Organizational & Progammatic Root Cause or Common Cause Analysis

Without a full understanding of the psychological basis for inappropriate actions -- which are often symptoms of O&P issues -- it is often impossible to find the true causes of O&P problems. PII's O&P root cause and common cause analysis methodology is the only psychologically-based investigation tool on the market. Our approach is both objectve and focused; we don't call out every issue irrespective of whether or not it is an appropriate indicator of the root causes of O&P issues. We focus on the true root or common causes of the problem. Our approach is effective in reducing similar-type event rates -- injury rates, tag-out failures, engineering-related failures, project failures, etc. -- by at least a factor of five, and often by a factor of ten, when our focused corrective action recommendations are implemented.

We refer to our methodology as the " PII-Fishsm " method, as depicted in the graphic below. The graphic is a visual representation of the steps essential to the PII process of performing a successful and accurate O&P Root Cause Analysis. Roll over the graphic's steps for more information.

PII-FISH graphic Why Did It Happen? Why Did It Happen? Inappropriate Action Mental States & Error Types O&P Failure Modes Management Failure Modes Under Management Control? Early in Sequence of Events? Prevent Recurrence? Substandard? CHOP'N? Root Cause Analysis and QVV Root Causes Corrective Actions Qualify Verify Validate

Determining the
sequence of events
why a particular inappropriate
action or error has
taken place.

Determining the
sequence of events
why a particular inappropriate
action or error has
taken place.

The initiating
inappropriate action
or event for which the
root cause analysis
is requested.

Determine the
mental states of
errors and
error types.

Determine
possible
O & P
failure modes.

Determine possible
management failure
modes
(if needed).

SUEP dominant
failure mode: Its improvement
is UNDER
management's control.

SUEP dominant
failure mode: It occurred
EARLY in the
sequence of events.

SUEP dominant
failure mode:
It can be corrected
to PREVENT
total recurence.

SUEP dominant
failure mode: It is a
SUB-STANDARD practice
(relative to that in companies
without similar events.)

A test for determining
a possible dominant failure
mode: "Why in this Company,
why He, why this Organization,
why this Program,
why Now?"

Use Stream Analysis
to eliminate
consequential failure
modes.


Determine root cause(s)
and contributing factors.


Determine corrective actions
and extended conditions.



QUALIFY



VALIDATE



VERIFY