Root Cause Analysis Quotes

Based on over a decade of doctors visits, I had concluded that there was a lack of root cause analysis.

So the hierarchy of goals is roughly: satisfy hunger; eat; cook; read cookbook; get more light. This is called a root cause analysis: asking “Why?” until the ultimate, fundamental cause of the activity is reached.

The point of industry analysis is not to declare the industry attractive or unattractive but to understand the underpinnings of competition and the root causes of profitability. P.29

Root cause analysis is the name of the game: investigate the accident until the single, underlying cause is found. What this ought to mean is that when people have indeed made erroneous decisions or actions, we should determine what caused them to err. This is what root cause analysis ought to be about. Alas, all too often it stops once a person is found to have acted inappropriately.

Complex operations, in which agencies assume complementary roles and operate in close proximity-often with similar missions but conflicting mandates-accentuate these tensions. The tensions are evident in the processes of analyzing complex environments, planning for complex interventions, and implementing complex operations. Many reports and analyses forecast that these complex operations are precisely those that will demand our attention most in the indefinite future. As essayist Barton and O'Connell note, our intelligence and understanding of the root cause of conflict, multiplicity of motivations and grievances, and disposition of actors is often inadequate. Moreover, the problems that complex operations are intended and implemented to address are convoluted, and often inscrutable. They exhibit many if not all the characteristics of "wicked problems," as enumerated by Rittel and Webber in 1973: they defy definitive formulations; any proposed solution or intervention causes the problem to mutate, so there is no second chance at a solution; every situation is unique; each wicked problem can be considered a symptom of another problem. As a result, policy objectives are often compound and ambiguous. The requirements of stability, for example, in Afghanistan today, may conflict with the requirements for democratic governance. Efforts to establish an equitable social contract may well exacerbate inter-communal tensions that can lead to violence. The rule of law, as we understand it, may displace indigenous conflict management and stabilization systems. The law of unintended consequences may indeed be the only law of the land. The complexity of the challenges we face in the current global environment would suggest the obvious benefit of joint analysis - bringing to bear on any given problem the analytic tools of military, diplomatic and development analysts. Instead, efforts to analyze jointly are most often an afterthought, initiated long after a problem has escalated to a level of urgency that negates much of the utility of deliberate planning.

Organizer—Using work breakdown, estimating, and scheduling techniques, determines the complete work effort for the project, the proper sequence of the work activities, when the work will be accomplished, who will do the work, and how much the work will cost. • Point Man—Serves as the central point-of-contact for all oral and written project communications. • Quartermaster—Ensures the project has the resources, materials, and facilities its needs when it needs it. • Facilitator—Ensures that stakeholders and team members who come from different perspectives understand each other and work together to accomplish the project goals. • Persuader—Gains agreement from the stakeholders on project definition, success criteria, and approach; manages stakeholder expectations throughout the project while managing the competing demands of time, cost, and quality; and gains agreement on resource decisions and issue resolution action steps. • Problem Solver—Utilizes root-cause analysis process experience, prior project experiences, and technical knowledge to resolve unforeseen technical issues and to take any necessary corrective actions. • Umbrella—Works to shield the project team from the politics and “noise” surrounding the project, so they can stay focused and productive. • Coach—Determines and communicates the role each team member plays and the importance of that role to the project success, finds ways to motivate each team member, looks for ways to improve the skills of each team member, and provides constructive and timely feedback on individual performances. • Bulldog—Performs the follow-up to ensure that commitments are maintained, issues are resolved, and action items are completed. • Librarian—Manages all information, communications, and documentation involved in the project.

The essential error of all the false methods lies in the fact that the proposed remedy does not reach the root-cause of the natural man's misery. Critical analysis of man's condition does not go deep enough into the determining cause of his inner phenomena; it does not follow the links of this chain down to the original phenomenon. It stops too quickly at the symptoms. The searcher who does not see further than such and such a symptom, whose analytic thought, exhausted, stops there, evidently is not able to conceive a remedy for the whole situation

To date, I don’t know what changed in her. Could I have found out, by requesting information or talking to her in the corridor? Maybe. But could I have done that and not gotten involved? Process is king, I believe, and so these things have to play themselves out; there’s no right answer. Sure, it takes some organizational cold-bloodedness, and it might leave the reader, as well as many Semco employees, miffed or unconvinced. That, however, is the price for giving up policies, procedures, missions, and credos. Just as our aversion to long-term analysis is based on the realization that it can be a waste of time and energy to attempt to foresee every possible twist and turn of the road ahead, finding the root cause of every problem can also be unproductive.

