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1...What would be done differently in these examples to improve results,
ASB Inquiry SDS Root Cause Analysis SDS ASB Standard
Root Cause Analysis Care About Understanding Cause Effect Inquiry on
Learning Continual Case Studies Experience History Knowledge Root Ca
Proof of Concept Connect Dots Experience Shows Attitudes Change New
Aerospace company Root Cause Analysis Inquiry SDS ASB Standard 08
Root Cause Analysis Connecting Dots Cause Effect Causation Understan
Business Case SDS Command Control Situational Awareness Saves Time M
SDS Inquiry Root Cause Analysis SDS ASB Standard
2910 - ..
2911 - Summary/Objective
291201 - Follow up ref SDS 27 0000, ref SDS 26 0000.
291203 - Exposure to SDS listed on the Aerospace company intranet yielded an
291204 - inquiry for root cause analysis. ref SDS 0 B36J POIMS explains
291205 - organizational memory and SDS reports assemble chronologies for case
291206 - studies that impart cause and effect for lessons learned. ref SDS 0
291207 - 2S4J Customer inquiry demonstrates people care about discovering and
291208 - understanding causation. We need feedback from customers on the
291209 - outline in NWO showing the scope for intelligence support that
291210 - includes root cause analysis. ref SDS 0 2T3K Research shows SDS meets
291211 - requirements for root cause analysis to access an accurate record
291212 - showing the chronology of events that caused particular results to
291213 - occur. ref SDS 0 AZ9J Root cause analysis is traditionally performed
291214 - by people remembering history of related events, and then building a
291215 - fishbone diagram to understand cause and effect. This is commonly
291216 - called "brainstorming." ref SDS 0 MM9N This method complements SDS
291217 - support for intelligence. Gary found a system of "root contradiction
291218 - analysis" used to reduce the cost of solving problems. ref SDS 0 YR6M
291219 - This article supports POIMS analysis showing SDS provides a new path
291220 - for optimizing productivity by changing the system of information
291221 - technology to a system of knowledge. ref SDS 0 QP9L He reported that
291222 - production plant measurements were not reviewed correctly in this
291223 - record. ref SDS 0 TE9R Further work listed records that complement
291224 - the list in NWO, and which may address Gary's point. ref SDS 0 LG6G A
291225 - letter to Gary linked to his record asks how typical uses cases for
291226 - SDS can be strengthened with improvements and/or complemented by other
291227 - methods. ref SDS 0 OV4L
291229 - [On 040907 request peer review from Morris on SDS support for
291230 - root cause analysis based on the record today. ref SDS 28 0001
291232 - ..
291233 - [On 040915 Gary responded to inquiry, and plans follow up on
291234 - clarifying application requirements. ref SDS 30 OY71
291240 - ..
2915 - Progress
291601 - Aerospace company Request Support Root Cause Analysis
291603 - Follow up ref SDS 25 7P6X.
291605 - A few days ago, Gary advised that Gil got an inquiry about support for
291606 - root cause analysis, based on the SDS standard at Aerospace company developed in
291607 - the record on 040720. ref SDS 25 7P6X Gary responded by telephone
291608 - explaining SDS has not been used for root cause analysis at Aerospace company so
291609 - far.
291611 - [On 040916 Gary wrote follow up letter explaining he was not aware
291612 - of SDS support for root cause analysis, and provided examples
291613 - showing this support. ref SDS 30 OX7F
291615 - ..
291616 - Root cause analysis is discussed in the Aerospace company SDS standard as
291617 - follows...
291619 - ..
291620 - 1. Description........................ 040720, ref SDS 25 7P6X
291622 - ..
291623 - SDS improves the linear model of information technology (IT) by
291624 - adding dimensions for time and context. A multi-dimensional
291625 - Knowledge Space tracks repetitive patterns of experience that
291626 - impart knowledge of cause and effect. ref OF 6 4N3O Context
291627 - management applies common classification methods for
291628 - accounting, WBS, taxonomy, ontology and library science to find
291629 - relevant details on demand. ref OF 6 1110 Chronologies
291630 - assembled by context automatically construct case studies in
291631 - seconds that support root cause analysis, and yield lessons
291632 - learned.
291634 - F:/05/00450/FR/SD/040826CE/00102.htm#7P6X
291636 - ..
291637 - [On 040915 Gary was unaware that SDS supports root cause
291638 - analysis. ref SDS 30 Z47N
291641 - ..
291642 - 2. Audience........................... 040720, ref SDS 25 EH8T
291644 - ..
