Documentos de Académico
Documentos de Profesional
Documentos de Cultura
by Duke Okes
2013 Duke Okes
Who am I?
Independent consultant/trainer since 1985 Process management, internal audits, performance metrics, root cause analysis (RCA) Manufacturers (design through field service), finance (insurance, credit cards), laboratories (research, calibration), hospitals, IT support, energy companies ~ 300 RCA workshops in past 9 years
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Risk management is often too soon and lessons learned may be too late
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Failure costs
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Types of Causes
Correction
Containment Remedial action
Corrective action
Physical causes System/root causes (not human error!) Contributing factors
Quite different from Process Improvement
Potential/Actual Impact
KEY
Medium
Correction and both Physical & System Causes Correction and Physical Cause Correction Only
Lo
Note: A third axis representing time is useful in some applications Lo Medium High
Frequency/Probability of Occurrence
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Activity/Event Timeline
Undesired Outcomes Designed Wrong Unclear Requirements Design Process Error Built Wrong Incorrect Interpretation of Design Took Shortcut
Cause-Effect/Why Analysis
2013 Duke Okes
The Causes
Integration management Scope management Time management Cost management Quality management Human resources management Communications management Risk management Procurement management Stakeholder management
2013 Duke Okes
Making things better: for this project for the next project for all projects for this project manager for this organization for all project managers
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Whats Missing?
Environment (e.g., weather) Economic shifts (e.g., exchange rates) Politics (e.g., power struggles) Culture (e.g., problems arent reported)
But good project management should help us deal with these through: Better planning Better execution
Yes
Yes
No No
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The Process
Initial definition, data collection, timeline In-depth analysis of physical causes In-depth analysis of system causes Modify project procedures/guidelines Monitor for impact
2013 Duke Okes
Contact Information
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