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METODE ANALISIS AKAR MASALAH

(ROOT CAUSE ANALYSIS)

Setiap masalah selalu mempunyai akar masalah. Akar masalah sangat penting diketahui untuk melakukan tindakan perbaikan dan pencegahan secara efektif. Untuk mengukur efektifitas tindakan perbaikan, tips berikut ini mungkin dapat dipakai sebagai acuan untuk menetapkan kriteria efektif:

tidak berulangnya kasus yang sama bisa diterapkan tidak membutuhkan investasi yang sangat tinggi fleksibel dengan komponen lainnya mudah dievaluasi dll

Jika saat ini efektif, mungkinkah bulan depan atau tahun depan bisa muncul kembali masalah yang sama? sangat mungkin, karena faktor variasi akan muncul secara alami dari faktor man, material, method, and machine.A process improvement and error or defect prevention tool that examines the individual processes within a system, identifies the control or decision points, and uses a series of why? questions to determine the reasons for variations in the process paths.

Contoh Definisi : In normal chaotic organizational environments it is often quite

difficult to find candidates for root cause analysis because the situations which repeat are either distributed over time so one doesn't realize they are actually recurring, or the situation happens to different people so there isn't an awareness of the recurring nature of the situation (systems-thinking.org).

On receipt of initial notification, the department will provide the hospital with a sentinel event reference number to be indicated on the root cause analysis, risk reduction action plan summary and other correspondence about the episode (Victorian State Government – Health).

Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues (bill-wilson.nrt).

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Root cause analysis (RCA) merupakan metode untuk menemukan dan mengoreksi alasan-alasan yang paling penting bagi masalah-masalah kinerja. Metode RCA lebih diarahkan pada isu-isu berikut ini.

Dalam kaitannya dengan proses bisnis, metode RCA mencari kendala-kendala yang dianggap tidak perlu dan control yang tidak memadai.

In safety and risk management, it looks for both unrecognized hazards and broken or missing barriers.

It helps target CAPA (corrective action and preventive action) efforts at the points of most leverage.

RCA is an essential ingredient in pointing organizational change efforts in the right direction.

Finally, it is probably the only way to find the core issues contributing to your toughest problems.

While it is often used in environments where there is potential for critical or catastrophic consequences, this is by no means a requirement. It can be employed in almost any situation where there is a gap between actual and desired performance. Furthermore, RCA provides critical info on what to change and how to change it, within systems or business processes.

Significant industries using root cause analysis include manufacturing, construction, healthcare, transportation, chemical, petroleum, and power generation. The possible fields of application include operations, project management, quality control, health and safety, business process improvement, change management, and many others.

Your problems may not be as spectacular as the ones pictured above, but they probably have many similarities under the surface. This is the point of root cause analysis -- to dig below the symptoms and find the fundamental, underlying decisions and contradictions that led to the undesired consequences. If you want your problems to go away, your best option is to kill them at the root.

Teknik analisis akar masalah merupakan teknik analisis yang bertahap dan terfokus untuk menemukan akar masalah suatu problem, dan bukan hanya melihat gejala-gejala dari suatu masalah.

Contoh Definisi: Saat ini Pendekatan Analisis Akar Masalah banyak di gunakan di

lingkungan pelayanan kesehatan / rumah sakit untuk menyelesaikan masalah akibat Kejadian Tidak Diharapkan (KTD) dan Sentinel Event

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untuk Program Keselamatan Pasien (

Institut Manajemen Resiko KliniS) Metode Analisis Akar Masalah dan Solusi (MAAMS) ini menyajikan

suatu cara berpikir yang diperagakan dengan tata-alir (flow chart), disertai dengan beberapa contoh. Penerapan MAAMS membantu penggunanya untuk berpikir induktif maupun deduktif, kualitatif maupun kuantitatif, lebih mendalam dan menyeluruh, serta mempermudah kerjasama inter, multi, atau transdisiplin (Jurnal

Universitas Indonesia) Untuk masalah sosial dan humaniora bisa digunakan metode

analisis akar masalah dan solusinya (MAAMS), yang mencari sebab-dari-sebab sekaligus berpikir out of the box. Pengalaman mempraktikkan MAAMS di kelas ilmu sosial dasar sejak pertengahan 1990-an menunjukkan mahasiswa mampu memahami secara metodis bahwa banyak masalah sosial berakar pada korupsi (harta, takhta, cinta asmara, dan gabungannya) dan mengajukan solusi dasarnya. Maraknya korupsi pada bangsa ini merupakan indikasi

banyaknya keterbelahan kepribadian.

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Definition from Wikipedia:Analisis akar penyebab ialah cara mengatasi masalah yang bertujuan untuk mengenali akar penyebab masalah atau kejadian.

Contoh definisi: Salah satu teknik analisis yang biasa digunakan dalam menganalisa

kegagalan suatu sistem adalah analisis akar penyebab (Root Cause Analysis). RCA adalah sebuah metode yang terstruktur yang digunakan untuk menemukan akar penyebab dari masalah

kerusakan poros (LP UNHAS). Untuk membedakan antara modus kegagalan (modes of failure),

penyebab (cause of failure), dan efek (effect of failure), maka diambil 3 kotak terakhir dari tiap-tiap analisis akar penyebab masalah masing-masing sebagai cause of failure, mode of failure

dan effect of failure (Mercu Buana).

Metode 5 Why dalam Analisis Akar Masalah

Institut Manajeme

http://pusdiknakes

Jurnal Universitas http://journal.ui.ac

Pojok Anti Korups

http://pojokantikor

LP Universitas Ha http://w w w .unha

Mercu Buana http://74.125.153.

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Banyak yang mengatakan bahwa analisa akar masalah itu adalah suatu aktivitas yang rumit dan kompleks, well, ada benarnya, tetapi ada juga cara untuk melakukannya dengan cara yang sangat sangat mudah.Hal penting yang harus diketahui adalah 5-Why, terjemahan bebasnya “5-Kenapa” atau “5-Mengapa”. Jika terlihat ada masalah oli tercecer di lantai, apa yang harus dilakukan? Tentu saja, yang pertama kali dilakukan adalah untuk membersihkannya.Langkah berikutnya, adalah bertanyalah MENGAPA oli bisa tercecer di lantai? Jawabannya adalah karena oli ini merembes dari tangki oli yang bocor. Tindakan kita adalah perbaiki tangki oli tsb.Apakah sudah Cukup jawabannya? Cobalah bertanya lagi KENAPA tangki oli bocor. Jawabannya adalah karena tangki ini tidak ada pemeriksaan berkala untuk kebocoran. Tindakan yang diperlukan adalah memasukkan hal pemeriksaan kebocoran tangki di jadwal pemeliharaan rutin.Cukup? Coba tanyakan lagi KENAPA tidak ada pemeriksaan berkala untuk kebocoran? Ternyata jawabannya adalah tidak ada aktivitas identifikasi mengenai apa saja check-point (poin pemeriksaan) dari tiap peralatan. Tindakan kita adalah memperkenalkan aktivitas identifikasi check point untuk tiap peralatan.Apa yang kita lakukan untuk mendapatkan akar masalah dan peluang perbaikan sebanyak diatas? Well, hanya bertanya, simply by asking.Cara menjalankannya, kumpulkan orang-orang yang relevan dan punya semangat perbaikan. Anda tentu saja tidak memerlukan seorang skeptis dan pesimis yang meragukan setiap action-plan kita. Kedua, lakukan dalam waktu yang singkat. Jika dibutuhkan waktu sampai 2 jam untuk menjawab, mungkin diperlukan perangkat (tools) yang lebih bagus, misalnya diagram tulang ikan (Fishbone diagram).

Diagram Tulang-Ikan

Dr. Kaoru Ishikawa seorang ilmuwan Jepang, telah memperkenalkan konsep user friendly control, Fishbone cause and effect diagram, emphasised the ‘internal customer’ kepada dunia. Ishikawa juga yang pertama memperkenalkan 7 (seven) quality tools: control chart, run chart, histogram, scatter diagram, pareto chart, and flowchart yang sering juga disebut dengan “7 alat pengendali mutu/kualitas” (quality control seven tools). Diagram Fishbone dari Ishikawa menjadi satu tool yang sangat populer dan dipakai dalam mengidentifikasi faktor penyebab masalah. Fishbone diagram tergolong praktis, dan memandu setiap orang untuk terus berpikir menemukan penyebab utama suatu permasalahan.Diagram “tulang ikan” ini dikenal dengan cause and effect diagram. Kenapa Diagram Ishikawa juga disebut dengan “tulang ikan”? Kangka analisis diagram Fishbone bentuknya ada kemiripan dengan tulang-ikan, dimana ada bagian kepala (sebagai effect) dan bagian tubuh ikan berupa rangka

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serta duri-durinya digambarkan sebagai penyebab (cause) suatu permasalahan yang timbul.Dari contoh gambar berikut terlihat bahwa faktor penyebab problem antara lain (kemungkinan) terdiri dari : material/bahan baku, mesin, manusia dan metode/cara. Semua yang berhubungan dengan material, mesin, manusia, dan metode yang “saat ini” dituliskan dan dianalisa faktor mana yang terindikasi “menyimpang” dan berpotensi terjadi problem. Ingat,..ketika sudah ditemukan satu atau beberapa “penyebab” jangan puas sampai di situ, karena ada kemungkinan masih ada akar penyebab di dalamnya yang “tersembunyi”. Bahasa gaulnya, jangan hanya melihat yang gampang dan nampak di luar.Ishikawa mengajarkan untuk melihat “ke dalam” dengan bertanya “mengapa?……mengapa?…dan mengapa?”. Hanya dengan bertanya “mengapa” beberapa kali seorang peneliti mampu menemukan akar permasalahan yang sesungguhnya. Penyebab sesungguhnya, bukan gejala yang tampak. Dengan menerapkan diagram Fishbone ini dapat menolong peneliti untuk dapat menemukan akar “penyebab” terjadinya masalah khusus khusus yang akan ditelitinya, karena memang banyak ragam faktor yang berpotensi menyebabkan munculnya permasalahan. Apabila “masalah” dan “penyebab” sudah diketahui secara pasti, maka tindakan dan langkah penelitian akan lebih mudah dilakukan. Dengan diagram ini, semuanya menjadi lebih jelas dan memungkinkan peneliti untuk dapat melihat semua kemungkinan “penyebab” dan mencari “akar” permasalahan sebenarnya.

Diagram tulang ikan (Sumber: http://hardipurba.com/2008/09/25/diagram-fishbone-dari-ishikawa.html)

Diagram Lingkar Sebab-Akibat: SISTEM PERIKANAN TANGKAP DI WILAYAH PALABUHANRATU

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Identifikasi kebutuhan adalah langkah awal mengkaji kebutuhan-kebutuhan yang diperlukan oleh para pelaku sistem kegiatan perikanan tangkap. Analisis kebutuhan diperoleh dari kebutuhan semua orang atau institusi yang terkait dengan sistem, dengan diketahuinya pelaku dan kebutuhan pelaku sistem, maka hal tersebut dapat digunakan dalam mengetahui sistem perikanan tangkap di Palabuhanratu. Para pelaku yang terlibat adalah pemerintah daerah, dinas perikanan dan kelautan, nelayan, pengusaha, dan pedagang, kebutuhan dari masing-masing sistem perikanan tangkap di PPN Palabuhanratu dapat dilihat sebagai berikut:

No Pelaku Kebutuhan1 Pemda -Peningkatan pendapatan Daerah-Peningkatan

Lapangan Kerja-Peningkatan kesejahteraan nelayan2 Dinas Perikanan

dan Kelautan-Produksi Hasil Tangkapan memenuhi kebutuhan pasar-Menjaga potensi sumberdaya perikanan-Peningkatan sumber informasi perikanan

3 Nelayan -Bantuan modal untuk biaya operasi-Penambahan unit penangkapan

4 Pengusaha -Peningkatan jumah alat tangkap-Tersedianya BBM-Pabrik es

5 Pedagang/Bakul -Bantuan modal-Fasilitas untuk berdagang-Mutu ikan yang bagus

Formulasi MasalahFormulasi masalah adalah suatu upaya untuk pendefinisian

permasalahan secara spesifik, sehingga masalah tersebut mencapai suatu individu yang dimungkinkan dilaksanakannya usaha ke arah pemecahannya. Formulasi masalah didasarkan pada penentuan informasi yang terperinci yang dihasilkan selama identifikasi sistem. Adapun beberapa masalah yang berkaitan dengan sistem perikanan tangkap di PPN Palabuhanratu, diantaranya :

1). Nelayan. Nelayan Palabuhanratu memiliki kesulitan dalam mengakses modal, sehingga para nelayan harus mencari modal sendiri. Tidak hanya itu, tingkat pendidikan yang rendah dan kulturnya yang tidak mudah menerima perubahan mengenai gaya hidup yang boros.