291645 - Executive and legal support, operations, projects, teams, and
291646 - meetings are typical consumers of "intelligence" for planning,
291647 - progress and action item review, collaboration, decision
291648 - support, case studies, root cause analysis and lessons
291649 - learned.
291651 - F:/05/00450/FR/SD/040826CE/00102.htm#A38H
291653 - ..
291654 - Root cause analysis is a derivitive of SDS "reporting" that enables
291655 - case studies, which yield lessons learned, as set out in POIMS....
291657 - [On 040907 followed up. ref SDS 28 0001
291659 - 1. Linking summary to the details of daily work, as a continuous
291660 - stream of information, builds continual case studies that are
291661 - organized and aligned for root cause analysis to solve
291662 - real-life problems day-to-day, and for discovering new ideas
291663 - and opportunity that save time and money. ref OF 5 7T9I
291665 - [On 040913 example using SDS for root cause analysis to
291666 - avoid and solve future problems. ref SDS 29 4Q5Y
291668 - ..
291669 - [On 040915 Gary was unaware that SDS supports root cause
291670 - analysis. ref SDS 30 Z47N
291672 - ..
291673 - 2. SDS supports capturing the record of organizational memory
291674 - that expands span of attention to strengthen the weak link in
291675 - management by continually creating and using traceability to
291676 - original sources for root cause analysis, by verifying
291677 - accuracy and managing context. ref OF 5 0504
291679 - ..
291680 - 3. Knowledge Space supports command and control by automatically
291681 - creating chronologies of related events that then give
291682 - instant access on demand to relevant history of all events,
291683 - based on situational awareness. Chronologies comprise an
291684 - "audit trail" of alignment based on sequence that imparts
291685 - knowledge of cause and effect, essential for understanding
291686 - the context of why things happened. Case Studies, Lessons
291687 - Learned, Continual Learning, Traceability to Original Sources
291688 - and Root Cause Analysis all derive from command and control
291689 - to construct and access chronologies of cause and effect
291690 - based on the organic structure of context. ref OF 6 4662
291692 - [On 040913 example using SDS for root cause analysis to
291693 - avoid and solve future problems. ref SDS 29 4Q5Y
Average User Cares About Accurate Memory Fast Easy Create Links Caus
Above Average User Cares About Above Average Results Will Invest Mor
Communication Failure Causes Projects to Get Fouled-up for Software
Planning Submit Letter Confirm Assignment for Gary to Become Subject
Perfection Utopia Not Objective Metric for Communication Improves Un
Root Cause Analysis Care About Understanding Cause Effect Inquiry on
Marketing Care About Things SDS Supports Com Metrics Practices for W
521001 - ..
521002 - Care About Understanding Cause and Effect to Solve Problems
521003 - Examples Root Cause Analysis Listed in Outline for Intelligence
521005 - Root cause analysis is an important part of SDS support that people
521006 - care about, which addresses Gary's questions on 020217. ref SDS 20
521007 - 425M The scope of root cause analysis, ref OF 12 QP5I, flows from
521008 - linking and reporting that are part of intelligence support listed in
521009 - NWO. ref OF 12 HH5L
521011 - ..
521012 - [On 040913 example using SDS for root cause analysis to
521013 - avoid and solve future problems. ref SDS 29 4Q5Y
521015 - ..
521016 - Aerospace company's inquiry about root cause analysis this past week, reflects
521017 - demand on a defense project, where a senior manager related a need for
521018 - analysis last year on 030830. ref SDS 22 TY9H Two (2) days earlier on
521019 - 030828 Aerospace company's customer wanted support on organizational memory that
521020 - enables case studies for root cause analysis. ref SDS 21 SE7L The
521021 - inquiry today illustrates opportunities for using SDS to save time and
521022 - money, based on the ASB, per above, ref SDS 0 B36J, and explained in
521023 - POIMS. ref SDS 0 2S4J
521025 - ..
521026 - Feedback from Aerospace company on support for "root cause analysis"
521027 - explained in foundational documents, e.g., POIMS, ref OF 5 12F2, can
521028 - help shape the list of examples in NWO for decision supprt, case
521029 - studies and lessons learned, ref OF 12 RF4M, to address the needs of
521030 - people on the job.
521032 - [On 040915 Gary performed this task; planned follow up.
521033 - ref SDS 30 OY71
521035 - ..
521036 - [On 040924 Gary followed up on inquiry for support to perform
521037 - root cause analysis. ref SDS 31 K46N
521039 - ..
521040 - Examples in NWO illustrate how failure to perform root cause
521041 - analysis causes failure; NASA morphed requirements into goals and
521042 - suggestions, because they could not exercise diligence to perform
521043 - root cause analysis with existing skills and tools. ref OF 12 N54O
521045 - ..
