english 105 – week 9!! teri “of doom” tosspon. note: meeting in commons 9-11am grammar review...

English 105 – Week 9!!Teri “of Doom” Tosspon

Note: Meeting in Commons 9-11amGrammar ReviewPart I – Revise/Edit• Make sure each sentence is complete

– NOT a Fragment or Run on. – Sentences have a subject, a verb, and a complete

thought/idea. • Read the student paper aloud to a partner. • Circle & correct the misused words (there, their,

they’re)Part II - create an outline (separate paper)Part III - Grade according to rubric

Assignment

• After break, gather in the commons for a demonstration.

• You will need paper and writing utensil

4

Causal Analysis

Pg 274-286

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What is Causal?

Dictionaries tell you that –caus·al [ káwz'l ] 1. being or involving cause: involving or being the cause of something else or the relationship of cause and effect.2. grammar expressing cause: expressing or indicating a cause or the relationship of cause and effect

http://encarta.msn.com/encnet/features/dictionary/Pronounce.aspx?search=causal

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What is Analysis?

Dictionaries tell you that –a·nal·y·sis [ ə nálləssiss ] (plural a·nal·y·ses) 1. close examination: the examination of something in detail in order to understand it better or draw conclusions from it.2. separation into components: the separation of something into its constituents in order to find out what it contains, to examine individual parts, or to study the structure of the whole.3. assessment: an assessment, description, or explanation of something, usually based on careful consideration or investigation.

http://encarta.msn.com/encnet/features/dictionary/Pronounce.aspx?search=analysis

http://encarta.msn.com/encnet/features/dictionary/Pronounce.aspx?search=analysis

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What is a Cause?

• One of the reasons for a problem which, when identified and corrected, will minimize the potential for the problem occurring.

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What is Causal Analysis?

• Causal analysis is the process of breaking down an event so that each part and causal factor in the event can be considered, examined, tracked and evaluated.

• Analyzing lesser significant trends before they become major issues is a proactive process.

• Causal analysis, by its very nature, is a reactive process

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• Causal Analysis, properly implemented, will reveal the real reasons for problems and help point out solutions.

• Causal Analysis is the building block for determining corrective action.

• The primary objective of Causal Analysis is to determine why problems occur, facilitate corrective actions, and prevent the recurrence of problems.

Causal Analysis is a tool.

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What is an Apparent Cause?

• The most likely reason for a problem to have occurred based on a review of the relevant facts determined during the preliminary investigation.

Note: We are not talking about an event; we are talking about a cause (problem) related to the event.In addition, this is not considered to be the last word until additional analysis has been performed.

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The components of Causal Analysis

Problem

Analysis

Solutions

Identify the Problem

Identify the Causes

Identify the Corrective Actions

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Problem Identify the Problem

During this phase it is discovered that one of the Goals, Standards or Requirements of the organization has been violated.

The balloon was popped

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Analysis Identify the Causes

This is the actual analysis phase. This is the stage where causes are identified and an outline is developed which shows how the relevant causes fit together.

Because I had a pin

Because I had a balloon

Because I went to the store to get them

Because I had the money to get themBecause I had a job to get the

money to get them

Because I had an education to get a job to get the money

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Solutions Identify the Corrective Actions

This is where the causes are evaluated for possible solutions and where the best solutions are chosen to implement. You cannot get here until you have performed a thorough analysis. If you rush to a solution phase prematurely you will not prevent the problem from occurring again in the long term or even the short term forecast.

Because I had a pin

Because I had a balloon

Because I went to the store to get them

Because I had the money to get themBecause I had a job to get the

money to get them

Because I had an education to get a job to get the money

Because I used a pin to pop the balloon

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Finding Causes

All of us are problem solvers . . .

although many of us may tend to think of our problem solving process as something less fancy than "cause analysis”.

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Analyzing our problems is an effort we make to control and prevent:interruptions, production obstacles, and counter-quality occurrences. During this process we discover the causal factors that make up an unplanned event and recognize the possible causes for that event. Correcting such causes helps to prevent future reoccurrence.

Analyzing Problems

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How do I know when I am at a real cause (Or, when do I stop asking why?)

• You may have taken root cause classes that tell you to keep asking “why” until you get to the problem, or until the factors are out of your control.

• Where do you stop?

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How do I know when I am at a causal stopping point? (Or, when

do I stop asking why?)