2). Unit penangkapan ikan. Alat tangkap secara umum memiliki beberapa permasalahan, misalnya umur teknis yang rendah sehingga membutuhkan perawatan yang ekstra, kondisi yang dipengaruhi oleh kondisi alam (arus perairan) dan hasil tangkapan yang tidak stabil.

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3). Perahu. Perahu yang digunakan untuk mengoperasikan beberapa alat tangkap terkadang tidak mampu untuk menjangkau daerah penangkapan yang lebih jauh.

Identifikasi SistemIdentifikasi sistem berhubungan dengan kebutuhan-kebutuhan yang

dibutuhkan oleh pelaku dalam system perikanan tangkap dengan masalah-masalah yang dihadapinya. Kebutuhan tersebut ebeliputi input-output yang terkendali dan input-ouput yang tidak dapat dikendalikan. Input yang terkendali merupakan faktor yang mempengaruhi pemasukkan dari suatu sistem yang dapat dikendalikan, seperti nelayan, kapal, bahan bakar, es, dan pasar. Adapun input yang tak terkendali yang merupakan faktor yang mempengaruhi sistem yang tidak dapat dikendalikan, seperti sumber daya ikan, iklim, dan musim. Sedangkan, output terkendali merupakan faktor yang mempengaruhi keluaran dari suatu sistem yang dapat dikendalikan, seperti harga ikan, upah ABK, retribusi, dan biaya perawatan kapal. Adapun output yang tak terkendali merupakan faktor yang mempengaruhi keluaran suatu sistem yang tidak dapat dikendaikan, seperti kenaikkan harga BBM, dan hasil tangkapan yang didapatkan.

Diagram Lingkar Sebab-AkibatDiagram lingkar sebab akibat merupakan penjelasan sederhana dari

sistem perikanan yang menjelaskan tentang hubungan dari sub-sub sistem yang ada. Dari diagram sebab akibat, sumber daya alam merupakan sub sistem utama yang sangat berpengaruh terhadap sub-sub sistem yang lain.

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Diagram lingkar sebab-akibat (Sumber: http://akhmadsyahbana.wordpress.com/2011/06/18/sistem-perikanan-tangkap-di-

wilayah-palabuhanratu/)

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Model Sistem dalam Pengendalian Pencemaran Danau:Diagram Lingkar Sebab-Akibat

Pendekatan sistem merupakan suatu metodologi pemecahan masalah yang dimulai dengan mengidentifikasi serangkaian kebutuhan sehingga dapat menghasilkan suatu operasi dari sistem yang dianggap efektif. Pendekatan sistem ini dilakukan untuk menunjukkan kinerja intelektual berdasarkan perspektif, pedoman, model, metodologi dan sebagainya yang diformulasikan untuk perbaikan secara terorganisir dari tingkah laku dan perbuatan manusia. Oleh karena itu, pada pendekatan sistem dalam penyelesaian suatu masalah selalu ditandai dengan: (1) pengkajian terhadap semua faktor penting yang berpengaruh dalam rangka mendapatkan solusi untuk pencapaian tujuan, dan (2) adanya model-model untuk membantu pengambilan keputusan lintas disiplin, sehingga permasalahan yang kompleks dapat diselesaikan secara komprehensif.

Analisis KebutuhanAnalisis kebutuhan pada dasarnya merupakan tahap awal

pengkajian dalam pendekatan sistem, dan sangat menentukan kelaikan sistem yang dibangun. Analisis kebutuhan juga merupakan kajian terhadap faktor-faktor yang berkaitan dengan sistem yang dianalisis. Oleh karena itu, dalam penelitian ini analisis kebtutuhan diarahkan pada pihak-pihak yang mempunyai kepentingan dan keterkaitan baik secara langsung maupun tidak langsung terhadap pengendalian pencemaran perairan danau.

Dalam pengendalian pencemaran perairan danau, pihak yang mempunyai kepentingan dan terkait secara langsung adalah

(1) Masyarakat lokal yaitu masyarakat yang tinggal di sekitar danau yang memanfaatkan perairan danau untuk berbagai kepentingan,

(2) Dinas instansi terkait yaitu semua dinas instansi pemerintah daerah yang mempunyai hubungan keterkaitan dengan perairan danau baik langsung mapun tidak,

(3) Akademisi (peneliti) yaitu orang yang melakukan penelitian pada perairan danau,

(4) Lembaga Swadaya Masyarakat (LSM) yaitu lembaga yang dibentuk masyarakat setempat yang mempunyai kepedulian terhadap kelestarian perairan danau, dan

(5) Badan usaha milik negara yaitu perusahaan yang melakukan kegiatan usaha di perairan danau.

Dalam analisis kebutuhan dilakukan inventarisasi kebutuhan setiap pelaku yang terlibat dalam sistem. Inventarisasi ini dilakukan dengan wawancara secara terbatas. Sebagai contoh misalnya, hasil wawancara menunjukkan kebutuhan pelaku usaha seperti disajikan pada tabel berikut.

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Sumber: http://menyelamatkandanaulimboto.wordpress.com/pengendalian-pencemaran-danau/marganof/3-metode-penelitian/

Formulasi Permasalahan SistemPermasalahan sistem pada dasarnya adalah terdapatnya gap antara

kebutuhan pelaku dengan kondisi yang ada (reel). Pada kondisi nyata di lapangan, permasalahan sistem ditunjukan oleh adanya isu yang berkembang sehubungan dengan terjadinya pencemaran di perairan danau. Formulasi sistem di sini adalah merupakan aktivitas merumuskan permasalahan dalam pengendalian pencemaran di perairan danau yang berkaitan dengan adanya perbedaan antara kebutuhan pelaku dengan kondisi yang ada.

Berdasarkan pada analisis kebutuhan para pelaku yang terlibat dalam pemanfaatan perairan danau dan kondisi yang dijumpai di perairan danau saat ini, maka permasalahan pengendalian pencemaran di perairan danau dapat diformulasikan sebagai berikut:

1. Tidak diperhatikannya limbah dari aktivitas KJA yang ditunjukan dengan tidak adanya pemahaman mengenai dampak dari limbah KJA terhadap kualitas air.

2. Tidak tersedianya sistem pengolahan limbah penduduk, menyebabkan buangan limbah dari permukiman akan langsung mengalir ke perairan danau, sehingga kualitas perairan danau menjadi turun.

3. Tidak diperhatikannya pemanfaatan tata guna lahan di kawasan sempadan danau yaitu banyaknya pengembangan permukiman, hotel, restoran, dan home stay serta pembukaan lahan pertanian yang tercermin dari tingginya padatan tersuspensi di perairan danau.

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4. Tidak diperhatikannya persepsi masyarakat di sekitar perairan danau dalam upaya pengendalian pencemaran yang terjadi di perairan danau.

5. Tidak adanya zonasi (penataan ruang) kawasan danau yang tercermin dari penyebaran atau letak keramba jaring apung yang tersebar hampir di seluruh tepian atau keliling perairan danau.

Identifikasi SistemIdentifikasi sistem merupakan suatu rantai hubungan antara

pernyataan dari kebutuhan dengan pernyataan khusus dari masalah yang harus dipecahkan untuk memenuhi kebutuhan-kebutuhan tersebut. Hal ini sering digambarkan dalam bentuk diagram lingkar sebab-akibat (cousal loop diagram) . Diagram tersebut merupakan pengungkapan interaksi antara komponen di dalam sistem yang saling berinteraksi dan mempengaruhi dalam kinerja sistem. Disamping itu, hubungan antara input (masukan) dan output (keluaran) dalam suatu sistem digambarkan dalam sebuah diagram inputoutput (masukan-keluaran) seperti disajikan pada gambar berikut. Diagram lingkar sebab-akibat merupakan gambaran dari struktur model pengendalian pencemaran di perairan danau yang dibuat berdasarkan diagram input-output.

Diagram lingkar sebab-akibat (cousal-loop diagram) sistem pengendalian pencemaran perairan danau. Sumber: http://menyelamatkandanaulimboto.wordpress.com/pengendalian-

pencemaran-danau/marganof/3-metode-penelitian/

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Secara garis besar ternyata variabel yang mempengaruhi kinerja sistem ada 6 variabel yakni:

(1) variabel output yang dikehendaki; ditentukan berdasarkan hasil analisis kebutuhan,

(2) variabel input terkontrol, variabel yang dapat dikelola untuk menghasilkan perilaku sistem sesuai dengan yang diharapkan,

(3) variabel output yang tidak dikehendaki; merupakan hasil sampingan atau dampak yang ditimbulkan bersama-sama dengan output yang diharapkan,

(4) variabel input tak terkontrol, (5) variabel input lingkungan; variabel yang berasal dari luar

sistem yang mempengaruhi sistem tetapi tidak dipengaruhi oleh sistem, dan

(6) variabel kontrol sistem; merupakan pengendali terhadap pengoperasian sistem dalam menghasilkan output yang dikehendaki.

Diagram masukan-keluaran (input-output diagram) sistem pengendalian pencemaran perairan danau adalah berikut ini.

Sumber: http://menyelamatkandanaulimboto.wordpress.com/pengendalian-pencemaran-danau/marganof/3-metode-penelitian/

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PENGANTAR METODE RCA (ROOT CAUSE ANALYSIS)(= ANALISIS AKAR MASALAH =)

There's a lot of information on Root Cause Analysis available on the web. Unfortunately, if someone a beginner, finding useful, easy-to-use information can be difficult. That's why it is the list of 4 useful web resources for an Introduction to Root Cause Analysis.

Root Cause Analysis for Beginners - Article from the July 2004 issue of Quality Progress, provides an overview of the purpose and justification for Root Cause Analysis, and demonstrates application.

Events and Causal Factors Analysis - Detailed guidance on the Event and Causal Factor method for event sequencing. Provides charting symbol standards and tips for application.

Control of Change Cause Analysis - Manual for performing "3CA" analysis of root causes, which seeks to identify changes that could have been controlled, or where controls failed.

Root Cause Live - Community site for users and providers of performance improvement, failure analysis, and incident investigation services. Non-proprietary and non-industry-specific.

Analisis masalah adalah penguraian masalah-masalah pokok yang teridentifikasisampai ke akar penyebabnya. Analisis masalah ini dalam Permendagri 66/2007 terdiri dari empat tahap, yaitu pengelompokan masalah, penentuan peringkat masalah, pengkajian tindakan pemecahan dan penentuan peringkat tindakan. Ada dua alternative metode yang dapat digunakan untuk melakukan analisis masalah, yaitu pohon masalah dan sistem masalah.

Pohon MasalahUntuk mencari MASALAH POKOK, metode pohon masalah ini mencobamenelusuri masalah hingga ke AKAR MASALAH. Harapannya, jika akar masalahtersebut bisa terpecahkan maka masalah utama akan terpecahkan.Instrumen yang paling umum digunakan adalah pohon masalah.