521046 - Diligence is linked to explain need for better tools, ref OF 13
521047 - FU6J, developed in NWO on 040709. ref SDS 24 5P8N
Root Cause Analysis Definition
Definition Case Studies Root Cause Analysis Lessons Learned
Root Cause Analysis SDS Makes Cost Effective Reduces Time Effort
Root Cause Analysis Definition
580701 - ..
580702 - Root Cause Analysis Definition Aligns with SDS Intelligence Support
580704 - There is a definition of support using SDS for root cause analysis,
580705 - based on case studies, per above. ref SDS 0 2S4J
580707 - Research on the Internet shows...
580709 - ..
580710 - Root cause analysis is generally defined....
580712 - http://www.rootcause.com/WhatIsRCADetail.htm
580714 - ...says in part...
580716 - Generally speaking, root cause analysis is a procedure for
580717 - ascertaining and "analyzing" the causes of problems in an
580718 - effort to determine what can be done to solve or prevent them.
580719 - ref OF 20 3P4X
580721 - [On 040913 example using SDS for root cause analysis to
580722 - avoid and solve future problems. ref SDS 29 4Q5Y
580724 - ..
580725 - This definition aligns with "root cause analysis" called out in POIMS
580726 - that flows from case studies that yield lessons learned, per above.
580727 - ref SDS 0 2S4J SDS support "good management" enables "working
580728 - intelligently" for proactive discovery that prevents problems, defined
580729 - in POIMS. ref OF 3 1X6G
580731 - ..
580732 - Another location on the Internet....
580734 - Sentinel Events and Root Cause Analysis in Healthcare
580736 - ...at...
580738 - http://www.rootcauseanalyst.com/credible.htm
580740 - ...describes....
580742 - ..
580743 - Thorough Root Cause Analysis:
580746 - 1. identifies proximate causes (late-stage variations and
580747 - related processes) and systems
580749 - ..
580750 - 2. reviews related systems and processes
580752 - ..
580753 - 3. identifies underlying/system-related cause(s) of the
580754 - proximate cause(s) and explains their potential role in the
580755 - event
580757 - ..
580758 - 4. continuously focuses on opportunities to improve systems,
580759 - and if none are apparent, can explain why
580761 - ..
580762 - 5. outlines a plan to address opportunities to improve or
580763 - explains why the organization isn't addressing those
580764 - opportunities
580766 - ..
580767 - 6. explains - when improvement plans are justified -
580769 - 1. who will carry out the plan;
580771 - 2. when that person(s) will carry out the plan; and
580773 - 3. the methods for measuring results
Root Cause Analysis Brainstorming Fish Bone Diagram Root Cause Analy
Brainstorming Root Cause Analysis Fish Bone Diagram Root Cause Analy
Strategic Planning Long Term Performed with Cursory Planning Methods
660601 - ..
660602 - Brainstorming Flow Fisheye Diagrams
660603 - Fish Bone Diagram Root Cause Analysis Ishikawa
660606 - Another location on the Internet...
660608 - http://systems2win.com/solutions/brainstorming.htm
660611 - ....Systems2win offers specially constructed templates for Excel
660612 - spreadsheets, and is described as...
660615 - ..
660616 - Brainstorming and Root Cause Analysis Templates
660618 - At some time or another, every Team needs to "put their heads
660619 - together". In the past, this has involved walls plastered with
660620 - sticky notes, and someone staying long after the meeting to
660621 - transcribe the group's decisions and insights.
660623 - ..
660624 - The Systems2win Root Cause Analysis Excel template makes it
660625 - easy to:
660627 - 1. Quickly record people's ideas as fast as they can generate
660628 - them - with "handwriting" that everyone can read!
660630 - 2. Keep asking "why?" until you begin to arrive at the root
660631 - causes for your problem - so that you can "dig it out by the
660632 - roots" instead of "hacking at the leaves".
660634 - ..
660635 - 3. Easily re-arrange ideas into logical groups - spawning even
660636 - better ideas.
660638 - ..
660639 - 4. When the session is over, everyone (including the leader) can
660640 - get right back to work - because everything is organized
660641 - perfectly, and ready to store electronically
660643 - ..
660644 - The Root Cause Analysis template makes it very easy to "draw
660645 - outside the lines" to quickly record people's ideas. You can
660646 - quickly move things around - ultimately ending up with a
660647 - professional-looking completed Ishikawa Fish Bone Diagram that you
660648 - can store electronically along with all of the other documents that
660649 - your Team used to improve this process.
660652 - ..