All problems have solutions.

Do not manipulate! A good engineer always focus on analysis of root causes.

the 9/11 Commission and the SSCI report on Iraqi WMD hardly appear to be convincing root causes of these recent intelligence failures.

many clients’ companies lose money, and typically one of a dozen or so common reasons can explain why. Thus, one commonly used issue tree deconstructs profits into component parts, enabling you to analyze each component to identify the root, or underlying, cause of the profitability problem. Because this is a somewhat standard analysis, we call this the profitability framework.

You will do one of two things as soon as you’ve exhausted what you can determine mathematically in the case: (1) Refine your hypothesis and create a custom issue tree to drive the rest of your analysis, or (2) shift to understand qualitatively what you’ve determined quantitatively as the root cause of the client’s problem.

root cause of the problem may be happening, further isolating the problem. This section begins with a brief explanation of how ping works. It then moves on to some suggestions and analysis of how to use the ping command to isolate problems by removing some items from consideration.

According to many experts the majority of the people won't be needed anymore for the coming society. Almost everything will be done by artificial intelligence, including self-driving cars and trucks, which already exist anyway. Some even mentioned that AI is making universities obsolete by how fast it can produce information. However, In my view, the AI has limitations that the many can't see, because on a brain to brain comparison, the AI always wins, yet the AI can only compute with programmable data. In other words, the AI can think like a human but can't imagine or create a future. The AI is always codependent on the imagination of its user. So the limitations of the AI are in fact determined by humans. It is not bad that we have AI but that people have no idea of how to use it apart from replacing their mental faculties and being lazy. This is actually why education has always been a scam. The AI will simply remove that from the way. But knowledge will still require analysis and input of information, so the AI doesn't really replace the necessary individuals of the academic world, but merely the many useless ones that keep copying and plagiarizing old ideas to justify and validate a worth they don't truly possess. Being afraid and paranoid about these transitions doesn't make sense because evolution can't be stopped, only delayed. The problem at the moment has more to do with those who want to keep themselves in power by force and profiting from the transitions. The level of consciousness of humanity is too low for what is happening, which is why people are easily deceived. Consequently, there will be more anger, fear, and frustration, because for the mind that is fixed on itself, change is perceived as chaos. The suffering is then caused by emotional attachments, stubbornness and the paranoid fixation on using outdated systems and not knowing how to adapt properly. In essence, AI is a problem for the selfish mind - rooted in cognitive rationalizations -, but an opportunity of great value for the self-reflective mind - capable of a metacognitive analysis. And the reason why nobody seems to understand this is precisely because, until now, everyone separated the mind from the spirit, while not knowing how a spiritual ascension actually goes through the mind. And this realization, obviously, will turn all religions obsolete too. Some have already come to this conclusion, and they are the ones who are ready.

I recommend several tactics for escaping the Five Blames. The first is to make sure that everyone affected by the problem is in the room during the analysis of the root cause.

On the surface, Five Whys seems to be about technical problems and preventing mistakes, but as teams drive out these superficial wastes, they develop a new understanding of how to work together. Tony put it this way: “I daresay that I discovered that the Five Whys transcends root cause analysis by revealing information that brings your team closer through a common understanding and perspective. A lot of times a problem can pull people apart; Five Whys does the opposite.

When you analyze mass shootings, you generally find root cause analysis points to the government.

Root cause analysis requires an extensive examination of history.