1. Tuliskan satu MASALAH POKOK pada selembar kartu dan tempelkan padapapan tulis atau pinboard

2. Carilah penyebab langsung terjadinya masalah pokok tersebut denganmenelusuri hubungan SEBAB AKIBAT

3. Telusuri SEBAB AKIBAT sampai ke akar penyebabnya, sampai POHON MASALAHterbentuk secara lengkap

4. Tulislah satu pernyataan yang dianggap sebagai penyebab langsung terjadinyaMasalah Pokok

5. Begitu seterusnya sampai tidak ada lagi yang masih dapat diidentifikasi sebagaipenyebab langsung terjadinya keadaan

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6. Tempelkan semua kartu pada papan tempel dan tunjukkan hubungan SEBAB-AKIBAT dengan tanda panah

7. Tanpa harus menjadi terlalu rinci, periksa kembali DIAGRAM pohon masalahuntuk melihat apakah pernyataan SEBAB-AKIBAT atas setiap keadaan yangditulis pada setiap kartu telah lengkap

8. Sepakati DIAGRAM Pohon Masalah sebagai hasil kerja bersama.

Contoh Pohon Masalah.

sampahkurangterawat

SISTEMIK MASALAHBerbeda dengan Pohon Masalah, metode ini melihat bahwa masalah itu saling bertautan dan saling mempengaruhi. MASALAH POKOK merupakan masalah yang mempunyai pengaruh terbesar terhadap MASALAH lainnya.Tahap-tahap yang harus dilalui adalah:

1. Menuliskan MASALAH-MASALAH masing-masing pada selembar kartu

2. Menempelkan semua kartu yang bertuliskan MASALAH pada papan

3. Menunjukkan SEBAB AKIBAT antar masalah-masalah tersebut denganmenggunakan TANDA PANAH

Pokok Masalah

Akar Masalah

Banjir

IrigasiHt gundul

Pembalakan Tdk ada reboisasi

Sampah

Tdk terawat

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4. Begitu seterusnya sampai dapat diidentifikasi MASALAH yang mempunyai pengaruh terbanyak

5. Tanpa harus menjadi terlalu rinci, periksa kembali DIAGRAM SISTEM MASALAHuntuk melihat apakah pernyataan SEBAB-AKIBAT atas setiap keadaan yang ditulis pada setiap kartu telah lengkap

6. Menyepakati DIAGRAM SISTEMIK MASALAHsebagai hasil kerja bersama

Contoh Sistemik Masalah

“ Analisa akar permasalahan adalah suatu penyelidikan / pengusutan yang terstruktur yang bertujuan untuk mengidentifikasi penyebab sesungguhnya dari suatu masalah, dan tindakan-tindakan yang dibutuhkan untuk mengeliminasi / menghilangkan”

Walau kedengarannya agak terus-terang, akan dapat dilihat bahwa analisa akar masalah tidak dilaksanakan dengan menggunakan satu alat atau strategi tunggal, tetapi dengan sejumlah alat yang sering dikombinasikan.Analisa akar masalah adalah suatu istilah yang kolektif yang digunakan untuk menggambarkan berbagai pendekatan, alat serta teknik yang digunakan untuk membongkar sebab-sebab suatu masalah, sebagian pendekatan lebih diarahkan untuk mengidentifikasikan akar-akar masalah yang sesungguhnya daripada lain-lainnya.Ada pendekatan yang lebih berupa teknik-teknik umum untuk pemecahan masalah, adalagi yang hanya menawarkan dukungan pada aktivitas inti dari analisa akar masalah. Ada alat-alat yang bercirikan pendekatan terstruktur, adapula yang lebih kreatif (dan serampangan / sembrono ).

Sekala Usaha Kecil

Sekala Usaha Kecil

Sekala Usaha Kecil

Akses modal lemah

Daya tawar lemah

Investasi Kecil

Profit Kecil

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Hal yang penting adalah bukan mempelajari dan menggunakan semua alat in, tetapi lebih untuk mengenal alat-alat analisa akar masalah dan mengaplikasikan teknik-teknik atau alat yang sesuai untuk menangani suatu masalah tertentu.

Alat-alat Analisa Akar Masalah

Beberapa alat analisa akar masalah telah dikelompokkan sesuai dengan tujuan (dan dititik mana alat itu digunakan). Untuk alasan-alasan berikut:

1. Ada sedemikian banyak alat sehingga perlu menjaga kejelasan selama presentasi alat- alat itu.

2. Meraka secara alami akan masuk ke kategori-kategori alat yang berfungsi untuk tujuan-tujuan yang agak berbeda.

Kelompok-kelompok alat, sesuai dengan tujuannya adalah sbb:

PEMAHAMAN MASALAH

1. FLOWCHART : Chart / Grafik yang digunakan untuk ‘melakukan gambar’ tentang proses dunia.

2. Kejadian yang kritis : Pendekatan yang anggun digunakan untuk mengeksplorasi / menyelidiki isu-isu yang paling kritis dalam suatu situasi.

3. Grafik Laba-laba / Spider Chart : Sebuah grafik perbandingan untuk menandai sebuah masalah-masalah.

4. Matriks Penampilan : Digunakan untuk membantu menentukan pentingnya masalah-masalah atau sebab-sebab.

ASAL TIMBULNYA PENYEBAB DAN PENCAPAIAN MUFAKAT

1. Brainstorming. Suatu pendekatan resmi yang dapat digunakan selama analisa akar masalah bila dibutuhkan banyak ide.Brainwriting. Sebenarnya merupakan sesi brainstorming tertulis.

2. Teknik kelompok nominal : Teknik yang digunakan untuk membantu sebuah kelompok dalam memprioritaskan berbagai alternatif – misalnya, sebab-sebab masalah.

3. Perbandingan berpasangan : Suatu teknik yang digunakan untuk mencapai mufakat dengan memperoleh partisipan atau peserta memilih antara dua alternatif yang dibandingkan.

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PENGUMPULAN DATA PENYEBAB DAN MASALAH

1. Sampling/Contoh : Digunakan untuk mengumpulkan data disuatu populasi yang besar dengan mengambil sedikit sample / contoh.

2. Survey : Digunakan untuk mengumpulkan data tentang pendapat-pendapat dan sikap-sikap dari pelanggan , pegawai dll.

3. Check sheet : Suatu pendekatan yang secara sistematis mengumpulkan data berdasarkan pada sheet (lembaran) yang sudah dibuat dulu yang digunakan selama periode pengumpulan data.

ANALISA PENYEBAB YANG MUNGKIN

1. Histogram : Suatu diagram yang mudah digunakan yang membantu mengidentifikasi pola-pola atau anomali / kelainan-kelainan.

2. Pareto Chart : Alat visual lain yang digunakan untuk memberi ilustrasi penyebab-penyebab dominan yang menimbulkan efek / pengaruh paling besar.

3. Scatter Chart : Digunakan untuk memberi ilustrasi hubungan antara dua sebab atau variable-variable lain dalam situasi bermasalah.

4. Diagram hubungan (Relation’s Diagram) : Suatu alat yang digunakan untuk mengidentifikasi hubungan logis antara berbagai ide atau isu dalam suatu situasi yang rumit atau membingungkan .

5. Diagram Afinitas (tarik-menarik) : Suatu pendekatan grafik (chart approach) yang membantu mengidentifikasi ide-ide, sebab-sebab atau konsep-konsep yang kelihatannya tidak berkaitan sehingga mereka semua bisa dieksplorasi / ditinjau lebih lanjut.

Diagram HubunganDiagram hubungan antara iklim dan tanaman.

Pengaruh cuaca terhadap tanaman berbeda dengan pengaruh iklim. Suatu wilayah pusat produksi tanaman yang telah berlangsung puluhan hingga ratusan tahun, kondisi iklimnya jelas sesuai bagi kultivar yang dibudidayakan. Walau demikian sesekali mengalami cuaca ekstrim selama beberapa hari sehingga gagal panen. Jadi, keadaan cuaca menentukan kondisi aktual hasil panen sedangkan kondisi iklim menentukan kapasitas dan rutinitas panen.

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Kondisi iklim /cuaca mikro secara langsung mempengaruhi proses fisiologi karena berhubungan dengan atmosfer di lingkungan tanaman sejak perakaran hingga puncak tajuk. Unsur yang berpengaruh kuat terutama radiasi surya, suhu udara, suhu tanah, kelembapan, kecepatan angin, presipitasi dan evapotranspirasi. Mekanisme pengaruh faktor pengendali dan unsur iklim terhadap tanaman dan lingkungan dapat dilihat pada gambar berikut.

Diagram hubungan antara iklim dan tanaman. (Sumber: http://rudikomarudin.blogspot.com/2011/03/hubungan-antara-iklim-dan-tanaman.html)

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DIAGRAM LINGKAR HUBUNGAN SEBAB AKIBAT: SISTEM AGRIBISNIS

Diagram lingkar sebab akibat selain menggambarkan hubungan antar elemen, pengaruh hubungan, juga membantu untuk melakukan identifikasi sistem. Inventarisasi hubungan dapat dilakukan menggunakan bantuan dafta atau tabel sebab akibat. Sebagai contoh hubungan sebab akibat adalah Sumber Daya Alam merupakan penyebab tumbuh berkembangnya IPTEK yang lebih efisien dan efektif untuk memanfaatkan Sumber Daya Alam. Ketersediaan, kesesuaian Sumber Daya Alam juga akan menyebabkan bertambahnya jumlah Agribisnis, demikian seterusnya.

Sumber: http://taman-agribisnis.blogspot.com/2010_02_01_archive.html

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DIAGRAM AFINITAS (Affinity Diagram)

Diagram afinitas (affinity diagram) merupakan suatu diagram atau tabel yang diperoleh sebagai hasil dari suatu tata cara pengumpulan ide, dimana sejumlah atau sekumpulan ide yang tidak beraturan dikelompokkan berdasarkan jenisnya. Kumpulan ide tersebut biasanya diperoleh dari brainstorming. Dengan demikian diagram afinitas adalah suatu alat analisis manajemen yang diterapkan untuk menjaring ide-ide yang diperoleh dari aktifitas brainstorming, Namun demikian, kumpulan ide yang akan dikelompokkan menjadi beberapa group kecil (misalnya 5 group) tidaklah mesti merupakan kumpulan ide yang diperoleh sebagai keluaran dari suatu aktifitas brainstroming. Misalkan dari suatu aktifitas brainstroming yang bertujuan untuk menjaring ide terhadap pertanyaan: Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?, maka kira-kira akan diperoleh hasil berupa daftar ide seperti yang diperlihatkan pada tabel berikut.Apabila dilakukan pengamatan yang saksama terhadap ide-ide tersebut, maka akan terlihat bahwa diantara ide-ide tersebut terdapat ide-ide yang mempunyai tema yang sama, misalnya tema tentang training dan keterampilan, tema tentang manajemen, tema yang menyangkut konsumen dan sebagainya. Oleh karena itu sekumpulan ide tersebut dapat dikelompokan menjadi sejumlah kecil kelompok ide yang lebih bermakna.

Diagram afinitas terutama bermanfaat jika digunakan dalam kondisikondisi seperti: a). tidak ada kepastian akan fakta dan pemikiran/opini yang

terkumpul sehingga perlu pengorganisasian akan hal tersebut, b). jika terdapat suatu ide atau paradigma yang dianut sebelumnya

dan perlu untuk diantisipasi, c). jika terdapat ide-ide yang perlu diklarifikasi dan d). jika ingin diciptakan keutuhan tim.

Penting untuk diingat bahwa penamaan terhadap kelompok ide (atau tema dari kelompok) sebaiknya dicantumkan setelah dilakukan proses pengelompokkan dan bukan sebelumnya. Sehingga dengan demikian tema kelompok ide akan relevan dengan ide-ide yang terkumpul pada kelompok tersebut. Sebagai contoh, kumpulan ide hasil brainstorming seperti yang diperlihatkan pada tabel berikut, setelah dilakukan penyaringan dan pengelompokan akan tampak seperti yang diperlihatkan pada tabel.

Diagram afinitas merupakan suatu teknik pengambilan keputusan yang digunakan/diterapkan pada sekelompok orang (grup), yang didesain sedemikian rupa untuk menyeleksi sejumlah besar ide (termasuk pula: variabel proses, konsep dan opini) yang saling berhubungan, sejenis atau memiliki tema yang sama ke dalam sejumlah kecil grup ide.

