Webinar Archives
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Cause Mapping Webinar archives
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Missed a Webinar? View our collection of archived Webinars below!

 

ROOT CAUSE ANALYSIS
PROCESS AND PROCEDURE
CAUSE MAPPING IN EXCEL
ROOT CAUSE ANALYSIS CASE STUDY
HEALTHCARE CASE STUDIES

5-Why DOs and DON’Ts

A widely known tool that is regularly misused. An accurate 5-Why provides a simple way to start a cause-and-effect analysis. This Webinar covers some important DOs and DON’Ts that will explain how the technique is confused and how it should be used. Topics will include:
• 5-Why Basics and Benefits
• Drawbacks and Misuse of a 5-Why
• Does a 5-Why align with a Cause Map®?
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How to Start with a 5-Why…and then Expand it

5-Why is one of the most recognized problem-solving tools. The concept is simple, but its application varies widely. Because it's misunderstood, 5-Why is frequently discounted as too simple, not quantitative and not repeatable. I’ll explain the confusion with each of those criticisms using an example problem. Learn how the effective use of 5-Why engages your front-line people to find simpler and better solutions
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Human Error, Human Performance and Human Factors

How does an organization reduce errors in their operations? There are different schools of thoughts on preventing human error and improving human performance. This webinar covers how the Cause Mapping method is used to investigate errors people make. It will explain different types of errors and provide simple approaches for minimizing human error within your organization.
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Basics of Cause Mapping - Effective Root Cause Analysis

Learn how to become better at solving problems in your job! During this Webinar, we’ll demonstrate the Cause Mapping method, as well as answer your specific questions about our approach to root cause analysis. The Cause Mapping method is evidence-based cause-and-effect, and can be used on day-to-day issues as well as catastrophic incidents. Anyone wanting to become a more effective manager or team member can benefit from this discussion. Take away practical tips that can be implemented immediately!
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Are you Missing Anything in Your Root Cause Analysis Program?

During this Webinar, you’ll learn more about the five basic elements for establishing a comprehensive root cause analysis program: the method; measurements; roles in the investigation process; facilitation, documentation & storage; and review of the entire program.
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Facilitating and Documenting a Root Cause Analysis

A problem in your business can be thought of as an “information knot.” Different people from different departments each know part of the problem. The facilitator collects and organizes all of the details in an incident. He or she essentially untangles the knot to provide complete explanation of what happened and why. An effective facilitator provides clarity. Sometimes people think of a facilitator as the person who leads meetings, but a root cause analysis facilitator manages the entire investigation process. It starts from the time an incident occurs and continues through the analysis and documentation, to the implementation of solutions and the communication of lessons learned. This Webinar explains the basics of facilitation and the role it plays in understanding and preventing problems in your business.
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Prevention vs. Blame: Which Approach Best Reflects Your Organization?

When a problem occurs in a company, it’s important to understand exactly how it happened. Organizations with a blame mentality typically have a difficult time getting details. People with first-hand information are less likely to share facts if they think it will result in disciplinary action, in short, because they don’t want to lose their jobs. Organizations focused on prevention have to make it easier for employees to share what they know so that the analysis is accurate. Management may believe that a prevention focus undermines accountability, but it doesn’t have to. A bias for prevention can actually help define accountability, especially if the specifics within a particular work process have not been clearly defined. In that case, the people closest to the work will have to be involved in both the problem investigation and the solutions. This Webinar covers the basic differences between these opposing approaches and explains the benefits of establishing a prevention culture.
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Risk, Reliability, & Root Cause Analysis

This presentation, for both you and your managers, clarifies the connection between risk, reliability and root cause analysis. These three topics can sometimes be vague theories rather than concrete disciplines. Companies inadvertently make problem solving too complicated. Six-week quality programs that leave people confused, 300 puzzling “cause codes” and frustrating investigations are not just counterproductive, they can be detrimental. It can erode the effectiveness of an organization. Your problems are confusing enough; your problem solving tools shouldn’t make it worse. Employees who are inundated with techniques, methods and software can lose track of the basics. All problem solving efforts should be focused on your company’s goals with a bias toward principles
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Six Common Errors in Problem Solving

Organizations apply a variety of tools to solve problems, improve operations and increase reliability—many times without success. Why? More than likely, they make one or a combination of six common errors. Overcoming these errors involves knowing why they happen and how to prevent them. Armed with this knowledge, both employees and managers can improve problem-solving in any organization.
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Titanic Problems - How to Make Complex Investigations Easier

Understand How to Untangle a Big Problem: A Titanic Problem in your organization is one of those big issues that consists of many little things. All of those little things, when they occur on their own are relatively minor, but when they happen together results in a major incident. A thorough root cause analysis provides a clear explanation of how and why a problem occurred. It untangles the incident to create a much clearer understanding of the details. This makes it easier to identify specific solutions. Big problems are solved by recognizing the little things that can be done to mitigate risk. This Webinar explains a consistent approach for working big and small issues in your business.
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Fishbone Diagram DOs and DON'Ts