key roles played by the project manager: Planner—Ensures that the project is defined properly and completely for success, all stakeholders are engaged, work effort approach is determined, required resources are available when needed, and processes are in place to properly execute and control the project. Organizer—Using work breakdown, estimating, and scheduling techniques, determines the complete work effort for the project, the proper sequence of the work activities, when the work will be accomplished, who will do the work, and how much the work will cost. Point Person—Serves as the central point of contact for all oral and written project communications. Quartermaster—Ensures the project has the resources, materials, and facilities it needs when it needs it. Facilitator—Ensures that stakeholders and team members who come from different perspectives understand each other and work together to accomplish the project goals. Persuader—Gains agreement from the stakeholders on project definition, success criteria, and approach; manages stakeholder expectations throughout the project while managing the competing demands of time, cost, and quality; and gains agreement on resource decisions and issue resolution action steps. Problem Solver—Utilizes root-cause analysis process experience, prior project experience, and technical knowledge to resolve unforeseen technical issues and take any necessary corrective actions. Umbrella—Works to shield the project team from the politics and “noise” surrounding the project, so they can stay focused and productive. Coach—Determines and communicates the role each team member plays and the importance of that role to the project’s success, finds ways to motivate each team member, looks for ways to improve the skills of each team member, and provides constructive and timely feedback on individual performances. Bulldog—Performs the follow-up to ensure that commitments are maintained, issues are resolved, and action items are completed. Librarian—Manages all information, communications, and documentation involved in the project.

suffered greater wetland loss than watersheds with smaller surrounding populations. Most watersheds have suffered no or only very modest losses (less than 3 percent during the decade in question), and few watersheds have suffered more than a 4 percent loss. The distribution is thus heavily skewed toward watersheds with little wetland losses (that is, to the left) and is clearly not normally distributed.6 To increase normality, the variable is transformed by twice taking the square root, x.25. The transformed variable is then normally distributed: the Kolmogorov-Smirnov statistic is 0.82 (p = .51 > .05). The variable also appears visually normal for each of the population subgroups. There are four population groups, designed to ensure an adequate number of observations in each. Boxplot analysis of the transformed variable indicates four large and three small outliers (not shown). Examination suggests that these are plausible and representative values, which are therefore retained. Later, however, we will examine the effect of these seven observations on the robustness of statistical results. Descriptive analysis of the variables is shown in Table 13.1. Generally, large populations tend to have larger average wetland losses, but the standard deviations are large relative to (the difference between) these means, raising considerable question as to whether these differences are indeed statistically significant. Also, the untransformed variable shows that the mean wetland loss is less among watersheds with “Medium I” populations than in those with “Small” populations (1.77 versus 2.52). The transformed variable shows the opposite order (1.06 versus 0.97). Further investigation shows this to be the effect of the three small outliers and two large outliers on the calculation of the mean of the untransformed variable in the “Small” group. Variable transformation minimizes this effect. These outliers also increase the standard deviation of the “Small” group. Using ANOVA, we find that the transformed variable has unequal variances across the four groups (Levene’s statistic = 2.83, p = .41 < .05). Visual inspection, shown in Figure 13.2, indicates that differences are not substantial for observations within the group interquartile ranges, the areas indicated by the boxes. The differences seem mostly caused by observations located in the whiskers of the “Small” group, which include the five outliers mentioned earlier. (The other two outliers remain outliers and are shown.) For now, we conclude that no substantial differences in variances exist, but we later test the robustness of this conclusion with consideration of these observations (see Figure 13.2). Table 13.1 Variable Transformation We now proceed with the ANOVA analysis. First, Table 13.2 shows that the global F-test statistic is 2.91, p = .038 < .05. Thus, at least one pair of means is significantly different. (The term sum of squares is explained in note 1.) Getting Started Try ANOVA on some data of your choice. Second, which pairs are significantly different? We use the Bonferroni post-hoc test because relatively few comparisons are made (there are only four groups). The computer-generated results (not shown in Table 13.2) indicate that the only significant difference concerns the means of the “Small” and “Large” groups. This difference (1.26 - 0.97 = 0.29 [of transformed values]) is significant at the 5 percent level (p = .028). The Tukey and Scheffe tests lead to the same conclusion (respectively, p = .024 and .044). (It should be noted that post-hoc tests also exist for when equal variances are not assumed. In our example, these tests lead to the same result.7) This result is consistent with a visual reexamination of Figure 13.2, which shows that differences between group means are indeed small. The Tukey and