660653 - Skymark History of Cause Effect Diagram
660654 - Background and History Ishikawa Fish Bone Diagram
660655 - Ishikawa Fish Bone Diagram Background and History
660658 - Another location....
660660 - http://www.skymark.com/resources/tools/cause.asp
660662 - ..
660663 - Pathmaker Software offers Management Resources for...
660665 - 800.826.7284 or 1 412 371 0680
660667 - The cause & effect diagram is the brainchild of Kaoru Ishikawa, who
660668 - pioneered quality management processes in the Kawasaki shipyards,
660669 - and in the process became one of the founding fathers of modern
660670 - management. The cause and effect diagram is used to explore all
660671 - the potential or real causes (or inputs) that result in a single
660672 - effect (or output). Causes are arranged according to their level of
660673 - importance or detail, resulting in a depiction of relationships and
660674 - hierarchy of events. This can help you search for root causes,
660675 - identify areas where there may be problems, and compare the
660676 - relative importance of different causes.
660678 - ..
660679 - Causes in a cause & effect diagram are frequently arranged into
660680 - four major categories. While these categories can be anything, you
660681 - will often see:
660683 - ..
660684 - manpower, methods, materials, and machinery (recommended for
660685 - manufacturing)
660687 - ..
660688 - equipment, policies, procedures, and people (recommended for
660689 - administration and service).
660692 - ..
660693 - These guidelines can be helpful but should not be used if they
660694 - limit the diagram or are inappropriate. The categories you use
660695 - should suit your needs. At SkyMark, we often create the branches of
660696 - the cause and effect tree from the titles of the affinity sets in a
660697 - preceding affinity diagram.
660699 - ..
660700 - The C&E diagram is also known as the fishbone diagram because it
660701 - was drawn to resemble the skeleton of a fish, with the main causal
660702 - categories drawn as "bones" attached to the spine of the fish, as
660703 - shown below
660705 - ..
660706 - To successfully build a cause and effect diagram:
660708 - 1. Be sure everyone agrees on the effect or problem statement
660709 - before beginning.
660711 - 2. Be succinct.
660713 - ..
660714 - 3. For each node, think what could be its causes. Add them to
660715 - the tree.
660717 - ..
660718 - 4. Pursue each line of causality back to its root cause.
660720 - ..
660721 - 5. Consider grafting relatively empty branches onto others.
660723 - ..
660724 - 6. Consider splitting up overcrowded branches.
660726 - ..
660727 - 7. Consider which root causes are most likely to merit further
660728 - investigation.
660730 - ..
660731 - Other uses for the Cause and Effect tool include the organization
660732 - diagramming, parts hierarchies, project planning, tree diagrams,
660733 - and the 5 Why's.
Analysis Paralysis When Root Cause Analysis Isn't the Way, Darrell M
S Curve Changing Systems Offers Path to Improve Productivity After C
SDS Changes Information Tech to New S Curve Culture of Knowledge Cur
Paradigm Shift Productivity Improves Historically Applies Moore's La
950701 - ..
950702 - Root Contradiction Analysis Innovation Avoids Paralysis
950703 - Analysis Paralysis New System Innovation Find Root Contradictions
950706 - A few days later, Gary submitted a letter citing an Internet
950707 - address...
950709 - http://www.triz-journal.com/archives/2002/05/b/
950711 - ...with an article....
950713 - Analysis Paralysis:
950714 - When Root Cause Analysis Isn't The Way
950716 - ..
950717 - Darrell Mann
950718 - Director, CREAX n.v., Ieper, Belgium
950719 - (1275) 342960
950720 - email@example.com
950722 - ..
950723 - The article says in part...
950725 - "The usual approach to problem-solving is to identify and
950726 - remove the cause of the problem. Sometimes this is not possible
950727 - because the cause cannot be found; because there are too many
950728 - causes; or because the cause is human nature and cannot be
950729 - removed. In such cases we are usually paralysed."
950731 - ..
950732 - Edward De Bono
950734 - [On 040913 example using SDS for root cause analysis to
950735 - avoid and solve future problems. ref SDS 29 4Q5Y
950739 - ..
950740 - Data Collection Research Makes Root Cause Analysis Difficult
950741 - S Curve Changing Systems Offers Path to Improve Productivity
950742 - Paradigm Shift Changes System to New Productivity Growth S Curve
950743 - SDS Changes Information Tech to New S Curve Culture of Knowledge
950746 - Abstract says root cause analysis identifies problems, and fits
950747 - Deming's understanding that quantifying problems is difficult. The
950748 - conclusion says that determining causation is not cost effective for
950749 - improving systems that have been optimized for many years. Better
950750 - performance requires changing the system to provide a new "S" curve
950751 - with greater potential for optimization; solving contraditions is a
950752 - great way to discover systemic changes. The author therefore
950753 - proposes...