The fishbone cause-and-effect diagram is recognized as a standard quality tool around the world. Working from Ishikawa’s original idea, there are five lessons that can improve the way people define a problem, dissect the causes and discover effective solutions.
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Creating and Using Cumulative Cause Maps

While most Cause Maps are built to investigate one specific issue, a Cumulative Cause Map provides a way to collect multiple failures on one map. The basics of cause-and-effect remain the same for a Cumulative Map, but the analysis builds a little differently. This Webinar will show the basics of building a Cumulative Cause Map and different ways organizations can use them.
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The Important Connection Between RCA & FMEA

Root cause analysis (RCA) is typically used for investigating why a problem did occur so that specific solutions can be implemented to prevent it from occurring again. Failure modes effect analysis (FMEA) is used to understand how a problem could happen in the future, to identify what actions should be taken to prevent it. Connecting these two approaches can improve the way your organization dissects and prevents problems.
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Investigating Workplace Injuries

This Webinar demonstrates the use of the Cause Mapping method of root cause analysis to investigate workplace injuries. We’ll look at burns, contamination, slips, trips and falls to better understand the factors influencing workplace injuries, how to investigate these injuries, and how to decrease the number of injuries in the workplace.
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5-Why Case Study: Start Simple, then Expand the Incident Investigation

During this case study Webinar, we review an actual incident of an ‘Eye Injury’ to show the issues around tool selection, personal protective equipment, procedures and a delayed response to medical treatment. Every investigation can begin with a few simple Why questions that can expand into a more thorough analysis. We will show you how better solutions get forfeited if the analysis stops too early.
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Evaluating Incident Investigations - 5 Checkpoints

Your team has completed an investigation – now what? This Webinar discusses specific ways to evaluate and improve Cause Mapping incident investigations, including tying investigations to work processes, using logical cause-and-effect reasoning, ensuring adequate evidence, and making a plan for implementing effective action items. We review 5 checkpoints to be used to evaluate an incident investigation.
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Where do you slice the cheese? Leveraging the real value of the Swiss Cheese Model to drive down risk

The Swiss cheese model of accident causation is a conceptual model that visually represents how a high severity problem is comprised of a system of breakdowns within an organization. Its value lies in its ability to demonstrate that a problem must pass through “layers of protection” that organizations have already designed and built into their systems and processes. This webinar will explain the important lessons within the model, address criticism, and highlight the most important takeaways that are often overlooked. We will demonstrate how to leverage the valuable lessons the model reveals on risk and reliability into real world application for your organization.
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Linking Work Process and Cause-and-Effect

This Webinar shows how work process and cause-and-effect tie together to complete an investigation. Attendees will see how a process map can be used to identify breakdowns in their work processes. The process map allows investigators to be more specific, leading to more effective solutions.
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How to Investigate 'Procedure Not Followed'

The term “procedure not followed” is used to explain when a person didn’t follow a defined work process. Many organizations mistakenly believe “procedure not followed” is the end of an investigation. The next question, “Why wasn’t the procedure followed?” is where you find the “good stuff.” Too often, companies don’t do an effective job digging into the details of why a particular procedure wasn’t followed. This Webinar introduces the basics for preventing “procedure not followed” issues in your operations.
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Checklist Basics

Checklists are a simple yet frequently overlooked tool in a company’s daily operations. A checklist is a summary of how a task should be done. People naturally keep a lot of information in their heads about how to perform a particular task, but sometimes a little thing can be missed. A checklist can help reduce those errors because checklists don’t forget. This Webinar covers some checklist basics and shows how they’re used by different organizations to reduce risk.
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Documenting Your Investigation in Excel - Tips & Tools

This Webinar provides an overview on how to use the Cause Mapping template in Microsoft Excel. We will demonstrate how powerful Excel can be to document, communicate and share your entire investigation without investing in expensive, complicated software.
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Executive Summary: Creating an Overview for Management

Got the basics of using the Cause Mapping template in Excel? In this Webinar, we'll teach you how to use the drawing tools to increase the speed of your Cause Mapping and we'll walk you through creating a one-page executive summary, like those created for our Cause Mapping examples.
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Advanced Cause Mapping Tools in Excel: Graphics & Diagrams

In this Webinar, we'll teach you how to create graphics and diagrams to aid in the understanding of your incidents using only tools available in Excel.
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Timelines & Graphs: Tools to Organize Investigation Information

The most common start to an investigation is understanding the sequence of events. A timeline is a key tool in organizing the details of an incident chronologically. In this Webinar, we'll teach you how to create timelines and graphs to aid in the understanding of your incidents using only tools available in Excel.
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A Better Way To Share Lessons Learned: Company Case Study Webinar

