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This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the pet food contamination of 2007 is captured as an example of the Cause Mapping method. The three steps to get to root cause analysis are:
1) Define the problem
2) Conduct the analysis
3) Identify the best solutions
Each step will be discussed below.
Step 1. Define the Problem
The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? One person may say that the problem was contaminated pet food. Another person might say that the problem was that the pet food got into the food supply, and a third person could say that the problem was that pets were sickened and killed. We can write down these three “problems” on the first line. In the Cause Mapping methodology the facilitator anticipates that the group may disagree so all three responses are written down. There is no need to spend time debating the problem. The magnitude of this incident is defined by the impact to the goals. Lets create a cause map to get to the root cause analysis of the problem.
The second question is the "When?" which is the date of the incident. When captures the timing of the issue and also has a line for what was different or unusual in this occurrence. The question of what was different is fundamental in any investigation. On the pet food contamination issue we capture the date as March 15, 2007 when the Food and Drug Adminstration (FDA) was notified that animals were dying from consuming pet food. The animals began to be affected when the pet food manufacturer switched to a Chinese supplier of wheat gluten, which we will capture as a difference.
In an investigation there can be several pieces of information that need to be captured when specifying the location. At a minimum the physical location, which is where geographically the incident happened, should be captured. The contaminated food affected pets around the world.
The next section is the impact to the overall goals. For a food manufacturer, one of the overall goals is to have zero injuries. Some veterinarians suggest that up to 1,000 dogs and cats were killed in the U.S. One of the other goals impacted is the customer service goal. In the case of the contaminated pet food, 150 brands (with 60 million containers of Menu Foods pet food, the most affected brand) were recalled. This was the largest recall in FDA history, and was estimated to cost Menu Foods $54 million. There were other goals that were affected but the magnitude of the loss of life makes any other impacts to the goals less significant. The two goals that are impacted in the pet food contamination example are the safety goal and the customer service goal.
Step 2. Identify the Causes (The Root Cause Analysis)
The Root Cause Analysis step is where the incident is broken down into causes which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in problem outline. For the pet food contamination the safety goal was impacted because of the up to 1,000 dogs and cats that were lost and the customer service goal was impacted because 150 brands of pet food was recalled. These are the first two cause-and-effect relationships in the analysis.
The root cause analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. In this example we’ll start with the loss of lives which was caused by renal failure. The next question is “Why did the renal failure occur?”
The renal failure in dogs and cats occurred because the dogs and cats ate contaminated pet food. The dogs and cats ate contaminated pet food because it was in the food supply.
The other impact to the goals is the recall, which also occurred because contaminated pet food was in the food supply.
Why was the contaminated pet food in the food supply? The food was contaminated with up to 6% melamine and cyanuric acid (CA), and the contaminants were not detected.
The melamine and cyanuric acid (CA) were found in the food because they were added to the raw ingredients to increase the apparent content of the wheat gluten. This reduced the cost for the manufacturer because melamine and cyanuric acid are cheaper than wheat gluten. It increased the apparent protein content because melamine and cyanuric acid mimic the protein response in protein testing.
The contaminants were not detected because standard tests did not detect them, and because of inadequate insepctions and inaccurate paperwork.
Standard tests did not detect the contaminants because melamine and cyanuric acid mimic protein response in protein testing, and because they were not tested for.
Inspections were inadequate because the material did not receive export inspections in China, because the exports were improperly labeled as non-food, and only food items are subject to mandatory inspection. The inspections were also inadequate because FDA officials do not have ready access to Chinese plants because there is no binding agreement between China and the FDA.
The paperwork was inaccurate because the broker certified that the material specification was met, and the material specification forbid foreign material.
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals. The specific action items from the pet food contamination can be matched to specific causes on the detailed Cause Map. The detailed Cause Map can be found on the worksheet labeled "CM - Detail".
Step 3. Select the Best Solutions (Reduce the Risk)
Once the Cause Map is build to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. It is easier to identify many possible solutions from the detailed Cause Map than the oversimplified high level analysis of "the pets were killed because the manufacturer was trying to reduce costs."
There are causes to every issue. The pet food contamination tragedy at a high level has only two causes. At a more detailed level it has 7 causes, 19 causes and 56 causes. All of the levels of the Cause Map are accurate - some simply have more detail that others. An issue should be worked to a sufficient level of detail to prevent the incident, meaning to reduce the risk of the incident occurring to an acceptable level. This is why solutions and work processes at a coffee shop are not as thorough or detailed as an airline or nuclear power facility. The risk or impact to the goals dictates how effective the solutions should be. Lower risk incidents will have relatively lower detail investigations while significantly high risk to an organization’s goals requires a much more through analysis.
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
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