps us with the problem solving afer all Apollo's four phases: 1. Defne the problem Most problems are reactve. That is the focus of this book. In event based problems, Efectve problem solving is identfying causal relatonships and controlling one or more of the causes to afect the problem in a way that meets our goals and objectves - which in many cases is avoid recurrence....