This Webinar explains the benefits of using a Client Specific Case Study within your organization to teach lessons learned and incorporate problem solving best practices. We will take you through an example Cause Mapping Workbook to show you what a case study covers. We will finish by explaining how you can use this powerful tool within your organization. Learn more about our Company Case Study Webinars and how you can get started on one for your group.
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Fires & Industrial Explosions

This Webinar discusses how the fire triangle, fire tetrahedron and dust explosion pentagon can be presented as a Cause Map to aid in finding solutions to reduce the risk of fires and chemical explosions, using case studies from several different industries. This Webinar also discusses how organization’s goals determined the solutions implemented to prevent future incidents.
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Root Cause Analysis Case Studies: Lessons from Space Program Disasters

During this Webinar we look at 3 disasters that have occurred in the US Space Program. On January 27, 1967, all three crewmembers were killed in a fire aboard Apollo 1. On January 28, 1986, Challenger broke up mid-flight, killing its seven crew members. On February 1, 2003, Columbia disintegrated upon re-entry, killing its crew of seven. During the Webinar, we will examine specific lessons that can be applied to your organization.
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How a 5-Why Expands Into a Complete Investigation: Deepwater Horizon

Every investigation, regardless of its complexity, can begin with a simple 5-Why. Bigger incidents will be broken down into more detail. Even as the investigation expands into a larger analysis it does not contradict the initial 5-Why. Smaller incidents have few parts and bigger incidents have more parts, but the cause-and-effect principle doesn't change. It can be applied consistently to all incidents.
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Earthquake, Tsunami Lead to Nuclear Accident: Fukushima Daiichi

The earthquake and tsunami that struck Japan on March 11, 2011 caused a catastrophic chain of events that led to significant damage and radiation release from the Fukushima Daiichi nuclear power plant. This Webinar will discuss the causes of the disaster, the current situation, and what has been, and still is being done to attempt to protect life and the environment in the area.
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Root Cause Analysis Case Study: Hubble Telescope

This Webinar presents a case study of the issues facing the Hubble Telescope. There are several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.
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Root Cause Analysis Case Study: I-35 Bridge Collapse

During the design of a structure, the analysis can be simplified by knowing which components are weaker, which are stronger and then designing to the weaker components. When assumptions aren’t verified, they can result in a compounded error 40 years later. In the case of the I-35 bridge collapse, an assumption of a part’s strength meant it was never rechecked or inspected, and ultimately resulted in the collapse of the Minneapolis bridge, the deaths of 13 people, and injury to 145. This Webinar is a root cause analysis case study of what led up to the disaster on August 1, 2007.
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Root Cause Analysis Case Study: Kansas City Hotel Walkway Collapse

This Webinar examines a case study of the hotel walkway that collapsed on July 17, 1981, killing 111 in Kansas City. There are several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.
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Root Cause Analysis Case Study: Lessons from Flight 1549 for your Organization

Root cause analysis identifies the underlying causes of why an incident occurred. Typically it’s used when something’s gone badly, but it can also be applied to something that’s gone well. A complete review of Flight 1549 includes both why the aircraft ditched in the river and why all 155 onboard survived. Losing both engines, ditching an aircraft and evacuating passengers in a river may not be part of your daily operations, but those scenarios contain valuable lessons for any organization interested in reducing risk, preventing problems and improving the reliability of their operations.
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Root Cause Analysis Case Study: Mars Climate Orbiter

The Mars Climate Orbiter was launched on December 11, 1998. The mission of the Mars Climate Orbiter was to function as an interplanetary satellite and service as a communication relay for the Mars Planetary Lander. Working together, the Mars Climate Orbiter and Mars Planetary Lander were planned to map Mars’ surface, profile the structure of the atmosphere, try to detect surface ice reservoirs and dig for traces of water beneath the surface. Eleven years ago, on September 23, 1999, the $125 million dollar Mars Climate Orbiter was lost during the attempt to establish orbit around Mars.
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Root Cause Analysis Case Study: Tacoma Narrows Bridge Collapse

The original Tacoma Narrows Bridge was nicknamed “Galloping Gertie” because it experienced large up and down movement on windy days. On November 7, 1940, the bridge’s up and down movement changed to a never before seen twisting mode, which increased until the cables snapped and the bridge was destroyed a little more than four months after it opened. This Webinar examines the collapse of the bridge using the Cause Mapping root cause analysis methodology to discover the causes that led to the bridge’s failure.
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Root Cause Analysis Case Study: Unaccompanied Minor

Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence with the same airline, this time out of Boston. Instead of going to Cleveland, this unaccompanied girl ended up in Newark, NJ. This root cause analysis case study will focuses on the failures that occurred within the work processes and emphasizes the use of process maps to help identify where the breakdowns occurred and how to identify specific solutions to prevent recurrence.
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Valdez Oil Spill: Things Aren't Always What They Seem