950755 - ..
950756 - root contradiction analysis
950758 - ..
950759 - ....which requires less analysis time and effort, and more often than
950760 - not delivers more powerful solutions using the knowledge/effects part
950761 - of the TRIZ problem solving toolkit for patent-search. The author
950762 - concludes that research gathering experimental data for several years
950763 - is not the best analysis method for understanding problems and
950764 - discovering solutions. Several years - or even months or weeks -
950765 - should suggest there ought to be a better way than the traditional
950766 - `trade-off' mind-set.
950768 - ..
950769 - NWO explains gathering data is the strength of military intelligence,
950770 - but that doing analysis is the weak link, ref OF 12 V39M, which is
950771 - supported by SDS, ref OF 12 A56M, and cited below. ref SDS 0 M46H
950773 - ..
950774 - People do not routinely research problems and discover opportunities
950775 - because gathering data and analysis take time and cost a lot of money
950776 - using traditional tools, per the article Gary submits, reviewed above,
950777 - ref SDS 0 JX87, which was previously noted during a meeting at
950778 - Stanford on 900703, ref SDS 3 1716, and cited in a study showing
950779 - people waste 70% of the day in unproductive meetings, because people
950780 - do not have time to be prepared, reported on 960205, ref SDS 6 114H,
950781 - and despite calls by Drucker that analysis is a core responsibility of
950782 - management, reviewed on 931130. This article further supports research
950783 - on 000307 that good management is a lot of hard work that discourages
950784 - performance using traditional information technology, ref SDS 16 5182,
950785 - noted by Gary on 040227. ref SDS 23 RH6K
950787 - [On 040907 Morris related experience at Chips and Intel showing
950788 - that root cause analysis is hard work. ref SDS 28 6D4O
950790 - ..
950791 - POIMS improves the performance "S" curve for the traditional system of
950792 - information technology based on the alphabet by changing to a new
950793 - system (i.e., a new way of working, see POIMS, ref OF 5 11G5) adding
950794 - intelligence to convert information into knowledge. ref OF 5 2000 As
950795 - set out in the article, this change from information to a culture of
950796 - knowledge lifts civilization to a new plateau, ref OF 5 6528,
950797 - introducing a new "S" curve that provides a new path with initial
950798 - "unlimited" potential to optimize improvements, shown by the record
950799 - the past few years, listed on 000824, ref SDS 17 0001, and encapsuled
950800 - by the Moore's Law. ref OF 6 SV9H
Root Cause Analysis SDS Makes Cost Effective Reduces Time Effort
Time to Think Com Manager Invests Time Produce Intelligence So Manag
AB0501 - ..
AB0502 - SDS Makes Root Cause Analysis Cost Effective Reduces Time Effort
AB0505 - The introduction says root cause analysis requires data. Asking `why'
AB0506 - means we have to understand the system. To understand the system
AB0507 - requires data. Usually, lots of data. Very often the cost and time
AB0508 - involved in capturing that data can be prohibitive.
AB0510 - An example illustrating the challenge of gathering data for "root
AB0511 - cause analysis" using traditional methods was presented at a Cal
AB0512 - Tech seminar on loss of the Challenger Space Shuttle, reported on
AB0513 - 970524. In that case the government spent a lot of money
AB0514 - collecting a lot of data. ref SDS 11 7298
AB0516 - ..
AB0517 - SDS solves this problem by making root cause analysis cost
AB0518 - effective, reported by USACE that found SDS saves time and money at
AB0519 - the rate of 10:1. ref DRP 5 0001
AB0521 - ..
AB0522 - In addition to constructing organizational memory that expedites
AB0523 - case studies for root cause analysis, SDS functionality, the design
AB0524 - based on chronology, and support for the organic structure of
AB0525 - context makes organization and creating connections, essential for
AB0526 - analysis to identify correlations and contradictions, mentioned in
AB0527 - Gary's second letter, per above, ref SDS 0 YR6M, faster and easier
AB0528 - than using traditional methods.
AB0530 - [...below, Gary feels more evidence is needed on using SDS to
AB0531 - analyse production measurements, in order to analyse the point
AB0532 - of this article. ref SDS 0 TE9R
AB0534 - ..
AB0535 - [On 040913 example using SDS for root cause analysis to avoid
AB0536 - and solve future problems. ref SDS 29 4Q5Y
AB0538 - ..
AB0539 - The authors describe a case study that says if root cause analysis
AB0540 - takes a few hours, this is not a problem. But if it means a
AB0541 - person-year and still no answer, we should start to ask whether there
AB0542 - is a better way.
