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Root Cause Analysis

Improving Performance for Bottom-Line Results

Second Edition

Robert J. Latino and Kenneth C. Latino

Because technology is outpacing humanity's ability to keep up with it, we are faced with a growing amount of losses.  Whether losses are measured in terms of units produced, quality of healthcare, customer satisfaction, etc., the common denominator of why our numbers do not measure up to expectation is the human being.

As corporations continue to reengineer or downsize to "trim the fat," they raise the bar on their production expectations.  Now we are faced with a paradox of having fewer people with more tasks to accomplish.  How can this be done?  The answer, and what we believe corporate America is trying to do, is reinvent the way we do work.  Doing things the way we have always done them will no longer obtain the goal.  Therefore, we must think outside the proverbial box and question, why we do the things we do and the way that we do them.

As complex as it seems in our respective environments, the answer is quite simple when we look at the big picture.  Corporations set earnings expectations, plants set production goals, or hospitals set expected profit margins;  whatever the case, they all set the bar at a certain level.  once that bar is set, all plans revolve around it.  The dilemma that we all face is where are we now compared to the bar?  The distance between our actual situation and where the corporation would like us to be is the "Gap."  The gap is composed of various undesirable outcomes, failures, incidents, events, etc.  What they all have in common is that they are siphoning money out of the corporate engine.  These events are costing organizations a fortune, and most organizations do not even know what or where these events are located.  Consider this thought, "Why does a maintenance budget exist?"  It exists to repair both expected and unexpected events.  For example, in a manufacturing plant when chronic type failures occur on a daily or weekly basis, we tend to become very good at repairing them.  They happen so often that we do not see them as a failure any more but as part of the job.  When this occurs, it is retired to the pasture of the maintenance budget and accepted as "a cost of doing business."  In essence, we will attain our goals in spite of these events.  This is a costly paradigm that is generally worth tens of hundreds of millions of dollars in accepted losses.

What if we decided we were not going to accept these small, chronic issues any more?  What if we set out to identify all the events in the gap?  What if we dedicated ourselves to understanding why error occurs and how to prevent it?  What if we were to eliminate chronic failure from occurring?  It is difficult for most to envision because it seems like it is such a distant goal.  Our people have the knowledge and the power to move our organizations to heights never imaginable, if we would just believe in them and let them soar.  This text in an effort for both management and analysts to help them fully understand why things do not always work out as planned and how to use root cause analysis to make sure they do not happen again.