Most of us know something about the Valdez Oil Spill, and most of what we know is from the 30 second soundbites from the news that focused the majority of their coverage on the captain and his history with alcohol. This Webinar reviews all of the causes of the Valdez Oil Spill in Alaska; the details may surprise you. View to learn more about the incident and how the Cause Map was built.
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Root Cause Analysis Case Study: Wrong Runway

On the morning of August 27, 2006, a flight scheduled to travel to Atlanta International Airport attempted to take off using the wrong runaway at Lexington Airport. The runway was too short and the plane wasn’t able to achieve the velocity needed for lift-off, causing it to crash, killing 49. This Webinar discusses the causes of the crash, using the Cause Mapping method of root cause analysis to illustrate lessons learned that can be applied across all disciplines.
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How A 5-Why Expands Into a Complete Investigation: Fire on the USS George Washington Aircraft Carrier

Every investigation, regardless of its complexity, can begin with a simple 5-Why. Bigger incidents will be broken down into more detail. Even as the investigation expands into a larger analysis it does not contradict the initial 5-Why. Smaller incidents have few parts and bigger incidents have more parts, but the cause-and-effect principle doesn't change. It can be applied consistently to all incidents.
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Root Cause Analysis Case Study: Concorde Crash

On July 25, 2000 a Concorde Supersonic jet crashed near Paris, France killing all 109 people onboard in addition to 4 on the ground. A tire on the left side disintegrated while the aircraft was accelerating during take-off and struck the underside of the wing, rupturing a fuel tank. Fuel poured from the tank and ignited. The Concorde had already reached a velocity where it could not stop safely by the end of the runway so it lifted off the runway with flames hanging from the left wing. This Webinar discusses the causes of the disaster, including several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.
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A Deeper Look into Distraction-related Accidents

Have you ever checked your phone while driving? You think to yourself, “it will just take a moment.” We’ve likely all been guilty of it at some point. And despite knowing that we’re not supposed to do it – it’s against the law in most states and we understand that the distraction increases our risk of having an accident – we still do it. So, why? During this webinar, we’re going to dig into what causes people to be distracted. We’ll talk about distractions related to technology, but we’ll also talk about other forms of distractions and what we can do to try to minimize their impact.
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When Lessons Aren’t Learned: A review of industrial incidents with similar causes

One of the hardest parts of any incident is when the causes are similar to a previous incident. It leads you to think- We’ve already had this incident, why weren’t we able to prevent it? During this webinar, we’re going to review a few industrial incidents in which lessons were not learned and we’ll discuss about how those lessons could have prevented similar incidents. We’ll also talk about methods to identify lessons learned and turn those into best practices for any industry.
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Healthcare Case Study - Blood Incompatibility

This Webinar looks at one of the National Quality Forum’s “Never Events” relating to Blood Incompatibility. “Never events” are so named because the events included should never happen at healthcare facilities. Learning about incidents relating to blood incompatibility and the procedures designed to prevent them can reduce the risk of these types of incidents happening at your facility.
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Healthcare Case Study - Medication Errors

According to The Joint Commission, “Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events.” Accordingly, medication errors have been named as one of the “”never events”” (i.e., events that should never happen). This Webinar looks at potential causes of medication errors using the Cause Mapping method, and will look at process-based solutions to preventing these types of errors.
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Healthcare Case Study - Patient Falls

Healthcare facilities are coming under increased scrutiny for medical errors, including “never events” as developed by the National Quality Forum. The Cause Mapping method of root cause analysis can be used to determine what went wrong and how to fix it in the case of medical errors, AND to prevent these errors from happening in the first place. This Webinar discusses the causes and solutions of patient deaths associated with a fall (one of the “never events”) including case studies of actual patient falls.
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Preventing Radiation Treatment Overdoses: Cause Mapping Case Studies

Learn about what causes radiation treatment overdoses and some methods to reduce the risk of overdoses while we examine some case studies of actual radiation treatment overdoses using the Cause Mapping method of root cause analysis.
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Healthcare Case Study - Surgical Fires

This Webinar will discuss what causes surgical fires and some methods to reduce the risk of surgical fires while examining some case studies of actual surgical fires using the Cause Mapping method of root cause analysis.
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Healthcare Case Study - Wrong-Site Surgeries

This Webinar discusses the causes and solutions of wrong-site surgeries (one of the “never events”) including case studies of actual wrong-site surgeries, providing useful information to medical practitioners and administrators alike.
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Healthcare Case Study - Healthcare-Acquired Infections

This Webinar discusses the causes of healthcare-acquired infections (HAIs) and lessons learned implemented by various healthcare facilities to reduce these infections. The Webinar includes discussions of case studies of actual cases of health-care acquired infections.
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