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Tabel kumpulan ide hasil brainstorming

Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?Mengetahui kebutuhan konsumen

Menyediakan training Menerapkan pengawasan; pemeriksaan dan pengendalian mutu

Mendapatkan komitmen manajemen

Mewawancarai konsumen

Mengetahui alat alat pengembangan dan perbaikan mutu

menerapkan tatacara analisa danpengukuran

melibatkan top manager dan middle manager sebagai steering commitee

Mengidentifikasikonsumen

Melakukan investigasi terhadap usaha usaha tentang perbaikan mutu secara terus menerus

Mengembangkan tata cara koreksi yang efektif terhadap penyimpangan

Menerapkan sistemrewarding yang konsisten

membuat defenisioperasional mengenai pengetian out-put

Melibatkan karyawan Menerapkan pengembangan berdasarkan project by project

menyediakan job security, seperti freedom to fail

Menciptakan keakraban dengan jalan menghilangkan penghalang diantara kariawan

membuat defenisi operasional mengenai pengetian proses

Menyediakan support staff bagi middle manager

Menghitung process capability.

membuat program goals yang jelas

meningkatkankomunikasi di semua sektor

menyediakanwaktu bagi middlemanager untukberpartisipasi

akses yang luasterhadap informasi

Membentuk steering committee dengan wewenang yang jelas

Tabel Penyaringan dan pengelompokan ide hasil brainstorming ke dalam 5kelompok

Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?Pengetahuan tentang konsumen

Training perbaikan dan peningkatan mutu

Pemeriksaan dan pengendalian mutu

Mendapatkan komitmen dari manajer

Meningkatkan komunikasi

Mengetahui kebutuhan konsumen

Menyediakan training

Menerapkan pengawasan, pemeriksaan dan pengendalian mutu

Mendapatkan komitmen manajemen

Meningkatkan komunikasi di semua sektor

mewawancaraikonsumen

Mengetahui alat-alat pengembangandan perbaikan mutu

menerapkantata cara analisa dan pengukuran

melibatkan topmanager danmiddle managersebagai steeringcommitee

akses yang luasterhadapinformasi

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Mengidentifi-kasi konsumen

melakukaninvestigasiterhadap usahausahatentang perbaikan mutusecara terus menerus

mengembangkan tata cara koreksi yang efektif terhadap penyimpangan

menerapkansystem rewarding yangkonsisten

melibatkankaryawan

membuatdefenisioperasionalmengenaipengetian output

menerapkanpengembanganberdasarkanproject byproject

menyediakanjob security,seperti freedomto fail

menciptakankeakrabandengan jalanmenghilangkanpenghalangdiantarakariawan

membuatdefenisioperasionalmengenaipengetianproses

menyediakansupport staffbagi middlemanager

menghitungprocesscapability.

Membuat program goals yang jelas

Menyediakan waktu bagi middle manager untuk berpartisipasimembentuksteering committee dengan wewenang yangjelas

Penerapan diagram afinitas bertujuan untuk menyaring dan mengelompokkan sejumlah besar ide ke dalam kelompok yang lebih kecil berdasarkan jenis, tema atau kesamaan lainnya.Dalam pelaksanaannya terdapat beberapa hal yang perlu diperhatikan dalam penyaringan dan pengelompokan ide ke dalam diagram afinitas, di antaranya:

a. Memastikan bahwa ide-ide yang terkumpul terdeksripsikan dengan kalimat atau frasa yang jelas maknanya

b. Melakukan pengelompokan ide-ide yang kelihatannya memiliki kesamaan secara cepat

c. Melakukan klarifikasi terhadap ide-ide yang tidak jelas, sehingga dengan demikian dapat digolongkan ke dalam salah satu kelompok.

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d. Jika suatu ide dapat digolongkan ke dalam lebih dari satu kelompok, buatlah copy atas ide itu dan tempatkan ke dalam kelompok-kelompok itu

e. Mengitung jumlah ide yang telah digolongkan ke dalam masing-masing kelompok

f. Mempertimbangkan untuk memasukkan anggota kelompok kecil ke dalam kelompok yang anggotanya lebih besar, demikian juga sebaliknya, membagi suatu kelompok menjadi dua bila ide yang terkumpul di dalamnya terlalu banyak.

g. Setelah semua ide habis dan selesai digolongkan, buatlah judul untuk masing-masing kelompok.

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ANALISIS SEBAB-AKIBAT

1. Cause and effect chart (CE diagram). Suatu alat yang mudah diaplikasikan / digunakan untuk menganalisa sebab-sebab yang mungkin dari suatu masalah.

2. Matrix Diagram. Suatu teknik visual untuk mengatur potongan-potongan informasi sesuai dengan aspek-aspek tertentu.

3. Five whys (Lima Mengapa). Suatu pendekatan yang digunakan untuk menyelidiki lebih mendalam tentang hubungan-hubungan sebab (causal relationships).

Contoh CE-diagram:How to draw CE diagram

Step 1Write down the effect to be investigated and draw the 'backbone' arrow to it. In the example shown below the effect is 'Incorrect deliveries'.

Step 2Identify all the broad areas of enquiry in which the causes of the effect being investigated may lie. For incorrect deliveries the diagram may then become:

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For manufacturing processes, the broad areas of enquiry which are most often used are Materials (raw materials), Equipment (machines and tools), Workers (methods of work), and Inspection (measuring method).

Step 3. This step requires the greatest amount of work and imagination because it requires you (or you and your team) to write in all the detailed possible causes in each of the broad areas of enquiry. Each cause identified should be fully explored for further more specific causes which, in turn, contribute to them.

Sumber: http://www.hci.com.au/hcisite3/toolkit/causeand.htm

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RCA – Seni atau Sain?

There are many commonly held beliefs about root cause analysis that bother people. Perhaps the single most irksome is the statement "it's an art, not a science." We don't have anything against art, but we don't believe that this statement does justice to the practice of root cause analysis. In fact, we believe it is one of the most damaging perceptions that can be held by an investigator or be communicated to others.So, why do people believe this? One widely-held perception is that root cause analysis is not repeatable, i.e. the belief that different analysts performing independent investigations of the same issue will not arrive at identical results. Another commonly-stated reason is that it can be difficult to state the results of a root cause analysis with much precision, especially if issues of human or organizational performance are involved.In addition, we believe that many people instinctively recognize that some aspects of root cause analysis are inherently subjective. By necessity, RCA requires that an analyst compare that which is to that which ought to be... and what ought to be is often a matter of opinion. Furthermore, the development of recommendations (the most obvious outcome of root cause analysis) is certainly subjective in nature, as there is rarely an absolute standard to determine which solution is best, even for purely technical issues.However, we don't believe any of the above justify characterizing root cause analysis as an art, or as "more art than science." In general, art is the application of creativity for its own sake without any objective criteria for judging quality. In contrast, root cause analysis, while containing elements of creativity, is rarely (if ever) applied without a specific purpose, or without objective criteria for what constitutes a quality outcome.We would argue that root cause analysis is a science, or is at least a process that must be performed scientifically. The following description of scientific method from Wikipedia provides a good summary of my viewpoint:

Scientific method is a body of techniques for investigating phenomena and acquiring new knowledge, as well as for correcting and integrating previous knowledge. It is based on observable, empirical, measurable evidence, and subject to laws of reasoning.

Note the emphasis on the use of evidence and reasoning for investigating and acquiring knowledge: this could very well serve as a working description of the root cause analysis process. Consider also that science can refer to

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both natural (or "hard") sciences like physics and chemistry, or social ("soft") sciences like economics and sociology.

The following description of social science from Wikipedia provides additional insight:

The social sciences are groups of academic disciplines that study the human aspects of the world. They diverge from the arts and humanities in that the social sciences emphasize the use of the scientific method and rigorous standards of evidence in the study of humanity, including quantitative and qualitative methods.

So, even root cause analysis efforts that delve into issues of human and organizational performance must be performed scientifically and be subject to rigorous standards of evidence. (Of course, this has little bearing on the parts of a root cause analysis that deal solely with physical/technical issues.)In summary, the root cause analysis process contains many elements that are not consistent with the belief that it is an art. These elements (evidence, reasoning, objective standards), however, are fully consistent with the characterization of root cause analysis as a science, or at least as a process dominated by scientific thinking. While certain aspects of the process may be subjective in nature, even these must be performed within an objective, scientific framework for the process to have any validity. Thus, the assertion that RCA is "more art than science" is not justified, and should not be promoted.

Makna Akar Masalah

In the practice known as Root Cause Analysis (RCA), we are generally looking for reasons to explain why a problem occurred. In most cases, we find that there are many reasons for any given problem. Some (or most?) of them may be far removed in time, space, and subject from the problem itself. We typically call such reasons Root Causes, and according to theory, correcting these Root Causes will prevent future occurrences of this problem, and potentially many others.

The basic RCA method is to simply ask "Why" over and over again until you arrive at a Root Cause. The real question then becomes: how do we know when to stop asking "Why"? At what point are we satisfied that we've identified a Root Cause? What is a Root Cause? These are questions that constantly spark disagreement among RCA practitioners. While there is some disagreement as to what constitutes a Cause, the real fireworks begin when you try to define the word Root.

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Dictionary.com has a rather lengthy definition of Root. I won't reproduce it here, but it should suffice to say that there are many different definitions. However, there are a few common meanings that run through most of them:

Akar-akar seringkali tersembunyi di bawah permukaan. Akar menyediakan dukungan atau berfungsi sebagai basis. Akar berhubungan dengan asal-usul dan sumber-sumber. Akar adalah primer dan fundamental. Roots are established and entrenched.

What about the etymology of Root? According to the Online Etymology Dictionary, Root comes from the Old Norse word rot for "underground part of a plant." The current meanings of Root make sense in this respect. The etymology tells us that when we use the word Root today, we are basically using it as a metaphor to suggest the qualities of plant roots. In addition to the list above, the following qualities come to mind.

Akar-akar dapat menyebar lebih jauh dari perkiraan. Akar-akar mungkin sulit ditemukan dan lebih sulit to get rid of. Akar-akar yang tidak dihilangkan dapat melangsungkan

pertumbuhan. Akar seringkali sangat kotor.

When RCA practitioners talk about Root Causes, they are basically talking about Causes that have all the qualities listed above. They want you to understand that problems are like plants that you don't want, i.e. weeds. If you leave a weed alone, you will end up with more weeds. If you try to remove a weed by cutting it off at the surface, your weed will grow back. The part of a weed you have to kill or remove to prevent future weeds is the root. The best overall solution would be to treat the soil so weeds don't take root in the first place!So, back to the real questions at hand: what is a Root Cause? At what point are you satisfied that you've found one? When can you stop asking "Why"? Here's a short answer: you're right next to a Root Cause for your problem when you reach a fundamental force, law, or limit that cannot be removed by any action taken within your system. The actual Root Cause is the contradiction between your system's values (purpose, rules, culture, etc.) and these fundamental forces, laws, or limits.That's all I'm going to say for now, but I'll be exploring this topic in more detail in the future. Keep watching my blog for more articles on this topic.

It has been discussed the definition of the word root as it applies to the concept of root cause. However, that article did not provide a definition for

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the word cause. While the meaning of cause may seem obvious to the casual observer, this article will develop a very precise definition that is useful for the incident investigator or root cause analyst.

The general definition of cause is the producer of an effect. This isn't a very precise definition, but we can use it to get at something more useful. Let us break it down into components with that goal in mind.

First, consider the concept of an effect. The word itself is fairly ambiguous, because it is so often tied to the word cause, as in cause and effect. Looking at the concept intuitively, however, yields some insight. What is the difference between having an effect, versus having no effect?In a situation where some action was taken, but there is no effect, then nothing changed. If there was an effect, then something must have changed. The difference is then the presence or lack of a change. In essence, an effect is a change.

The definition for cause can now be written as the producer of a change. Let us now try to refine this by expanding upon the concept of a producer. What is required to produce a change?

A change requires that there be a discrete difference between initial and final states. Except for processes like radioactive decay, where the impetus driving the change of state is completely internal, there must be an external driver. Additionally, there are usually other factors required to exist coincident with the driver.What is required, then, is a set of factors sufficient to drive a particular change of state. One or more of these factors may be active in nature, such as an action or another change. Others may be passive or constant, such as local ambient conditions or object properties.Given a set of factors sufficient to drive a change, it would be instructive to ask what happens if one or more of the factors were not present. If the factor is not necessary, then it doesn't matter whether it does or does not exist. However, if the factor truly is necessary but not present, then the change cannot happen.So, in order for a change to be produced, we must have a sufficient set of factors in which all necessary factors are present. If any of the necessary factors are not present, the change does not occur -- each of the necessary factors is a sort of on/off switch for the given change. In this sense, each of the necessary factors can be considered a cause of the effect.

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Incorporating all the points discussed above leads to the following definition for cause:

A cause is any necessary component of a set of factors sufficient to drive a change.

This definition is somewhat wordy, but is very precise. It is also valuable because it provides a clear test of whether an action or condition is in fact a cause for a given effect. Using this definition, it is possible to screen out factors that are irrelevant. Conversely, this definition can be used to identify missing evidence or even rule out invalid hypotheses.

