Wetin be root cause analysis?

Di habit to dey ask why sometin go wrong until di answer no dey shift again, so dat wen you fix di root, di symptoms wey dey on top go comot.

Wen group suppose do root cause analysis instead of one analyst?

Wen di causes spread among di pipo wey dey involved and no single analyst hold all of dem. Structured Democratic Dialogue dey collect causes from evribodi and e dey let evribodi judge di links at 75% bar.

How big root cause analysis group suppose be?

E suppose small reach make pipo fit read one wall and hold one conversation — from twelve reach about two dozen. Dem dey divide bigger rooms into groups and merge dia maps; di bar na di same for evri group.

Root cause analysis example: delivery wey dey delay, from cards reach root causes

Root cause analysis example

Fifteen pipo wey dey work inside and around one regional delivery operation — drivers, dispatchers, one depot manager, two customers — dey answer one question. Di stages, wetin each one produce, and di map for di end. Di wording na di group own, wey we shorten small.

Di question

Wetin dey drive delivery delays across di region?

Write → 61 cards.

Some of dem: dem dey dispatch loads bifor dem check di paperwork · drivers dey get routes wey dem no fit finish · route plans dey ignore school-run traffic · depot radios dey for wrong channel · dem dey book yard slots two times for di same hour · handovers between shifts dey lose important details · na di wrong desk dey fill customs forms · agency drivers no dey ever see di site notes · drivers dey share fuel cards among demself · di scanner app dey log out evri hour.

Explain → 61 cards, 4 merged.

“Handovers dey lose important details” and “di 6am handover no get checklist” come out as one claim. Dem explain “routes wey dem no fit finish” to mean di stops wey dem plan, no be driving time — and dat one change wetin pipo link am to later.

Bunch → 7 bunches.

Paperwork and customs · route planning · yard and slots · handovers and briefing · equipment and radios · agency staff · wetin dey hold di customer side.

Pick → 15 for di shortlist, 2 through seat.

Spreadthink 41% — 25 out of 61 cards get at least one sticker, and na di normal range be dat. “Na di wrong desk dey fill customs forms” no get any sticker but one dispatcher nominate am with di customs office own returns figures; two pipo gree say di source relate and e take seat.

Arrange → 210 pairs, 86 asked, 79 settled, 7 with argument.

Di rest come out by implication. Di pairs wey get argument all na about whether agency drivers dey cause di oda problems or dem just dey suffer dem; di room divide 8–7 on dem and dem stay for di record as divide.

Di map.

Level 4 (symptoms): late deliveries · customer windows wey dem miss · overtime
Level 3: routes wey drivers no fit finish · yard slots wey dem book two times · scanner app wey dey log out
Level 2: route plans dey ignore school-run traffic · handovers between shifts dey lose details · agency drivers no dey ever see site notes
Level 1 (root causes): dem dey dispatch loads bifor dem check di paperwork · na di wrong desk dey fill customs forms

Two roots. Di second one na di card wey take seat wey no get votes. Evri symptom wey di room rank pass — late deliveries, overtime — dey three levels above dem. Nobodi enter with di belief say paperwork na di problem; di links, wey dem judge one at a time, put am for di bottom.

Actions → 3 wey dem judge against di roots.

“Paperwork check bifor dispatch, with hard stop” move di two roots at 75%. “Give agency drivers di site notes” no move any of dem — good action, but no be root-cause action, and di matrix tok am. Di pesin wey write “Fix di scanner app” withdraw am once di map show say e dey three levels up.

Wetin five-whys session for find: di depot manager chain, wey run from late deliveries reach route planning and stop dia — level 2 of dis map. Di paperwork root dey inside one dispatcher head and inside one customs officer figures, and no analyst go ask any of dem.

Run di same seven stages · Di methods side by side · Di same process for any number of groups · Structured dialogue examples: one problem, eight kain map