Examples

Listed below are some Apollo Root Cause Analysis incident reports and cause and effect charts (also known as Realitycharts) that are in development.  These were created using the RealityCharting™ software, which greatly enhances the Apollo RCA process by automating tasks such as integrity checks.

Note that these are work in progress and do not represent anything close to a fully completed report.   Check back to see how these are progressing.

Engineers and Accident Investigators, please see special note at the bottom of this page.

Note:  All examples are in .pdf files and require the Adobe reader to view.  You can get the reader for free at this address:
http://www.adobe.com/

Construction Crane Collapse, Bellevue Washington, November 16, 2006

This resulted in the tragic death of a young patent attorney from Microsoft, along with tens of millions of dollars worth of property damage and lost revenue.  This Apollo Root Cause analysis shown in this example is at a relatively early stage, and draws primarily from newspaper reports through December 4, 2006.   The analysis is limited as much of the way forward at this point will depend on the engineering and metallurgists reports.  This analysis will be continually refined as the investigation proceeds.  Stay tuned to see of the chosen solutions match with the true root causes of the incident.  (2/27/07: note:  New information was released in Mid February and will be added into this example shortly)

• Incident Report (note no solutions identified as the causal analysis is not yet complete.)

• Apollo Cause and Effect Chart (aka Realitychart)

Arctic Rose

This maritime accident occurred in 2001 and resulted is the loss of 15 lives.  The example shown below was done by an Apollo RCA class at the beginning of day 2.  Note that none of the students in the group that created these Realitycharts had any experience in engineering or accident investigation, yet still did an excellent job in documenting the causes of the accident.  This helps illustrate how even after one day of training, students have begun to think causally.

• Incident Report

• Apollo Cause and Effect Chart (aka Realitychart)

Causes of AIDS Spreading in the United States

This analysis was inspired by the 2006 world AIDS day, along with some insightful articles from the Bill and Melinda Gates Foundation web site. ( www.gatesfoundation.org )  This example illustrates the Apollo RCA method in more of a general problem solving mode (as opposed to a specific incident shown above).  Again, this analysis is far from complete and has not passed the robust integrity checks administered by the RealityCharting™ software.  Regardless, the analysis already illustrates the complexity of the problem and thus the solutions.

• Incident Report (note no solutions identified as the causal analysis is not yet complete.)

• Apollo Cause and Effect Chart (aka Realitychart)

Here’s how you read the cause and effect charts:

Component	Comments
Primary Effect	The event that you want to prevent from recurring
Action Cause	An action type of cause (momentary in nature)
Condition Cause	A condition type of cause (existed over time, as in pre-existing condition
Evidence for Cause	The text below a cause is the evidence for that cause (a ? means evidence must be found or that cause can not be used).  A ? within a cause box is common during an investigation and indicates that the cause is a possibility.  If evidence for that cause is found, it can remain.
Terminations	All causal paths must be properly ended or identified as needing additional investigation

 

Special notes for engineers and accident investigators:

What you see in the Realitycharts (Cause and Effect Charts) appears simple, yet it represents a highly sophisticated approach to accident investigation.  This approach is used in the nuclear, aviation, chemical, petroleum and other fields.  Consider these points:

• The Realitycharts are mapping, in a highly precise way, the cause and effect interactions that culminated in the accident.  These are similar to diagrams used in Fault Tree Analysis, but include only the specific cut-set of what actually happened.
   

• The Realitycharts represent, to a certain degree, the mental processes used by a highly experienced and capable accident investigator.  The Apollo RCA methodology greatly assists the accident investigator by providing a means to document their thinking, the direction to go, and actions required.  The Realitycharts are also helpful for documenting the accident report, and how the evidence supports the recommendations.  Finally, the Realitycharts are highly beneficial as a tool to teach lessons learned about this accident.
   

• The cause and effect interaction is based on simple, yet powerful theory on cause and effect behavior, taught in the Apollo RCA class and explained in Dean Gano's book, Apollo Root Cause Analysis.
   

• Not shown in these diagrams is how solutions (corrective actions) are generated.  This is also explained in Dean Gano's book listed above and covered in class.  Of primary importance is that the Realitycharts and other reports generated by the RealityCharting™ software lets you explain how your proposed solutions map to actual causes of the incident.  (If your solutions don't map to causes, you either haven't solved the problem, or you haven't adequately analyzed it.)
   

• The RealityCharting™ software includes features to automate problem definition, analysis and solution generation.   Depending on the situation (level of risk involved, regulatory requirements, etc.) engineering analysis may be needed in the evaluation and selection of solutions.  For example, appropriate engineering analysis may be required to determine of a solution will prevent recurrence and meets your goals and objectives.   Apollo RCA and engineering evaluation work hand in hand to develop effective solutions.
   

• Apollo RCA is particularly effective for OSHA reportable incidents.  It includes all the basic reportable information, along with a highly effective means for investigation and resolution.