Hubungan antara sebab dan akibat yang ditimbulkannya dapat dilukiskan dalam bentuk diagram tulang ikan , seperti contoh berikut:

Sumber: http://syque.com/quality_tools/toolbook/cause-effect/example.htm

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Tahapan dalam RCA (Root Cause Analysis)

Root Cause Analysis (RCA) is generally conducted in several phases. I've seen some methodologies that break down the RCA process into as many as a dozen different steps. In reality, however, there are just three main phases we need to be concerned about. More importantly, these three phases are very different from each other... so different that they should always be kept distinctly separate. I've designated these phases Investigation, Analysis, and Decision. Read on to see why.

Tahap 1: InvestigationThe purpose of the investigation phase is to discover facts that show HOW an incident occurred. During investigation, we are not concerned with what didn't happen, or what should have happened -- the only concern is what actually happened, without any judgement of value. Investigation deals with facts in a value-neutral manner.During the investigation phase, if you find yourself using words like "not", "should", "error", "incorrect", "inappropriate", etc., STOP! You are injecting value judgements into a practice that requires absolute neutrality. Facts exist regardless of what we think or feel about them. Jumping too early into what should have happened will obscure your vision of what did happen.There may be times when required facts simply aren't available -- critical evidence was destroyed in the process, or there were no witnesses to a critical event. In such cases, you have some options. Consider secondary sources that may not be conclusive, but could provide enough circumstantial evidence to guide further investigation. Attempt to reconstruct the event using plausible scenarios and then perform controlled tests to confirm or deny the most likely explanations.Regardless of the tools you use, the final product of the investigation phase should be a factual representation of the incident. If some facts were not available, and theory (backed up by testing) had to be used instead, ensure this is clearly evident in the representation of the incident. This representation should then be thought of as a complete script or plan for reproducing the incident in detail. Only after you've reached this point should you progress to the next phase, Analysis.

Tahap 2: AnalysisThe purpose of the analysis phase is to discover reasons that explain WHY an incident occurred. This is when you take the purely factual representation of the incident and view it within the context of the system (or organization) that created it. The values of the system (purpose, rules, culture, etc.) can now be used to compare what actually happened against what should have happened, at any point during the incident.

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During the analysis phase, do not let yourself fall into the trap of believing that the values of the system are always correct! You are not just analyzing the incident itself, but also the system that created it. Mentally place yourself within the incident, watch events unfold, and then determine if the system's values were, for example: correct but inadequately applied, insufficient to prevent the incident, or incorrect such that the system's values actually created (or contributed to) the incident.Don't get too caught up in the mechanics of the analysis tool being used. Many tools are available to aid the analysis phase. Each has it's own strengths and weaknesses, and preferred realms of application. For example, if you're not getting any insight using barrier analysis, switch over to change analysis. The point of any analysis tool is to provide insight, and in some situations, one tool may be vastly superior to another.Finally, do not let questions like "how can I fix this? ..." be considered during the analysis phase. It is all too easy to let desired corrective actions colour your perceptions of an incident's causes. However, analysis is about discovering conditions that exist now or existed in the past. The future must not enter into the equation. Jumping too early into what could be risks obscuring your vision of what is.Regardless of the tools you use, the final product of the analysis phase should be a finite set of root causes for the incident that show why it was inevitable. Yes, inevitable -- these are fundamental, latent conditions that were just laying around waiting for some kind of trigger to activate. Only after you've reached this realization should you progress to the next phase, Decision.

Tahap 3: DecisionThe purpose of the decision phase is to develop recommendations that identify WHAT should be learned and WHAT needs to be done. In this phase, we are concerned with correcting or eliminating the root causes of an incident. This can only be accomplished if both learning and action occur. Learning without action is mere mental trickery, while action without learning is simply useless physical exercise. Both are required for long-term, effective results.During the decision phase, beware of overly-specific, conditional corrective action recommendations! It is often tempting to save effort by cramming one more feature or condition into an existing mechanism. However, doing so often just adds complexity to a situation that has already shown itself to be prone to failure. Do not be afraid to recommend complete redesign in such situations.In some situations, there may be several options available to correct or eliminate a root cause. In such cases, a structured decision analysis method should be used to gauge competing recommendations against criteria such

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as simplicity, effectiveness, longevity, cost, etc. However, do not forget to consider potential risks or side-effects of each recommendation as well. In correcting one set of root causes, be sure you are not creating another set of latent conditions or weaknesses that could lead to future (perhaps completely different) incidents.

Finally, once it is decided which lessons must be learned and which actions must be taken, make one final check. Evaluate the recommendations against the original incident. Ask yourself "if we had known these lessons, and had these measures in place, would the incident still have occurred?" Similarly for the root causes, ask "... would these root causes still exist?" Only when you can honestly answer "NO" to both of these questions do you have a plan that has a good chance of being effective.

Diagram Pohon Keputusan dalam pengendalian bising (Sumber: http://www.dot.ca.gov/ser/vol1/sec3/physical/ch12noise/chap12noise.htm

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Catatan PenutupHopefully, by this point you have begun to understand why I've identified three different phases of Root Cause Analysis and why they should be kept separate. I hope this one final thought will help you understand completely: the three phases of Root Cause Analysis differ in their balances of objectivity versus subjectivity. Moving subjectivity too early into the process ultimately destroys it's integrity.

Investigation must be completely objective, in order to expose only factual relationships.

Analysis can be subjective, but only to the extent that different systems or organizations have different values, some of which may be contradictory or incorrect.

Decision is subjective in that multiple options may exist to correct or eliminate root causes, and selection of the right options must be coloured by what we want our values to be in the future.

Finally, note that in this whole article, I've not taken us past the point of deciding what to do. In other words, what about actually doing? In my opinion, that's a completely different process, perhaps the subject of a future article. All I will say at this point is that the Root Cause Analysis philosophy outlined above fulfills the "Plan" portion of the "Plan-Do-Check-Adjust" cycle (PDCA). Hopefully, what I've written here will help you Plan better!

Implementtation of the PDCAPDCA cycle (Plan-Do-Check-Adjust) is broken down into 7 steps.

1. Problem StatementThe Problem Statement is a clear, concise and measurable description of waste, rework or deviation from a standard (the norm). It should explain WHO is experiencing the problem, WHEN they experienced the problem, and WHERE they experienced the problem. The description must be measurable, and should refer to the standard.

2. Goal StatementThe Goal Statement is the clear, concise, measurable and attainable objective. It must include a precise target date to accomplish the goal. The Goal Statement must mirror the problem statement.

3. Point of CauseThink Cause and Effect. If the problem is waste or the deviation from standard, then the point of cause is the physical time and/or location the deviation is occurring. Apply the Because Equation to the problem to help define the Point of Cause (The problem occurs BECAUSE of the point of cause).

4. Root Causes

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The root cause is the underlying reason – often hidden or obscure – that is creating the problem. If the PDCA does not identify and eliminate the true root cause (or causes, there could be several of them) then the problem will most likely come back. You get to root causes through 5-Why Analysis and other PDCA tools.

5. Counter MeasuresCounter measures — the “do” phase of the PDCA — are the actions the PDCA group will take to eliminate the root causes, and ultimately prevent the problem from recurring. These actions are specific activities that have a clear function, a beginning and an end. Each counter measure must tie back to a root cause, and each counter measure must support achieving the goal statement. A counter measure must have a begin date and a target date (or expected date to complete). One member of the PDCA group is responsible for ensuring the counter measure is implemented by the target date; that group member may only assist in doing the actual work or many not even be involved in the actual work, but he or she is ultimately responsible to ensure that it happens.

Diagram PDCA (Sumber: http://www.yml.cc/en/pdca.html)

6. Follow UpThis is the “Check and Adjust” phase of the PDCA. When the group first plans the counter measures to be taken, they should schedule a time to return to check on their success. This can be a week into the future, a month, six months, a year – depending on the target date set in the

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goal statement. If the counter measures were successful, standardize. If the problem still exists – which happens – then adjust. That may mean simply modifying the counter measure or stepping back and reviewing the Point of Cause and Root Causes. Follow-up is often the most ignored step in a PDCA cycle, and is arguably the most critical.

7. StandardizationStandardization is developing the logistics of the process so that work is performed the same way across communities, companies, cities and states. Standardization includes communication and education. The group communicates the standard through sharing the PDCA, creating a Standardized Work Instruction Sheet (SWIS), creating a Value Stream or Process Map, updating a manual, among other tools. The group educates through reviewing a SWIS at a team meeting, creating a certification program, one-on-one coaching, and so on.

PDCA, singkatan dari "Plan, Do, Check, Act" (Indonesia: Rencanakan, Kerjakan, Cek, Tindak lanjuti), adalah suatu proses pemecahan masalah empat langkah iteratif yang umum digunakan dalam pengendalian kualitas. Metode ini dipopulerkan oleh W. Edwards Deming, yang sering dianggap sebagai bapak pengendalian kualitas modern sehingga sering juga disebut dengan siklus Deming. Deming sendiri selalu merujuk metode ini sebagai siklus Shewhart, dari nama Walter A. Shewhart, yang sering dianggap sebagai bapak pengendalian kualitas statistis. Belakangan, Deming memodifikasi PDCA menjadi PDSA ("Plan, Do, Study, Act") untuk lebih menggambarkan rekomendasinya.

Plan (Rencanakan)Meletakkan sasaran dan proses yang dibutuhkan untuk memberikan hasil yang sesuai dengan spesifikasi.

Do (Kerjakan)Implementasi proses.

Check (Cek)Memantau dan mengevaluasi proses dan hasil terhadap sasaran dan spesifikasi dan melaporkan hasilnya.

Act (Tindak lanjuti)Menindaklanjuti hasil untuk membuat perbaikan yang diperlukan. Ini berarti juga meninjau seluruh langkah dan memodifikasi proses untuk memperbaikinya sebelum implementasi berikutnya.

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Metode-metode untuk RCA

Maslow's Law of Problem Solving: If the only tool you have is a hammer, every problem looks like a nail.Wilson's Corollary: Even if a problem really is a nail, you've still got to know whether to bang it in or yank it out.This is a constant work in progress... the only root cause analysis tools available for review at the moment are:

Barrier Analysis : Analisis Kendala Change Analysis : Analisis Perubahan Causal Factor Tree Analysis : Analisis Pohon Faktor-Penyebab ...

Komparasi alat-alat analisis RCA

As a discipline, Root Cause Analysis (RCA) has been approached from two different areas, industrial safety or performance improvement. The industrial safety viewpoint is oriented primarily at preventing bad things, while the performance improvement viewpoint is aimed at producing good things. There is overlap between the two priorities, but overall, the differing viewpoints have led to the development of different "schools" of RCA, with different tools and philosophies.There has historically been extensive research and development dedicated to RCA tools for industrial safety (worker safety, process safety). The requirements are well-known, a wide variety of tools have been developed, and the strengths and weaknesses of specific approaches are understood. (This is not to say that the tools are perfect, because they're not.) However, the story is a little different in the performance improvement area. The theoretical underpinnings are generally not as well-developed, and while there are a number of tools available, there is less knowledge about the usefulness of the various tools.A recent study by Dr. Anthony Mark Doggett [Ref 1] tries to improve the state of knowledge regarding three tools used widely in the performance improvement school of RCA: the cause-effect diagram (CED), the interrelationship diagram (ID), and the current reality tree (CRT). The purpose of the study was to "...compare the perceived differences... with regard to causality, factor relationships, usability, and participation." In doing so, Doggett attempts to address the perception that "...one tool is as good as another tool."Note: Please have a look at my RCA Tools page if you're interested in detailed information on other tools.

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Hasil-hasil Statistik

A key feature of this study is that it is qualitative, and measures perceived differences between the tools. The measurements were obtained by having several groups of college students actually perform RCAs. They were introduced to the tools, given opportunities to ask questions, and then presented with a problem and asked to "...find the perceived root cause of the problem." Afterwards, the students' perceptions were captured using question surveys and analyzed statistically.

Participation: No statistical differences (between the 3 tools) were perceived regarding the ability to spark constructive discussion in a group setting.

Causality: No statistical differences were perceived regarding the ability to identify interdependencies between causes, or to find root causes.

Factors: No statistical differences were perceived regarding the ability to find factors (causes, effects, or both), or relationships between them. However, post-hoc testing showed that the CED was perceived to be better at categorizing factors.

