Paperback - 144 pages
Published by: Productivity Inc
Publication Date: 1998
Dimensions (in inches): 0.37 x 9.02 x 5.98
ISBN: 0527763268
Our Review
The Root Cause Analysis approach outlined in this book appears to be best suited to those who use Root Cause Analysis to investigate single, catastrophic failures, rather than repetitive, chronic failures. Max Ammerman's background is in safety and accident investigation, particularly in the Nuclear Power industry which explains this perspective.
The book is relatively short, at 135 pages, and most will find it to be easily readable. After a short introduction, each of the chapters follows the nine steps in Ammerman's Root Cause Analysis process, namely:
Define Problem/Collect Data
Task Analysis
Change Analysis
Control Barrier Analysis
Event and Causal Factor Charting
Interviews
Determine Root Cause
Develop Corrective Actions
Report
Throughout the book, an example is used, of a high voltage electrical switch that was found to have been incorrectly switched, causing a potential safety incident. This example illustrates the process at work, although I, personally, found the event, and the analysis, to be somewhat simplistic in nature.
There are a number of elements of Ammerman's approach that makes it appropriate only for investigating single events, rather than chronic, repetitive events. These are:
the change analysis step, which asks the question "what was different this time, from all the other times that this task was carried out without an inappropriate action or equipment failure", and
the Event and Causal Factor charting (ECFC) step. Unlike most other Root Cause Analysis processes, the core of the ECFC is not a logical cause-effect sequence, but a time-based sequence of events (with causes and effects attached). In practice, this seems a rather complicated charting method, which runs contrary to the subtitle of this book, which is "A Simplified Approach to Identifying, Correcting, and Reporting Workplace Errors".
Many root cause analysts will also tend to shy away from Ammerman's use of the word "error", as it implies human failure, rather than any deeper systemic or equipment design-related causes. And Ammerman seems to imply, throughout his book, that there is a single "root" cause for every failure, which those who have read Gano's book will see to be simply not the case, in most situations.
Nevertheless, there are some useful techniques illustrated in here, which some may find to be useful in certain situations - for example, Ammerman's outline of Control Barrier analysis is a useful way to identify the various administrative and physical control barriers that are in place which are supposed to have prevented the particular event being analysed from having happened. There is also a very useful chapter on Interviews, which contains many practical tips to ensure that interviews are both time-efficient, and achieve their desired results.
In summary - this book contains some interesting techniques, but would be of most relevance to those who wish to conduct root cause analysis on single, significant events. For those who wish to become experts in Root Cause Analysis, it is a useful addition to the library, but overall, if you were to buy only one book on Root Cause Analysis, I would recommend either Gano's outline of the Apollo method, or Latino and Latino's outline of the ProAct method in preference to this book.
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