AB0544 - SDS takes only seconds to assemble root cause analysis that enables
AB0545 - people to understand why problems occurred, and point to a solution
AB0546 - that saves time and money, reported on 981027. ref SDS 15 IA3G
AB0548 - ..
AB0549 - SDS is so cost effective, that a report on root causes was provided
AB0550 - a second time, after USACE lost the first report. ref SDS 15 H661
AB0552 - ..
AB0553 - On 970723 USACE reported that traditional methods of root cause
AB0554 - analysis using popular methods and tools is not cost effective,
AB0555 - ref SDS 13 2026, citing the record on 970702. ref SDS 12 9999
AB0557 - [...below, Gary feels more evidence is needed on using SDS to
AB0558 - analyse production measurements, in order to analyse the point
AB0559 - of this article. ref SDS 0 TE9R
Rod Missed Point Article Root Contradiction Analysis Says Root Cause
SDS Limitations Data Gathering Not SDS Use for Production Plant Meas
AG0501 - ..
AG0502 - Gary explains in a follow up letter....
AG0504 - 1. Subject: RE: SDS Makes Root Cause Analysis Cost Effective
AG0505 - Date: Wed, 8 Sep 2004 07:23:16 -0700
AG0513 - ..
AG0514 - Rod Missed Point Root Cause Analysis not Always Right Tool
AG0515 - Root Cause Analysis not Always Right Tool Rod Missed Point
AG0516 - Production Measurements Present Challenges for Analysis
AG0519 - Gary says...
AG0521 - 2. I think you missed the point of the article to some degree. It
AG0522 - isn't addressing only the expense, but the feasibility of root
AG0523 - cause analysis in some situations. The De Bono quote makes it
AG0524 - clear that there are times when root cause analysis is simply
AG0525 - not the right tool.
AG0527 - [On 040913 example using SDS for root cause analysis to
AG0528 - avoid and solve future problems. ref SDS 29 4Q5Y
AG0530 - ..
AG0531 - [On 040915 Gary cited this record to Michael illustrating
AG0532 - how SDS supports root cause analysis. ref SDS 30 W74H
AG0534 - ..
AG0535 - [On 041210 frustration, anger about inaccurate, exaggerated
AG0536 - claims for SDS, overlooking good points of other tools.
AG0537 - ref SDS 32 F08O
AG0539 - ..
AG0540 - [On 041210 Gary objects to proposal for reciprocal review
AG0541 - of Ceryle and SDS, based on inference that proposal is for
AG0542 - copying a source, rather than using the source for a
AG0543 - template to prepare fresh content. ref SDS 32 F08O
AG0545 - ..
AG0546 - 3. "The usual approach to problem-solving is to identify and
AG0547 - remove the cause of the problem. Sometimes this is not possible
AG0548 - because the cause cannot be found; because there are too many
AG0549 - causes; or because the cause is human nature and cannot be
AG0550 - removed. In such cases we are usually paralyzed."
AG0552 - Edward De Bono
AG0554 - ..
AG0555 - 4. Having said that, it is clear that, when in regular use to
AG0556 - maintain organizational memory, SDS can dramatically reduce the
AG0557 - discovery effort involved in root cause analysis, which is the
AG0558 - point you make.
AG0560 - [On 040913 example using SDS for root cause analysis to
AG0561 - avoid and solve future problems. ref SDS 29 4Q5Y
AG0563 - ..
AG0564 - 5. Note, however, that the costs you refer to in the record on
AG0565 - 040905, ref SDS 0 FT48, involve production plant measurements,
AG0566 - which is not the sort of data for which SDS is generally used.
AG0567 - The case study involved running experiments in an attempt to
AG0568 - isolate variables, where the history wasn't available. The
AG0569 - technique being applied was wrong, and the fact that a person
AG0570 - year had been spent without resolution should have been far
AG0571 - more than enough to indicate to someone that they were on the
AG0572 - wrong path.
AG0574 - [On 040913 example using SDS support to run experiments
AG0575 - isolating variables for root cause analysis to avoid and
AG0576 - solve future problems. ref SDS 29 4Q5Y
AG0578 - ..
AG0579 - [On 040915 Gary cited this record to Michael illustrating
AG0580 - how SDS supports root cause analysis. ref SDS 30 W74H
AG0582 - ..
AG0583 - 6. Now, where SDS would have been immensely effective in this case was in
AG0584 - helping diagnose that the approach wasn't producing results far earlier, and
AG0585 - to suggest that a different approach be tried.
AG0588 - ..
