As an international provider of RCA training and services, Apollo consultants address this question often.  Thank you Denise for bringing this to attention!  Problems are adverse events.  A good root cause analysis process analyzes the causes of any event, regardless of whether the outcome is deemed to be good or bad.  If you want more (or less) of an outcome, the only way to do it is by controling causes.  So RCA on positive events is a terrific idea.  A couple of things to consider:  1)  Managers should analyze causes of positive events.  But they should do a lot of things... and in today's lean employment environment, it's often hard to get them to analyze anything at all simply because they don't have the resources.  I would be interested in reading a case study where this was done successfully, including how the effort was sold to decision makers.  2)  The fishbone process may not be the best choice.  While good at identifying a range of causes, it comes up short in part because it doesn't do a great job at uncovering and documenting causal relationships.  Understanding these relationships is important because they show how/which causes interact to create effects.  This gives the investigative team better opportunities to come up with creative ways of controling those causes, as well as controling the way they interact.  Brian Hughes
Vice President
Apollo Associated Services, LLC
bhughes@apollorca.com, @brian_hughes 

In conducting various RCA projects, there has been a tendency to only use Dr Ishikawa's first Cause & Effect Diagram. Some even still use "Manpower" which many organizations including QCI International showed me to use "People" way back in the early eighties (thanks Don Dewar). Dr Ishikawa had three (3) types of C&E and as Denise's article correctly stated, that most use the "Event" C&E. However, Ishikawa (page 24 'Guide to QC' 1971) says the third type is the 'Process Classification C&E' - QCI called it simply Process C&E.  With so many problems/effects coming from the process (all work occurs through process aka P Cosby) and for Lean and Six Sigma folk think they invented 'SIPOC' - well I contend that most RCA's are sub-optimised if they do use Process C&E. Denise's article well describes the use of a 'diagram' like a C&E and can be said for Process C&E as to why something went well. Similarly for ISO9001:2008 folk and QMS implementations, they were meant to be documented by Processes and not by the Clauses of the Standard (ISO9001 2010 Forum is now recommending reinforcement of this for the revision under TC176) – all Lean, TOC, RCA, Six Sigma process analysis work and activities by individuals and teams should have started with diving into the said processes that should have been documented within these QMS’ – that is difficult if not written under the business processes. There is RCA fast tracking available if we go to the QMS Processes to do the “Should-Be” and then consider RCA for why the process is not stable then not capable, instead of pushing the As-Is and To-Be process analysis as yet another consultancy piece which when finished or Lean Six Sigma and RCA projects completed, are hardly embedded within the QMS process documentation. Many Organisational Change and Behavior lectures in MBAs use the Ishikawa Diagram not so much for the C&E but for why change worked and drivers for Change. A nice and timely reminder Denise as sometimes we get too stuck on strict use of some techniques and we should as Dr Ishikawa said "We should adapt then adopt these Tools and Techniques". See you in Australia again soon Denise, Michael

Michael W McLean Managing Director McLean Management Consultants Pty Ltd Embedding Strategic Change (Established.1988) PO Box 917 North Ryde BC 1670 NSW Australia M: +61 419 225 996 P: +61 2 9706 8566 F: +61 2 9706 8366 E:michael@mclean-mc.com.