Boat was launched into the water

No pre-launch inspection performed

Involved parties assumed plug to be in place

Safety Impacted

Cost impacted

Schedule Impacted

Water entering through boat’s drain hole

Boat not designed

to operate when filled with water

No policy or process for pre-launch inspectionDrain

plug not installed

Bass-boat sunk at pier

Owner relied on memory to prepare for launch

AND

AND

AND Looking at a Causal Map, you should

normally stop asking “why” when you reach a point in which the problem is eliminated by:

The use of a process. The improvement of a process.Writing a process.

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Introduction to Cause and Effect

Another method used for performing cause analysis

is a method called Cause Mapping which involves

investigating an event using the cause and effect

approach. The following is some ideas and theory

recommended for use when investigating an event.

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Two Simple Problem Solving Tools

Process MapsA map of the specific steps of a work process.

When a process doesn’t produce the desired

results our first question should be “WHY?”

These “WHY?” questions are the

analysis of the problem.

Cause MapsA map of the causes of a problem.

The work process defines how the organization would like to conduct its business every day.

I. ProblemI. Problem

II. AnalysisII. Analysis

III. SolutionsIII. Solutions

I. ProblemI. Problem

II. AnalysisII. Analysis

III. SolutionsIII. Solutions

The Cause Map is a visual explanation of why the organization didn’t get the desired results from their work process.

Start Here

The corrective actions after an investigation

make specific changes to the work process.

This is the cycle of Continuous Process

Improvement.

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Cause and Effect

Sprained Ankle

Trippedon

Barrier

Effect Cause

Time flows from right to left

This analysis moves backwardsTime

What did it cause What was it caused by

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Sprained Ankle

Trippedon

Barrier

Did Notsee

Barrier

What did it cause What was it caused by

Cause/Effect Cause/Effect Cause/Effect

Every effect is also a Cause

Every Cause is also an effectTime

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Sprained Ankle

Trippedon

Barrier

For every Effect there is a Cause

Steppingover

Barrier

CarryingBoxes

Going toStation

#4

Barrier in Path

Did Notsee

Barrier

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Sprained Ankle

CarryingBoxes

Barrier in Path

Steppingover

Barrier

Sprained Ankle

Sprained

Ankle

One point of view

Another point of view

Yet another point of view

Was caused by

Was caused by

Was caused by

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Right Answer vs.System Thinking• 2+2 = 4• The Capital of Virginia is

Richmond• The amount of inches in a foot

= 12

• The most important component of a car?

• How many ways are there to New York?

• What is the best car to buy?

There is one correct answer

There are many possible solutions

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Cause and Effect

For everything that happens there is a cause that sets the condition for it to happen, or prevents it from happening.

CauseEffect

27

CauseEffect

Titanic Sank

Cause and Effect

Was caused by?

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CauseEffect

Titanic Sank

Ship Hit Iceberg

Cause and Effect

Why? Was caused by?

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CauseEffect

Titanic Sank

Ship Hit Iceberg

Cause and Effect

Cause

Why? Was caused by?

30

Cause and Effect

CauseEffect

Titanic Sank

Ship Hit Iceberg

Cause

Why? Was caused by?

Couldn't Turn Quickly Enough

31

Cause and Effect

CauseEffect

Titanic Sank

Ship Hit Iceberg

Cause

Why? Was caused by?


Have we figured it out? Can we go back to work now? Will our people be safer? Are our people aware,

smarter, better prepared? Will the cost of the mistake be minimized in the future and will the schedule

interruption occur again?

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How Many Causes ?

• Normally there is more than one cause for a particular event.

• In most cases there are a number of conditional factors that have to be present for the event to take place.

effect

Cause

Cause

Cause

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The fire triangle (revisited)

Effect

Fire

The fire triangle is a good example that demonstratesmultiple causes for each effect (causal factor).

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Effect

Fire

Ignition source

Cause

It illustrates the normal propensity toward multiplecauses for a single effect.

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Effect

Fire

Ignition source

Cause

Fuel source

Cause

Ask “What causes the effectto happen or occur?”

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

Ensure all apparent related causes are considered.

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

Notice if you take one cause away……..,

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Effect

Fire

Ignition source

Cause

Oxygen

Cause

Cause

Notice if you take one cause away, the effect cannot occur.

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Fire

Ignition source

Fuel source

Oxygen

Look for this recurring pattern in all cause and effect models.

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

You will also notice causes you want to address and those that you may choose not to address.

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

In this case, although oxygen is a cause, you may not choose to address it in your corrective actions

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

However, the other two causes are items you will want to control, remove, fix or limit.