AG0589 - Different Method from Root Cause Analysis Finds Contradictions
AG0590 - Contradiction Different Method Using SDS from Gary's Experience
AG0592 - 7. The fact that there is an entirely *different* analysis method
AG0593 - that can be used in some cases where root cause analysis in not
AG0594 - appropriate is a *big idea*. I intend to pursue this a bit, as
AG0595 - it is clear that this is a problem solving technology worth
AG0596 - investigating.
AG0598 - ..
AG0599 - Wayne Wetzel's report on SDS received on 010725 explains how conflict
AG0600 - and contradition are critical Communication Metrics based on negative
AG0601 - response, supported by SDS. ref SDS 19 KM7G
AG0603 - ..
AG0604 - Below is a list of problems reviewed with SDS by analysing
AG0605 - contraditions along with correlations. ref SDS 0 AH4F
AG0607 - [...below request explanation of how this different method
AG0608 - of analysis would contribute to examples using SDS.
AG0609 - ref SDS 0 OV4L
AG0611 - ..
AG0612 - [On 040913 example using SDS support to run experiments
AG0613 - isolating variables for root cause analysis to avoid and
AG0614 - solve future problems. ref SDS 29 4Q5Y
AG0616 - ..
AG0617 - [On 040915 Gary cited this record to Michael illustrating
AG0618 - how SDS supports root cause analysis. ref SDS 30 W74H
Examples Use Cases SDS Production Measurement Analysis Rod Distorted
AL0401 - ..
AL0402 - Examples Use Cases SDS Production Measurement Analysis
AL0403 - Cherry Picking the Record Causes Distorted Analysis
AL0404 - Analysis Must Address Issues Rather than Merely the Gist
AL0405 - Distorted Analysis Causes Incorrect Conclusions Solutions
AL0408 - Gary continues...
AL0410 - We need to be aware that when we use analysis of some reported
AL0411 - case in the literature as was done here, that we need to take
AL0412 - care to address the issues raised correctly. Whenever we use
AL0413 - the "gist" of an article to launch an unrelated support of SDS,
AL0414 - we run the risk of losing credibility.
AL0416 - ..
AL0417 - This is a good point; investing time to find and list evidence on
AL0418 - "measurements," "production measurements," and on "production plant
AL0419 - measurements," noted by Gary, per above, ref SDS 0 FT48, might help
AL0420 - demonstrate how SDS saves time and money doing analysis.
AL0422 - [On 040915 Gary cited this record to Michael illustrating
AL0423 - how SDS supports root cause analysis. ref SDS 30 W74H
AL0425 - ..
AL0426 - Gary continues...
AL0428 - 8. We need to do careful and correct analysis of what is actually
AL0429 - said rather than taking a few select points to support our
AL0430 - point of view.
AL0432 - ..
AL0433 - Gary makes a good explanation using SDS for the 8 steps of Com
AL0434 - Metrics, listed in the record on 001219, ref SDS 18 4W4L, and cites
AL0435 - consideration of "production plant measurements," ref SDS 0 UH5V, was
AL0436 - not expressly discussed in analysis that concludes SDS makes root
AL0437 - cause anlaysis cost effective. ref SDS 0 FT48
AL0439 - ..
AL0440 - Examples in the NWO that ouline intelligence support for root cause
AL0441 - analysis that drives decision making show that "production
AL0442 - measurements" have been analysed in SDS many times. ref OF 12 RF4M
AL0443 - Many of these examples illustrate using SDS for understanding what
AL0444 - was actually said, per Gary's point.
AL0446 - [On 040913 example using SDS support to run experiments
AL0447 - isolating variables for root cause analysis to avoid and
AL0448 - solve future problems. ref SDS 29 4Q5Y
AL0450 - ..
AL0451 - Examples using SDS for analysing causation when all of the data was
AL0452 - not available, and was facilitated by the SDS design listed above,
AL0453 - ref SDS 0 M46H, that facilitates studying contradictions, as well as
AL0454 - correlations, proposed by the research Gary submits today, also, per
AL0455 - above. ref SDS 0 YR6M
AL0457 - ..
AL0458 - These additional examples analyse production measurements discussed in
AL0459 - Gary's letter today, per above, ref SDS 0 UH5V, as follows...
AL0461 - [On 040915 Gary cited this record to Michael illustrating
AL0462 - how SDS supports root cause analysis. ref SDS 30 W74H
AL0464 - 1. Draft Tube Liner on Broadwater
AL0465 - Dam production measurements
AL0466 - root cause analysis solves
AL0467 - tolerance deviations................ 880823, ref SDS 1 0Y5R
AL0469 - ..