The idea that parents shape their children’s personalities is so ingrained, and still supplies so many psychoanalysts with their livelihoods, that any challenge to it is bound to meet a lot of resistance. Yet the evidence has been getting more and more clear: variations in personality are determined by a combination of genes and random influences, but not by parents. The central premise of Freudian analysis – that childhood events cause adult psychological problems – has been shown to stand on no good evidence whatsoever. Says Harris: ‘The evidence does not support the view that talking about childhood experiences has therapeutic value.’ Remember, in the early twentieth century all the advice to parents stressed discipline; in the later part of the century, all the advice stressed indulgence. Yet there is absolutely no evidence that this caused a shift in human personality in the Western world. Because people wanted there to be something they could do about our actions and tendencies, they argued that there must be an agent to blame. The nurture assumption was fuelled by many factors – worries about a return to Nazi eugenics, Rousseau-esque idealism, the doctrines of Marx, Freud and Durkheim – but the root of its appeal lay in the need to think of somebody being in charge. Instead, the truth is that personality unfolds from within, responding to the environment – so in a very literal sense of the word, it evolves.

Many historians still cite Lloyd George's previously quoted comment that the European nations 'stumbled into war' as evidence that no nation was entirely free of guilt for the conflict, but a careful analysis of German plans and ambitions in the pre-war years by the German historian Fritz Fischer confirms the popular opinion that the root causes of the Great War were German militarism and political ambition - and that these roots had been established for some time.

To understand how revolutionary Pasteur’s contributions were, consider the previously popular ideas that attempted to explain why people got sick. For nearly two thousand years, the medical profession believed that four different bodily fluids—blood, phlegm, yellow bile, and black bile—dominated the health and moods of people. When they were in harmony, all was right with the world. When they were out of sync, people fell ill or into “bad humor.” The theory was known as humorism. Doctors were never quite certain what caused imbalance among these humors—ideas ranged from seasons to diet to evil spirits. So they experimented by trial and error to restore the necessary harmony of fluids—often with now seemingly barbaric methods such as bloodletting, which at the time was said to remedy hundreds of diseases. Sometimes, people got better. But most of the time, they got worse. And doctors were never sure why. By the nineteenth century, people began to blame disease on “miasmas” or “bad airs” that floated around dangerously. As hare-brained as it sounds today, “miasma theory” was actually an improvement over humorism because it spawned sanitary reforms that had the effect of removing real disease agents—bacteria. For example, in 1854, when cholera gripped London, the miasma explanation inspired massive, state-sponsored clearing of the air by draining cesspools. A physician of the time, John Snow, was able to isolate the pattern of new cholera cases and to conclude that new cases correlated to proximity to a specific water pump on Broad Street. Disease, he concluded, correlated with that pump—and therefore cholera was not transmitted through miasma, but likely through contaminated water. Snow’s work saved countless lives—and he has subsequently been recognized as one of the most important physicians in history. But while an improvement, Snow’s analysis still didn’t get to the root cause of what actually made those people sick.

When researching human sickness, it is beneficial to have extensive root cause analysis skills.

The racial conflict and self-segregation described [...] are not what we would expect if widespread assumptions about the advantages of diversity are true. The prevailing view in the media and some parts of academia is that race is not even a legitimate biological category, and that it is only because of prejudiced conditioning that we even notice it. This view ignores the large body of scientific work that suggests racial and ethnic consciousness is deeply rooted in human psychology. Our species seems to have an instinct for determining who is in our group and who is not. Studies of individuals point to unconscious processes in the brain that reflect a suspicion of people unlike ourselves, leading some researchers to conclude that ethnocentrism is part of human nature. At the same time, studies at the group level show that ethnic conflict is universal. In all countries, diversity of religion, ethnicity, or race causes conflict. For the better part of the post-war period, sociologists and political scientists downplayed ethnic conflict, on the assumption that it was a pre modern relic that would be replaced by competition based on class or professional affiliation. This has not happened. As one researcher has concluded, “ethnicity based on common descent tends to be more important than class based on common interest. Blood runs thicker than money.” It is from two directions, therefore, that scientists have begun to question the view that ethnic or racial mixing can be easily achieved. Laboratory investigations of individuals have found what may be tribal or ethnocentric instincts, while analysis of societies suggests that diversity invariably brings conflict.

This covert or overt biological determinism, paraphrased in Freud's statement that anatomy is destiny, perhaps the most deep rooted obstacle to the analysis of the causes of women oppression and exploitation

can deal with them openly and transparently, without doing fault-finding. What we do in those cases is a very rigorous root cause analysis and we look what needs to be better.

To help with root cause analysis, the provider implemented a business analytics tool – at no additional cost – to better diagnose service issues.