43


Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

Investigating and analyzing factors in such a manner allows us to uncover all relevant causes

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Effect

Fire

Ignition source

Cause

Fuel source

Oxygen

Cause

Cause

Was caused by?

Was caused by?

Insure you uncover all causes relevant to the problem you are analyzing.

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Cause and Effect Exercise

Titanic Sank

Try to see if your thought process aligns with the logic of this exercise.

If the effect was the Titanic sinking, what was the cause?

46


Water Filled Hull

Titanic Sank

If the effect was the hull filling with water,

what was the cause?

47


Water Filled Hull

Titanic Sank

Ship in Water

Continue to follow the logic

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Water Filled Hull

Why?

Titanic Sank

Ship in Water

49


Water Filled Hull

Opening in Hull

Titanic Sank

Ship in Water

AND

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Water Filled Hull

Why?Opening in Hull

Titanic Sank

Ship in Water

AND

51


Water Filled Hull

Why?Opening in Hull

Titanic Sank

Ship in Water Why?

AND

52


Water Filled Hull

Steel Plates Buckled on Hull

Opening in Hull

Titanic Sank

Ship in Water Why?

AND

53


Water Filled Hull


Opening in Hull

Titanic Sank

Ship in Water

Atlantic crossing

AND

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Water Filled Hull


Opening in Hull

Titanic Sank

Ship Hit Iceberg

Ship in Water

Atlantic crossing

AND

55


Water Filled Hull


Opening in Hull

Titanic Sank

Ship Hit Iceberg

Ship in Water

Iceberg Present

Atlantic crossing

AND

56


Water Filled Hull


Opening in Hull

Titanic Sank

Ship Hit Iceberg

Ship in Water

Iceberg Present

Atlantic crossing


AND

AND

57


Can you see where additional causes would fit into the map?

Water Filled Hull


Opening in Hull

Titanic Sank

Ship Hit Iceberg

Ship in Water

Iceberg Present

Atlantic crossing

Ship's undersized Rudder


AND

AND

58


Can you see which causes could be corrected or eliminated?

Can you see the causes that you would not want wish

to address

Water Filled Hull


Opening in Hull

Titanic Sank

Ship Hit Iceberg

Ship in Water

Iceberg Present

Material problem with hull

Atlantic crossing



Also, if we did not have the steel plates being buckled, we

possibly would not discover the material problem

AND

AND

59


Lets take the “Couldn't Turn Quickly Enough” cause and expand on it…


Water Filled Hull


Opening in Hull


Titanic Sank

Ship Hit Iceberg

Ship in Water

Iceberg Present

Material problem with hull

Atlantic crossing

AND

AND

60


Couldn't turn Quickly Enough


61




Ship's Rudder design

62




Excessive Speed (18 knots)


AND

63





Potential record crossing


AND

64


Late response to the Iceberg






AND

AND

65








Lookouts saw iceberg late

AND

AND

66



Binoculars not in crows nest







AND

AND

67




Difficult to see iceberg in calm waters







AND

AND

AND

68




Difficult to see iceberg in calm waters







No water splashing on iceberg

AND

AND

70

Cause and Effect Examples800 Calls come in per hour

Call center response is slow ( x minutes)

6 People are available to answer

Average call takes 3 minutes

Knife slipped

Cut finger

Holding tomato

Finger present

Object Fell

Object struck person

Performing work operations

Person Present

$500 was taken out

Overdrew Checking Acct

Insufficient Funds in Acct

$400 was the balance

Knife Contacted Finger

Object slipped off of hook

71

Switch Theory

• This theory is based on the principle that when all the switches are open, the system, work or process is running optimal.

• Each switch represents a causal factor in the chain.• In order for the problem-event to occur all of the

switches have to close.

Prob 1 Prob 2 Prob 3 Prob 4 Prob 5

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Switch TheoryInstallation of incorrect material in a mechanical system

Inspection does not question the use of non-level material data entry within a mechanical system.


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Identified and

opened


74

Switch Theory

Shop personnel questioned the installation of a non-level component butaccepted a verbal answer without documenting the problem for technical resolution. The component installation is completed.

Installation of incorrect material in a mechanical system


75


Identified and

opened


76

Switch Theory

A related problem was documented on a similarjob however the link between the two is not recognized. This problem is written up on that job but, Engineering does not recognize or tiein the similar material errors.



77


Identified and

opened


78

Switch Theory

Engineering did not recognizethe non-level componenterror during review of theProcedure.