Usability: There were significant statistical differences observed in this area. Generally, the CRT was judged to be much harder to use than both the CED and the ID.

Contoh Analisis FaktorDalam kajian-kajian social seringkali peneliti membutuhkan pengembangan pengukuran untuk bermacam-macam variabel yang tidak dapat diukur secara langsung, seperti persepsi, perilaku, pendapat, intelegensi, personality dan lain-lain. Faktor analisis adalah metode yang dapat digunakan untuk pengukuran semacam itu. Tujuan dari analisis faktor adalah untuk menggambarkan hubungan-hubungan kovarian antara beberapa variabel yang mendasari tetapi tidak teramati, kuantitas random yang disebut faktor. Vektor random teramati X dengann p komponen, memiliki rata-rataμ dan matrik kovarian. Model analisis faktor adalah sebagai berikut :

X1−μ1=ℓ11F1+ℓ12F2+. . ..+ℓ1mFm+ε1

X p−μ p=ℓ p1F1+ℓp 2F2+.. . .+ℓ pmFm+ε p

Atau dapat ditulis dalam notasi matrik sebagai berikut :

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X pxl=μ( pxl)+L( pxm)F(mxl )+ε pxl

Dimana: μi= rata-rata variabel i ;

ε i= faktor spesifik ke – i; F j= common

faktor ke- j; dan ℓ i j= loading dari variabel ke – i pada faktor ke-j

Bagian dari varian variabel ke – i dari m common faktor disebut komunalitas ke – i yang merupakan jumlah kuadrat dari loading variabel ke – i pada m common faktor, dengan rumus :

hi

2=ℓi 12 +ℓ i 2

2 +. .. .+ℓ i m2

Tujuan analisis faktor adalah menggunakan matriks korelasi hitungan untuk (1) Mengidentifikasi jumlah terkecil dari faktor umum (yaitu model faktor yang paling parsimoni) yang mempunyai penjelasan terbaik atau menghubungkan korelasi diantara variabel indikator. (2) Mengidentifikasi, melalui faktor rotasi, solusi faktor yang paling masuk akal. (3) Estimasi bentuk dan struktur loading, komunality dan varian unik dari indikator. (4) Intrepretasi dari faktor umum. (5) Jika perlu, dilakukan estimasi faktor skor.

Kaiser Meyer Oikin (KMO)Uji KMO bertujuan untuk mengetahui apakah semua data yang telah

terambil telah cukup untuk difaktorkan. Hipotesis dari KMO adalah sebagai berikut :Hipotesis

Ho : Jumlah data cukup untuk difaktorkan H1 : Jumlah data tidak cukup untuk difaktorkan

Statistik uji :

KMO =

∑i=1

p

∑j=1

p

rij2

∑i=1

p

∑j=1

p

rij2+∑

i=1

p

∑j=1

p

a ij2

i = 1, 2, 3, ..., p dan j = 1, 2, ..., prij = Koefisien korelasi antara variabel i dan jaij = Koefisien korelasi parsial antara variabel i dan j

Apabila nilai KMO lebih besar dari 0,5 maka terima Ho sehingga dapat disimpulkan jumlah data telah cukup difaktorkan.

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Uji Bartlett (Kebebasan Antar Variabel)Uji Bartlett bertujuan untuk mengetahui apakah terdapat hubungan antar

variabel dalam kasus multivariat. Jika variabel X1, X2,…,Xp independent (bersifat saling bebas), maka matriks korelasi antar variabel sama dengan matriks identitas. Sehingga untuk menguji kebebasan antar variabel ini, uji Bartlett menyatakan hipotesis sebagai berikut:

H0 : ρ = IH1 : ρ ≠ I

Statistik Uji :

r k=1p−1∑i=1

p

rik , k = 1, 2,...,p

r= 2p( p−1)∑∑

i<krik

γ̂=( p−1)2 [1−(1−r )2 ]p−( p−2)(1−r )2

Dengan :r k = rata-rata elemen diagonal pada kolom atau baris ke k dari matrik R (matrik korelasi)

r = rata-rata keseluruhan dari elemen diagonal

Daerah penolakan :tolak H0 jika

T=(n−1)(1−r )2 [∑∑

i<k(rik−r )

2−γ̂∑

k=1

p

(rk−r )2]> χ2¿

Maka variabel-variabel saling berkorelasi hal ini berarti terdapat hubungan antar variabel. Jika H0 ditolak maka analisis multivariat layak untuk digunakan terutama metode analisis komponen utama dan analisis faktor.

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Hasil-hasil Akar-Penyebab (Akar-Masalah)

Beyond the statistical results, the study examined the ability of the students to identify root causes that were specific and reasonable. Note that this factor was examined separately from the usability factor discussed above.

CED: In general, students using the CED were not able to identify specific root causes, even though they perceived it to be better at "... facilitating productive problem-solving activity, being easier to use, and more readable."

ID: Students using the ID were able to find (i.e., identify and agree upon) root causes, but they were of mixed quality as regards specificity and reasonability. Otherwise, the ID was perceived to be no worse than the CED, in general.

CRT: The students perceived the CRT as complex and difficult to use. However, even though most students using the CRT were uncomfortable doing so, the quality of their outputs was better. They were able to find root causes most of the time, and with high integrity in over half the cases.

Contoh CED = cause-effect diagram

Diagram CED Degradasi mangrove (Sumber: http://thesisondisastermanagement.blogspot.com/2011_04_01_archive.html

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Contoh aplikasi ID :An Interrelationship Digraph is used to analyze the cause and effect relationships that exist between ideas so that the key drivers and outcomes can be determined. An Interrelationship Digraph consists of circularly positioned ideas with arrows indicating the direction of influence of one idea upon another. Only the dominant direction of influence is drawn, therefore arrows pointing in both directions between ideas are not present in a traditional Interrelationship Digraph (ID).The following steps show how a traditional ID is constructed.

1. Define an issue or problem and collect the related ideas (5 to 25 ideas).2. Write the ideas on cards in large letters and arrange them in a large

circular pattern on a wall or other surface such that arrows can be easily drawn between them.

ID untuk isu kemacetan lalu lintas (Sumber: http://www.sorach.com/items/pid/pid.php)

Contoh CRT = current reality treeCRT pada dasarnya tool untuk mencari akar masalah seperti halnya fishbone diagram. Bedanya crt digambarkan dari atas ke bawah.pada top diagram terdapat gejala masalah. Pertanyaan why-why dapat kita angkat untuk mendapatkan apa penyebabnya. Penyebabnya diletakkan di bawahnya dengan arah panah menuju akibat (dalam hal ini gejala masalah). Hal ini terus dilakukan sehingga kita tidak dapat lagi menemukan jawaban terhadap why. Dengan demikian tidak ada pengelompokkan masalah seperti 4m / 5m dalam fishbone. Semuanya dibiarkan bebas agar keterkaitannya dapat dilihat dengan jelas.Pada prinsipnya “sebab” yang paling akhir di setiap ujung diagram akan menjadi akar masalah yang harus dicari solusinya. Mungkin saja CRT berujung pada satu akar masalah, mungkin juga banyak akar-masalah. Jika yang belakangan terjadi, dalam terminologinya ada yang dikenal dengan core problem, yaitu akar yang

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menyebabkan dampak terbesar ~ 80%. Walau angka ini bisa diperdebatkan, kalau bercermin dari konsep pareto, maka kita tidak perlu ragu menggunakannya.Pada prakteknya, diagram yang digunakan mirip dengan fault tree analysis, setiap node dalam cabang masalah ini dikenal dengan UDE – undesireable effect. Solusi atau injection (meminjam istilah pengobatan) pada akar dapat juga disertai injection pada UDE karena boleh jadi ada prasyarat agar hasilnya lebih optimal.Biasanya CRT digunakan untuk menggambarkan kondisi saat ini (as-is). Oleh karenanya dengan CRT kita dapat mengetahui kondisi pencemaran lingkungan pada saat ini. Kalau ingin membangun kondisi yang seharusnya (to-be or should be) maka CRT dapat dimodifikasi dengan memberikan injection di bagian tertentu plus wording-nya diubah sesuai dengan kondisi yang diinginkan (kalimat positif). Diagram baru ini disebut FRT (future reality tree).

Sumber: http://www.pinnacle-strategies.com/ Theory%20of%20Constraints%20Jonah%20Thinking%20Processes.htm

Current Reality Tree (CRT, similar to the current state map used by many organizations) — evaluates the network of cause-effect relations between the

undesirable effects (UDE's, also known as gap elements) and helps to pinpoint the root cause(s) of most of the undesirable effects.

Future Reality Tree (FRT) - Once some strategies (injections) are chosen to solve the root cause uncovered in the evaporating cloud and current reality tree, the FRT maps the future states of the system to identify all

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components of the solution required to completely eliminate the undesirable effects.

Negative Branch or Branch - A subset of the Future Realty Tree, it identifies potential negative outcomes of any action. The goal of the Negative Branch is to understand the causal implications between the action and negative outcomes so that the negative effect can be avoided.

Sumber: http://www.pinnacle-strategies.com/ Theory%20of%20Constraints%20Jonah%20Thinking%20Processes.htm

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Prerequisite Tree (PrT) - states that all of the intermediate objectives necessary to carry out an action chosen and the obstacles that will be overcome in the process.

Sumber: http://www.pinnacle-strategies.com/ Theory%20of%20Constraints%20Jonah%20Thinking%20Processes.htm

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Transition Tree (TrT) - describes in detail the actions that will lead to the fulfillment of a plan to implement a certain outcome, the expected intermediate states and the assumptions of why one believes the actions will work.

Sumber: http://www.pinnacle-strategies.com/ Theory%20of%20Constraints%20Jonah%20Thinking%20Processes.htm

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Strategy & Tactics Tree (S&T) - a tool to develop and integrate strategy and tactics to achieve significant objectives. It uses many of the underlying logic structures of the thinking process tools to create synchronized implementation tactics that can be evaluated and tested.

Sumber: http://www.pinnacle-strategies.com/ Theory%20of%20Constraints%20Jonah%20Thinking%20Processes.htm

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Checklists Akar-Masalah

Visi Akar-Masalah (The Root Cause Vision)

A vision of how an organization would look if it had a fully developed culture of continuous improvement, from The Root Cause Vision.

1. Continuous improvement is acknowledged by all as a core business activity.

2. Root cause thinking has permeated all levels of the organization. 3. The seeking out of underlying truths has become instinctual. 4. We respond to problems quickly and rationally, with appropriate

focus and engagement.5. We do not waste time or energy on blame; learning is the focus.

The Root Cause WayOne expression of the basis for root cause analysis, from The Root Cause Way.

1. Problems occur as a result of cause and effect. 2. The severity (or significance) of a problem is more dependent on the

system landscape than on the nature of the initiating disturbance (the immediate active and permissive causes).

3. The immediate causes of a problem are usually caused by something else that is more important.

4. Causes almost always come in groups (or, it is rare that any given effect is the result of just a single isolated cause).

5. Cause and effect form a continuum that can be traced from the point of occurrence, back to some underlying, fundamental cause or set of causes.

6. Some of the fundamental causes for a given problem may be very far removed from the point of occurrence.

7. The fundamental causes shape the landscape in which our systems and processes operate.

8. The fundamental causes can be found through investigation and analysis.

9. If fundamental causes are modified appropriately, the conditions necessary for occurrence of the problem will cease to exist... thereby preventing recurrence of the problem.

10. The activity by which fundamental causes are found and corrected is called Root Cause Analysis.

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Incident Response

Initial questions to ask the next time you experience a problem, from Patterns of Response.

1. What is the current, actual impact of the problem?2. What is the potential impact if the problem is not solved?3. What level of risk are we willing to live with, that is also supportable

from a moral/legal/contractual viewpoint?4. What would be an acceptable outcome that balances risk, cost, and

benefit?

Uji Logika Faktor-Penyebab (Akar-Masalah)

Fundamental logic checks to employ for verification of any and all causal claims arrived at through investigation or analysis, from Five-by-Five Whys.

1. What proof do I have that this cause exists? (Is it concrete? Is it measurable?)

2. What proof do I have that this cause could lead to the stated effect? (Am I merely asserting causation?)

3. What proof do I have that this cause actually contributed to the problem I'm looking at? (Even given that it exists and could lead to this problem, how do I know it wasn't actually something else?)

