Root Cause Analysis In Process-Based Industries by Horev Menachem

Author:Horev, Menachem [Horev, Menachem]
Language: eng
Format: epub
Published: 2013-05-30T00:00:00+00:00

But more important to us is that learning every one of the above three elements could promote understanding of the others. Identifying the problematic resource (learning the inputs) may provide understanding of the product’s failure mechanism.

Localizing and understanding the flaw within the product (learning what is going within) may point to the problematic resource or process step that caused it. Thorough learning of the product behavior or its measurable properties (learning the outputs) may help in understanding the flaw within it and/or the conditions that created it.

Let’s look at a very old and solid example that shows how learning IUI properties can teach us about the conditions that were needed to create it.

One day King Hiero approached Archimedes and said, “I gave the goldsmith 1 kg of gold and asked him to make the most beautiful crown that ever existed. The goldsmith made a golden wreath, and indeed it is the most beautiful crown I have ever seen. The goldsmith said that he used all the gold and nothing was left. However, I suspect that he took some of the gold for himself and used some silver to build the crown. Please take this crown, check it, do not harm it in any way, and let me know if the goldsmith was honest with me.”

Archimedes could not go to the goldsmith and investigate him or check his tools. He could also not cut out any part of the crown to melt it for checking. But, he knew that 1 kg of gold has the same volume whether in the shape of a gold bar or a crown. So he took an equal weight of pure gold, placed it in a tub of water and marked the water level. Then he took the crown and placed it in the same tub and checked whether the water level reached the exact level of the gold bar. Thus Archimedes identified and used two properties of the crown (IUI) that could teach him about the supplies (conditions).

It is quite obvious that when we discussed the conditions tree earlier, we emphasized our attention to the conditions but neglected the other two elements that are critical to cause identification.

How can we use the other elements in cause identification?

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.