79


Identified and

opened


80

Switch Theory

During the initial planning of the job the appropriate technical reviewswere not accomplished.



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Identified and

opened


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Switch Theory

• The easiest switch to open is the last switch (personnel or QA oversight).

• The hardest switches to find are process or engineering related.

• Switches tied to personnel error always lead to bigger and deeper rooted causes .

• Associate switches can be related to the Interactive Work Model.

• High Performance Organizations - once they find a problem, they work to open all RELEVANT switches.

83

Questions That Uncover Problems

? Open ended.

Requires fill-in of missing information.

Makes the responder do the talking.

Uncovers opinions as well as facts.

84

Typical Interactive Work Model for High Performance Organizations- the right mix for the job!

TRAINING

PROCEDURE

SUPERVISION

This philosophy depicts a balance of Training, Supervision and Procedure

85

Questions For Procedure Issues

• Was the procedure format confusing?– Many drawings or procedures were used when the

information could have been placed in a single procedural step?

• Did the personnel understand the procedure?• Did the procedure reflect the actual work practice?• Was the procedure technically accurate?• Were there to many actions required in the step?

PROCEDURE

86

Questions For Training Issues

• What qualifications were required to perform this work?– Did the worker have these qualifications?

• Did the job have the right skill mix?• Was there a change in work practices from the mock-

up to the shipboard application?• Was there a difference in the classroom training and

shipboard application?

TRAINING

87

Questions For Supervisory issues

• Was there a lack of coordination with all trades? • Was an interactive brief used? What questions were asked

at the briefing? Did the supervisor effectively communicate his/her expectations?

• What oversight did the supervisor provide on the deckplate?• Were the instructions unclear or inadequate?• Did we provide individuals the tools (training, instructions,

guidance, etc.) needed to succeed?

SUPERVISION

88

Data types …use both flavors

Hard Data

Facts, requirements, statistics, goals, procedures, metrics, trends, deviations, time factors, productivity, quality & performance levels.

Soft Data

Feelings, opinions, human factors - frictions, attitudes, satisfaction levels, frustrations, personality conflicts, behaviors, hearsay, intuition, “gut” reactions, mental blocks.

Many times soft data will

lead you to discover additional facts

89

Other Tools We Can Use

Use non-adversarial questioning techniques.

Keep asking “The effect was caused by?”

Look for the Process weakness.

Brainstorming.

Listing unknowns.

Analyze time-lines.

This is your Captain speaking...er...sorry for the little bump...

it’s probably just a passing whale.

This is your Captain speaking...er...sorry for the little bump...

it’s probably just a passing whale.

Do not assume you know what the problem iswithout performing a proper investigation .

91

• Remember to always review any previous similar corrective actions. This is the test to ensure that you are not doing the same corrective action and expecting different results.

Don’t get caught up in the false security of Apparent Causes

92

• Make sure all agree on the name of a particular item (component) and that it is referred to as same throughout a written report. Calling the same item different names distracts from an events clarity and leads to confusion within a given investigation.

Don’t get caught in the nomenclature bait and switch trap

93

Review your causes against Previous Actions. Look deeper than just the last switch. Ensure you identify and open all relevant switches. Make sure they are logical. Relate them to the work model.

Don’t move to a solution phase until you have performed thorough causal analysis

94

Missed Opportunities

• Without a systematic approach to problem solving– You allow your actions to be set by opinion and

conjecture rather than a process that keys to the actual causal circumstances of an event.

– This will put you back into the “grab bag” analysis game.

95

Cause Analysis is the building block for determining corrective action.Finding the real reasons that problems occur, facilitating corrective action, and preventing the recurrence of problems is the primary objective of Cause Analysis.

Remembering our Purpose

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Preventing Recurrence

• Determine best preventive measure.• Implement and monitor.

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In Summary

1. Causal analysis should be the systematic process of gathering all relevant data.

2. Breaking an event apart to look at all of it’s pieces.

3. Identify the causes that have generated or allowed the problem.

4. Identify the possible solutions.5. Provide to the decision-makers, options so the

best solutions (Corrective Actions) can be implemented.

Final Benchmark Assignment

English 105

Student Learning Outcomes

1. Write formal academic essay.2. Use correct grammar spelling and punctuation when

writing.3. Critically analyze readings.4. Integrate new vocabulary in writing.5. Prepare presentation(s) using principles of organization

and formal language.

Deliverables

• Essay must be typed and a minimum of 3 pages in length. MLA format should be used.

• Research scaffold handout for each reading and a list of the 10 new vocabulary words.