4. Is anything else needed, along with this cause, for the stated effect to occur? (Is it self-sufficient? Is something needed to help it along?)

5. Can anything else, besides this cause, lead to the stated effect? (Are there alternative explanations that fit better? What other risks are there?)

Pertanyaan tentang Human Error

Questions for probing the reasons for events that appear to be caused by human error, from Human Error.

1. Was the possibility of the error known? *2. Were the potential consequences of the error known? *3. What about the activity made it prone to the occurrence of the

error?4. What about the situation contributed to the creation of the error?5. Was there an opportunity to prevent the error prior to it's

occurrence? *

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6. Once the error was committed, was there any way to recover from it? *

7. What about the system sustained the error instead of terminating it?

8. What fed the error, and drove it to become a bigger problem?9. What made the consequences as bad as they were?10. What (if anything) kept the consequences from being worse?

* If YES, why did the event proceed beyond this point? If NO, why not?

The BOGUS Test

A simple test for evaluating the quality / believability of root cause statements, from The BOGUS Test.

1. Beyond Control : Some conditions are beyond our control, like stupidity, gravity, or the weather. We can't make them go away, nor can we change their fundamental natures. The problem is that by identifying such a condition as a cause, we run the risk of deciding to ignore it because its "beyond our control." The attribution of cause should instead be made to a lack of protection against a hazard.

2. Obvious : At times, the cause of a problem seems completely obvious -- so obvious that we can't resist naming it. Items that fall in this category often involve actions by people, including "operator error" and "lack of procedure compliance." Stopping at this point is akin to finger-pointing, though. People do what they do for a reason, good or bad... dig deeper and find out why.

3. Grandiose : Sometimes you hear cause statements that make you wish you knew what the investigator was smoking. "We did not leverage our core competencies to instill a culture of knowledge discovery and effect a paradigm shift to agile performance..." is an example of a grandiose cause statement. It would be better to say something like "... we don’t learn from our past mistakes, and that is hurting us." There is virtue in simplicity -- try to distill cause statements down to their pure essence.

4. Unrelated : We often have more than one problem to deal with, and it can be tempting to tie one problem to another in order to save time and effort. However, in doing so we must ensure that we do not attempt to "force-fit" an unrelated cause onto a different problem. In trying to kill two birds with one stone, we might later find that both birds are alive and well, and happily making new baby birds that can't wait to grow up and come peck your eyes out.

5. Simplistis : Earlier I said that there is virtue in simplicity. However, there is danger in being overly simplistic. We must recognize that

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some problems are more complex than others, and may result from the interaction of several different causes. If we don't identify all the relevant interactions, we may miss something truly important.

The fields of incident investigation and root cause analysis are over-abundantly supplied with acronyms, like E&CF, ETBA, MORT, MES, etc. After much investigation, I've determined that to become really famous in this business, you've got to have at least one acronym attributed to you. Therefore, I hereby unleash the BOGUS test upon the world at large, as defined by these five factors:

Beyond Control Obvious Grandiose Unrelated Simplistic

Obviously, BOGUS is an acronym. What makes BOGUS better than most acronyms, however, is that it is easily pronounceable, is spelled the same as a real English word, and the meaning of that word is applicable to the concept. In other words, it is the perfect acronym, and it is all mine! Well, okay... you can use it too, but you should first read the explanatory text below.

Beyond Control: Some conditions are beyond our control, like stupidity, gravity, or the weather. We can't make them go away, nor can we change their fundamental natures. The problem is that by identifying such a condition as a cause, we run the risk of deciding to ignore it because its "beyond our control." The attribution of cause should instead be made to a lack of protection against a hazard.

Obvious: At times, the cause of a problem seems completely obvious -- so obvious that we can't resist naming it. Items that fall in this category often involve actions by people, including "operator error" and "lack of procedure compliance." Stopping at this point is akin to finger-pointing, though. People do what they do for a reason, good or bad... dig deeper and find out why.

Grandiose: Sometimes you hear cause statements that make you wish you knew what the investigator was smoking. "We did not leverage our core competencies to instill a culture of knowledge discovery and effect a paradigm shift to agile performance..." is an example of a grandiose cause statement. It would be better to say something like "... we don’t learn from

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our past mistakes, and that is hurting us." There is virtue in simplicity -- try to distill cause statements down to their pure essence.

Unrelated: We often have more than one problem to deal with, and it can be tempting to tie one problem to another in order to save time and effort. However, in doing so we must ensure that we do not attempt to "force-fit" an unrelated cause onto a different problem. In trying to kill two birds with one stone, we might later find that both birds are alive and well, and happily making new baby birds that can't wait to grow up and come peck your eyes out.

Simplistic: Earlier I said that there is virtue in simplicity. However, there is danger in being overly simplistic. We must recognize that some problems are more complex than others, and may result from the interaction of several different causes. If we don't identify all the relevant interactions, we may miss something truly important.The best defenses against BOGUS cause determinations are rigorous application of necessary and sufficient logic during an investigation, and requiring corroborating evidence for every causal claim. Then when you're done investigating, use the BOGUS test as a final check of root cause statements, prior to developing corrective actions. Think of it as a quality control check of your root cause analysis.Alternatively, you might want to use the BOGUS test if you're responsible for giving final approval for implementation of a corrective action plan. Please do me a favour, though... if you do decide to reject a report because of the BOGUS test, don't tell the report's author about me. I don't need that kind of attention!

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ANALISIS KENDALA (BARRIER ANALYSIS)

Deskripsi

Barrier analysis is an investigation or design method that involves the tracing of pathways by which a target is adversely affected by a hazard, including the identification of any failed or missing countermeasures that could or should have prevented the undesired effect(s).

Pros and Cons

Pros Conceptually simple, easy to grasp. Easy to use and apply, requires minimal resources. Works well in combination with other methods. Results translate naturally into corrective action recommendations.

Cons Sometimes promotes linear thinking. Sometimes subjective in nature. Can confuse causes and countermeasures. Reproducibility can be low for cases that are not obvious or simple.

Definisi-definisi

Barrier: A construct between a hazard and a target, intended to prevent undesired effects to the target. A barrier is often passive, i.e. it’s protective nature is inherent to it’s structure, and no additional action on the part of any agent is required to afford this protection.Control: A mechanism intended to prevent undesired effects to the target. A control is often active, i.e. it’s protective nature is brought into being through the actions of an agent.Countermeasure: A barrier or control intended to cut off a pathway between hazard and target.Hazard: An agent that can adversely affect a target.Pathway: A route or mechanism that provides the means, or medium, through which a hazard can affect a target.Target: An object that requires protection, or needs to be maintained in a particular range or set of conditions.

DiskusiAt the heart of barrier analysis is the concept of the target. The primary quality of a target is that it exists under a specified range or set of conditions, and that we require it to be maintained within that specified

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range or set of conditions. This very general quality means that almost anything can be a target -- a person, a piece of equipment, a collection of data, etc.Given the concept of the target, we then move to the means by which a target is adversely affected. By adverse effect, we mean that the target is somehow moved outside of it's required range or set of conditions. Anything that does this is called a hazard. This is a very general quality -- almost anything can be a hazard. However, it is possible to uniquely define hazard/target pairs by the pathways through which hazards affects targets.Having identified hazards, targets, and the pathways through which hazards affect targets, we arrive at the concepts of barriers and controls. These are used to protect and/or maintain a target within it's specified range or set of conditions, despite the presence of hazards. The primary quality of a barrier or control is that it cuts off a pathway by which a hazard can affect a target. Barriers and controls are often designed into systems, or planned into activities, to protect people, equipment, information, etc. The problem is that design and planning are rarely perfect. All hazards may not be identified beforehand, or unrecognized pathways to targets may surface. In both of these cases, appropriate barriers and controls may not be present. Even if they are present, they may not be as effective as originally intended. As a result, targets may lack adequate protection from change or damage.The purpose of barrier analysis is thus to identify pathways that were left unprotected, or barriers and controls that were present but not effective. All pathways relate to specific hazard/target pairs, and all barriers and controls relate to specific pathways. Success in barrier analysis depends on the complete and thorough identification of all pathways.

Konsep-konsep

Energi dan PerubahanThe concept of energy has historically been used to characterize the pathways by which hazard affects target. Very generally, energy is any physical quantity that can cause harm. There are many types of energy, including electrical, mechanical, hydraulic, pneumatic, chemical, thermal, radiation, etc. Note again that these are all physical quantities, and can only be used to describe physical hazards. Consequently, the types of barriers and controls that can be considered are primarily physical in nature, or relate to physical harm.More recently, hazard pathways have been characterized by the concept of change. This concept is based on the recognition that any change in a target's condition, physical or otherwise, could be detrimental or undesired. This allows us to consider hazards and damage mechanisms other than the purely physical, and can lead us into areas that are more administrative,

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knowledge based, or policy based in nature. Furthermore, the concept of change does not prevent us from investigating purely physical phenomena.The pathway characterization (or viewpoint) affects the types of hazards, targets, and damages that will be seen and considered during investigation and analysis. Investigation from a purely energy-based viewpoint will tend to concentrate on physical, energy-based hazards and damage mechanisms. Alternatively, a change-based viewpoint can be used to find both physical and non-physical damage pathways. For this reason, it is recommended that a change-based characterization for hazard/target pathways be adopted for general usage.

Efektivitas Umpan-balik

Recall that the purpose of a barrier or control (i.e., countermeasure) is to cut off a pathway by which hazard affects target. Many options may be available for cutting off a hazard/target pathway, and some options may be more effective than others. Some variables that can be used to differentiate various countermeasures include action, placement, function, and permeability.Action: This refers to whether the countermeasure is passive or active. Passive constructs (i.e., barriers) tend to be more effective than those requiring action or intervention (i.e., controls).Placement: This refers to the location (in space, time, sequence, etc.) of a countermeasure along the hazard/target pathway. Those located closer to the hazard end of the pathway are often more effective than those located closer to the target.Function: This refers to how the countermeasure cuts off the hazard/target pathway. Those that prevent creation, accumulation, or release of a hazard tend to be more effective than those that harden, warn, or rehabilitate the target.Permeability: This refers to the extent that the countermeasure cuts off the hazard/target pathway. Those that completely cut off the pathway tend to be more effective than those that only limit or reduce the hazard.Given the variables above, it is easy to say that the most effective countermeasure against a potential hazard would be a hard, passive barrier at the source that completely prevents creation of the hazard. This is rarely (if ever) practical, however. We are then forced into designing or planning countermeasures that merely reduce risk. This means that no single countermeasure can ever be 100% effective.Reduction of risk to acceptable levels often requires the use of multiple, diverse countermeasures. Multiple, because usually no single countermeasure can provide the required risk reduction. Diverse, because

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the possibility of common-mode failure itself increases overall risk. Barrier analysis thus needs to consider all the following:where countermeasures should have been provided, but were not;how existing countermeasures failed to prevent undesired change;whether an appropriate mix of multiple and diverse countermeasures was provided; andif the overall risk of undesired change was acceptable.

KelemahannyaThe use of barrier analysis presupposes that countermeasures were considered during the design of a system, or planning of an activity. The results of a complete and thorough barrier analysis may identify many opportunities to create new countermeasures, or to improve existing countermeasures. However, given the same consequence to investigate, different investigators might propose any of the following (or variations and/or combinations thereof) as root causes:

preliminary hazard analysis was inadequate; appropriate countermeasure was not provided; inappropriate countermeasures were provided; existing countermeasure was inadequate; existing countermeasure was not properly employed; existing countermeasure was rendered inoperative; hazard was not controlled; target should not have been exposed to hazard; etc.

All these statements may be true. However, such variability makes it extremely difficult to rely on barrier analysis alone as a root cause analysis tool. It is therefore recommended that barrier analysis results always be reviewed independently, and that barrier analysis never be used as the sole method for determining root causes.In the opinion of the author, the only statement above that qualifies as a potentially valid root cause statement is the first, "preliminary hazard analysis was inadequate." This statement could then be qualified with supporting evidence and analysis; in fact, all the other items listed might be provided to illustrate how the preliminary hazard analysis failed.

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ANALISIS PERUBAHAN (CHANGE ANALYSIS)

DeskripsiChange analysis is an investigation technique that involves the precise specification of a single deviation so that changes and/or differences leading to the deviation may be found by comparison to similar situations in which no deviation occurred.