AL0470 - 2. Curb ring failed to meet specified
AL0471 - tolerances, but all of the data
AL0472 - was difficult to obtain, similar
AL0473 - to Gary's issue today, ref SDS 0
AL0474 - TE9U................................ 881201, ref SDS 2 CP5Y
AL0476 - ..
AL0477 - 3. Root cause analysis reviewed
AL0478 - contraditions and conflicts,
AL0479 - recommended by article on
AL0480 - "Analysis is Paralysis",
AL0481 - ref SDS 0 JX87 to develop a
AL0482 - solution posture for allowing
AL0483 - work to proceed, and protecting
AL0484 - interests of the
AL0485 - parties............................. 881201, ref SDS 2 0R69
AL0487 - ..
AL0488 - 4. Root cause analysis shows
AL0489 - front loading bid distorts
AL0490 - profit on production
AL0491 - measurements, leading to
AL0492 - false claim for extra
AL0493 - payment when data quantities
AL0494 - increase............................ 960919, ref SDS 7 7855
AL0496 - ..
AL0497 - 5. Root cause analysis of Navy
AL0498 - Sewer Line problem shows
AL0499 - opportunity for Contractor,
AL0500 - Owner and Railroad to all
AL0501 - benefit............................. 961010, ref SDS 8 4562
AL0503 - ..
AL0504 - 6. Case study on Navy Sewer Line
AL0505 - solution illustrates using
AL0506 - SDS for analysis to assist
AL0507 - people in saving time and
AL0508 - money on complex production
AL0509 - measurement problems where
AL0510 - data is hard to collect
AL0511 - and is regularly lost after
AL0512 - being found, again, and
AL0513 - again and again..................... 971017, ref SDS 14 6430,
AL0515 - ..
AL0516 - 7. Analysis shows errors in
AL0517 - production measurements do
AL0518 - not support Schedule proposal....... 961113, ref SDS 9 5838
AL0520 - ..
AL0521 - 8. Analysis of schedule shows
AL0522 - conflicts in data offered for
AL0523 - production measurements............. 961113, ref SDS 9 5838
AL0525 - ..
AL0526 - 9. Root cause analysis found
AL0527 - errors in Dutra's Schedule
AL0528 - based on conflicts in
AL0529 - measurements of production
AL0530 - data................................ 970202, ref SDS 10 0000
Analysis Construct Organizational Memory Aided by SDS History Need N
AS0401 - ..
AS0402 - Gary continues...
AS0404 - ..
AS0405 - Analysis Construct Organizational Memory Aided by SDS
AS0406 - Organizational Memory Concurrent Discovery Supported by SDS
AS0408 - 10. The point in the record [on 970702, ref SDS 12 9999, that a
AS0409 - carefully crafted SDS record which maintains the relationships
AS0410 - among documents, decisions, and actions is much more cost
AS0411 - effective than trying to create such a record long after the
AS0412 - fact is a telling one.
AS0414 - ..
AS0415 - SDS has been effective for starting project, as Gary discusses in this
AS0416 - part of his letter. There is a common perspective that SDS is only
AS0417 - effective when used to start a project; and this criteria has been
AS0418 - used often to disapprove using SDS to support work in progress; people
AS0419 - select instead methods like root contradiction analysis, that seem to
AS0420 - indicate getting things done at less cost. (see for example Bill
AS0421 - DeHart's comments on 940628, ref SDS 4 9052)
AS0423 - ..
AS0424 - Gary continues...
AS0426 - 11. Any attempt to analyze business events in the absence of such a
AS0427 - record is far more difficult than it should be, which is one of
AS0428 - the main points of using SDS for organizational memory. As we
AS0429 - have discussed, any reasonable form of organizational memory
AS0430 - would be better than none, but SDS provides a set of features
AS0431 - that support this effort far better than other tools.
AS0433 - ..
AS0434 - POIMS explains advantages of organizational memory that align with
AS0435 - Gary's comments.
AS0437 - ..
AS0438 - SDS functionality, noted above, ref SDS 0 OY5O, has been effective for
AS0439 - analysing causation to strengthen decision support on work that has
AS0440 - been in progress for many years prior to using SDS, shown by examples
AS0441 - above. ref SDS 0 LG6G On 941004 Bill DeHart at PG&E commented on this
AS0442 - support. ref SDS 5 0785
AS0444 - ..
AS0445 - What would be done differently in these examples to improve results,
AS0446 - either by improving SDS or adding support from other methods, cited by
AS0447 - Gary today, per above? ref SDS 0 TF3Q
AS0449 - ..
AS0450 - Gary concludes...
AS0452 - 12. Thanks,
AS0454 - ..
AS0455 - 13. Gary