• Presentation should be 3-5 minutes in length.

Assignment Description

• Develop a three page academic essay.

• The essay must be written with correct grammar, spelling and punctuation.

• This is a two part assignment with a written and presentation component. (SLO# 1, 2)

Part I: Written Component– Option one: Critically analyze two outside readings, by

completing the research scaffold handout provided. Integrate 10 key vocabulary words from the readings into your essay. (SLO# 3, 4)

– Option two: Critically analyze one reading from the textbook, completing the research scaffold handout and integrate 10 key vocabulary words from the textbook readings into their analysis. (SLO# 3, 4)

– The scaffold is on pg 5

Writing Option 1. Choice A• A.) You will decide on a problem to solve and write a formal

academic essay (SLO#1). It can be a problem in one of following three categories:

• An issue or problem in the industry of your chosen major.

• An issue or problem in your neighborhood, community, or local school.

• An issue or problem in your everyday life.• • Use EBSCO and/or GOOGLE SCHOLAR to research information

about your topic. • Critically analyze at least two readings you find relating to

your topic using the research scaffold handout (SLO#3, 4). • Determine the best solution to the problem . After you have

critically analyzed at least two readings. • Use MLA format. • Clearly state the problem, discuss information gathered from

your research, and propose the best solution to the problem.

Writing Option 1: Choice B• Choose a topic for a Cause/Effect theme and write a formal

academic essay. Consider one of the following topics or choose your own:

• • The Cause/Effect of a social issue such as homelessness.• The Casue/Effect of a health issue such as heart disease.• The Cause/Effect of an educational issue such as tuition

costs.• The Cause/Effect of a historical event such as World War II.

• Student topic must be approved by the instructor.• Use EBSCO and/or GOOGLE SCHOLAR to research information

about your topic. • Critically analyze at least two readings you find relating to

your topic using the research scaffold handout (SLO# 3,4). • Determine the cause(s) of the issue and the effect(s) of that

issue. Finally, write your essay using MLA format.

Vocabulary component

• NOTE:• Students must integrate new

vocabulary.

• The student can select their own list of vocabulary words from their research.

Part 1 Option 2• Select an essay from the textbook.• Critical Analysis Essay should include:

– Discussion of the main ideas expressed by the author in the selected reading and how those themes relate to you.

– Analysis of the specific attitude the author takes towards the main ideas.

– Analysis essay must be supported with direct evidence from the textbook reading. Evidence may include examples, dialogue, or direct quotes.

– Integration of selected vocabulary words.For example, a thesis may read: • (Authors Names) are discussing _______________________;

the specific point they are making is that________________.• Support the idea with evidence from the selected textbook

reading. • You may have a personal connection to the author’s attitude

towards the subject.

Part II: Presentation• You will prepare a 3-5 minute oral presentation about your

essay. You will not read your essay to the class. • Visual Component Required.

– You might want to use a power point presentation, poster board, handouts, or other multi-media for your presentation.

SLO #5

Prepare presentation(s) using principles of organization and formal language.

Demonstrates a lack of understanding of the topic. Information seems unfamiliar to presenter, who cannot answer questions. Organization of presentation indicates limited effort to address audience appropriately. Tone and voice inappropriate for audience, and presentation uninformative.

Demonstrates some understanding of the topic. Presenter has some difficulty answering questions. Organization of presentation strained at times, with some issues in tone and voice. Presentation somewhat informative and appropriately engages audience.

Demonstrates adequate understanding of topic. Presenter can answer most questions. Organization of presentation generally sound. Tone and voice appropriate. Presentation is informative and appropriately engages audience.

Demonstrates mastery of topic. Presenter can answer all questions. Organization of presentation very polished, tone and voice completely on target and engages the audience in a profound way.

10%

Resources

• www.google.com/scholar for research

• www.easybib.com – to create your MLA format.

• http://ttosspon.wikispaces.com/

http://www.google.com/scholar

http://www.easybib.com/

http://ttosspon.wikispaces.com/

http://ttosspon.wikispaces.com/

Due Next Class

• Rough Draft of Final Paper• Vocabulary• Research Scaffold

–For at least 2 articles

For research, use www.google.com/scholar

Or EBSCO

http://www.google.com/scholar

english 105 – week 9!! teri “of doom” tosspon. note: meeting in commons 9-11am grammar review...

Documents

causal kwzl

causal factor

causal analysispg

relationship of cause

grammarexpressing cause

unwanted event

recurrence of problems

im stubborn