Pros and Cons

Pros Conceptually simple, easy to grasp. Works well in combination with other methods. Results translate naturally into corrective action recommendations. Can be used to find causes that are obscure, or that defy discovery

using other methods.Cons

Requires some basis for comparison. Resource intensive, requires exhaustive characterization of

deviation. Applicable only to a single, specific deviation. Provides only direct causes for a deviation. Results may not be conclusive; testing usually required.

Definisi

PERUBAHAN: A discrete difference between an occurrence exhibiting the deviation, and a similar occurrence that did not exhibit the deviation.DEVIASI: A situation in which actual results or actual performance differed from what was expected.

DiskusiAs suggested by the name of the technique, change analysis is based on the concept that change (or difference) can lead to deviations in performance. This presupposes that a suitable basis for comparison exists. What is then required is to fully specify both the deviated and undeviated conditions, and then compare the two so that changes or differences can be identified. Any change identified in this process thus becomes a candidate cause of the overall deviation.What is a suitable basis for comparison? There are basically three types of situations that can be used. First, if the deviation occurred during performance of some task or operation that has been performed before, then this past experience can be the basis. Second, if there is some other

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task or operation that is similar to the deviated situation, then that can be used. Finally, a detailed model or simulation of the task (including controlled event reconstruction) can be used, if feasible.Once a suitable basis for comparison is identified, then the deviation can be specified. Various schemes exist for performing this specification. Perhaps the most useful scheme (attributed to Kepner and Tregoe) involves four dimensions (WHAT, WHERE, WHEN, and EXTENT) and two aspects (IS and IS NOT). Regardless of the scheme used, the end result should be a list of characteristics that fully describe the deviated condition.Given the full specification of the deviated condition, it becomes possible to perform a detailed comparison with the selected undeviated condition. Each difference between the deviated and undeviated situations is marked for further investigation. In essence, each individual difference (or some combination of differences) is a potential cause of the overall deviation.After the potential causes are found, each is reviewed to determine if it could reasonably lead to the deviation, and under what circumstances. The most likely causes are those that require the fewest additional conditions or assumptions. In this way, a large list of potential causes can be whittled down to a short list of likely causes. Finally, given the likely causes, the actual or true cause(s) must be identified. Generally speaking, the only way to verify which likely cause is the true cause is by testing.The purpose of change analysis is thus to discover likely causes of a deviation through comparison with a non-deviated condition, and then to verify true causes by testing. True causes found using change analysis are usually direct causes of a single deviation; change analysis will not usually yield root causes. However, change analysis may at times be the only method that can find important, direct causes that are obscure or hidden. Success in change analysis depends ultimately on the precision used to specify a deviation, and in verification of true cause through testing.

Konsep-konsep

Perubahan (Change)Change is introduced in all factors of life continuously. Some sources of change are planned, as in deliberate actions taken to achieve a purpose. Other sources of change are unplanned, as in natural, random variation, or as in factors introduced unintentionally due to outside influences or as the result of error. Whatever the source, change is often a source of disruption in the normal, expected, or usual flow of events. When change is not accounted for or compensated, it can lead to deviations.As discussed above, change analysis depends on the recognition of changes or differences that could have led to a specific deviation. Sometimes, however, multiple changes may have occurred over time that combine to

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cause the deviation. Therefore, it is important for the investigator to consider combinations of changes or differences as potential causes, in addition to individual changes or differences.

Kesamaan (Kemiripan, Similarity)Change analysis is heavily dependent on comparison with similar situations. However, there are varying degrees of similarity, depending on how close the undeviated condition is to the deviation under investigation. The best case scenario for change analysis is when you have previous operational history for the exact same task or operation. In this case, changes or differences that could have contributed to the deviation are easily identifiable.The problem with trying to compare situations that are less similar is that other, inherent differences in underlying conditions may mask differences that were responsible for the deviation. Since each difference identified in the change analysis procedure is considered a potential cause, the list of potential causes may include some of these inherent differences -- which may or may not bear any causal relation to the specific deviation under investigation.It therefore is critical that an appropriate basis for comparison be selected when performing change analysis. Furthermore, inherent differences between the actual deviated condition and the situation chosen for comparison must be fully identified and handled with extreme care. Finally, when verifying true cause by testing, the test condition must be made as identical to the actual deviated condition as possible.

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ANALISIS POHON-PENYEBAB (Causal Factor Tree Analysis)

DeskripsiCausal factor tree analysis is an investigation and analysis technique used to record and display, in a logical, tree-structured hierarchy, all the actions and conditions that were necessary and sufficient for a given consequence to have occurred.

Pros and ConsPros

Provides structure for the recording of evidence and display of what is known.

Through application of logic checks, gaps in knowledge are exposed. Tree structure is familiar and easy to follow. Can easily be extended to handle multiple (potential) scenarios. Can incorporate results from the use of other tools. Works well as a master investigation/analysis technique.

Cons Cannot easily handle or display time dependence. Sequence dependencies can be treated, but difficulty increases

significantly with added complexity. Shows where unknowns exist, but provides no means of resolving

them. Stopping points can be somewhat arbitrary.

Definisi

CABANG: A cause-effect link from one item in the tree to another immediately above it. This assumes the tree is drawn from the top down, i.e. consequence on top and causes below it.RANTAI: A continuous sequence of branches from one item that is lower in the tree, through one or more intervening items, to one item that is higher in the tree.TITIK-AKHIR: An item in the tree that has no branches leading into it; the first (or lowest) item in a chain leading to the final consequence.

A tree diagram, probability tree, or root cause analysis is geared more towards thinking in terms of causality, while using a fishbone diagram tends to make people think in terms of categorization. Using the fish bone diagram loosely may result in a combination of the two approaches as the group

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oscillates between categorizing different causes and asking "Why?" or "Why else?".Although It have never seen any reference for this technique, the following rule can be used to distinguish between categorization vs. causality when using a fishbone diagram:

Just as the main categories (Equipment, People, etc.) are highlighted by placing a circle or box around them, if you include sub-categories in your cause-and-effect diagram, circle the sub-category so you can distinguish between categorization vs. causality.

The following tree diagram shows the difference between categorization (grouping of causes) and causality (the tree).

Diagram Pohon untuk identifikasi “penyebab” (Sumber: http://www.vertex42.com/ExcelTemplates/fishbone-diagram.html)

DiskusiTree structures are often used to display information in an organized, hierarchical fashion: organization charts, work breakdown structures, genealogical charts, disk directory listings, etc. The ability of tree structures to incorporate large amounts of data, while clearly displaying parent-child or other dependency relationships, also makes the tree a very good vehicle for incident investigation and analysis. Combination of the tree structure with cause-effect linking rules and appropriate stopping criteria yields the causal factor tree, one of the more popular investigation and analysis tools in use today.Typically, a causal factor tree is used to investigate a single adverse event or consequence, which is usually shown as the top item in the tree. Factors

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that were immediate causes of this effect are then displayed below it, linked to the effect using branches. Note that the set of immediate causes must meet certain criteria for necessity, sufficiency, and existence. More information on what constitutes a necessary and sufficient cause can be found in this article on the definition of cause. Proof of existence requires evidence.Once the immediate causes for the top item in the tree are shown, then the immediate causes for each of these factors can be added, and so on. Every cause added to the tree must meet the same requirements for necessity, sufficiency, and existence. Eventually, the structure begins to resemble a tree's root system. Chains of cause and effect flow upwards from the bottom of the tree, ultimately reaching the top level. In this way, a complete description can be built of the factors that led to the adverse consequence.Often, an item in the tree will require explanation, but the immediate causes are not yet known. The causal factor tree process will only expose this knowledge gap; it does not provide any means to resolve it. This is when other methods such as change analysis or barrier analysis can be used to provide answers for the unknowns. Once the unknowns become known, they can then be added to the tree as immediate causes for the item in question.Each new cause added to the tree should be evaluated as a potential endpoint. When can a cause be designated as an endpoint? This is an object of some debate. Several notable RCA practitioners use some version of the following criteria:

The cause must be fundamental (i.e. not caused by something more important), AND

The cause must be correctable by management (or does not require correction), AND

If the cause is removed or corrected, the adverse consequence does not occur.

These three criteria, taken together, are basically just a statement of the most-widely used definition for "root cause". An alternate set of criteria, preferred by the author, is presented below. Note that these are all referenced to the system being analyzed. (An article deriving and explaining these criteria is forthcoming.)

The cause is a system response to a requirement imposed from outside the system, or

The cause is a contradiction between requirements imposed from within the system, or

The cause is a lack of control over system response to a disturbance, or

The cause is a fundamental limit of the system design.

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A causal factor tree will usually have many endpoints. The set of all endpoints is in fact a fundamental set of causes for the top consequence in the tree. This fundamental set includes endpoints that would be considered both beneficial or detrimental; every one of them had to exist, otherwise the consequence would have been different. Endpoints that require corrective action would typically be called root causes, or root and contributing causes if some scheme is being used to differentiate causes in terms of importance.

Creative Root Cause Analysis “Terminology” (Jack Oxenrider, 2011)The imagery and metaphor of the Creative Root Cause Analysis (CRCA) logo presents a symbol of a team working together to solve a complex problem, with a clump of crabgrass representing a systemic problem. The “terminology” of Creative Root Cause Analysis offers insight into the process.

Sumber: http://www.oxenrideronsynergy.com/2011/09/creative-root-cause-analysis-terminology/

Creative: A new and different approach through insight and intuitionTeam: Two or more people working together to accomplish a common

goalSurface Problem: Obstacle that blocks the expectationRoot Causes: Factors that fuel (feed) the surface problemAnalysis: Logical, rational, viable inquirySolution: The course of action chosen to address causes and eliminate the

problem.

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Diagram lingkar sebab-akibat perkembangan kota dengan permasalahan obesitas (Sumber: Br J Sports Med 2009;43:109-113 doi:10.1136/bjsm.2008.054700)

The built environment and physical activity agenda provides a unique opportunity for public health, physical activity and planning researchers to be front and centre of a movement aimed at creating healthier and more sustainable environments. However, in order to optimise environments that encourage physical activity across the life course, researchers in this field need to think beyond their “square” —that is, the target group, setting and physical activity behaviour with which they work. We suggest that researchers working in this field need a better understanding of systems theory to appreciate that a change to one part of a complex system can positively and negatively influence other parts of the system. An understanding of systems theory would help minimise unintended negative consequences to other population subgroups or to other types of physical activity from the implementation of our research findings. In this way, a more comprehensive set of research, practice and programme-related activities may emerge, which will advance physical activity research and practice, and improve population health across the life course.

In summary, the causal factor tree is an investigation/analysis tool that is used to display a logical hierarchy of all the causes leading to a given effect or consequence. When gaps in knowledge are encountered, the tree exposes the gap, but does not provide any means to resolve it; other tools are required. Once the required knowledge is available, it can be added to the tree. A completed causal factor tree provides a complete picture of all the actions and conditions that were required for the consequence to have occurred. Success in causal factor tree analysis depends on the rigour used in adding causes to the tree (i.e., ensuring necessity, sufficiency, and existence), and in stopping any given cause-effect chain at an appropriate endpoint.

Contoh penggunaan Diagram-Pohon:

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Sustainable development indicators: a scientific challenge, a democratic issue (Paul-Marie Boulanger, 2008)

Social indicators, and therefore sustainable development indicators also, are scientific constructs whose principal objective is to inform public policy-making. Their usefulness is dependant on trade-offs between scientific soundness and rigor, political effectiveness and democratic legitimacy. The paper considers in this perspective three important stages in the building of sustainable development indicators: the identification of the various dimensions underlying the concept of sustainable development, the process of aggregating lower dimension indicators in higher level composite indices and the attribution of weights at various levels of the indicators hierarchy. More specifically, it assesses the relative fruitfulness for indicators construction of the four most widespread conceptions of sustainable development, in terms of domains or pillars (economy, society, and environment), in terms of resources and productive assets (manufactured, natural, human and social capitals), in terms of human well-being (needs, capabilities) or in terms of norms (efficiency, fairness, prudence…). It concludes with a plea for the construction of synthetic indices able to compete with and complement the GNP as an indicator of development.

The construction of indicators: The successive phases - From concept to indices

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The first phase consists in identifying the various dimensions constituting the concept, given that these are always multidimensional. The concept of poverty, for example, covers a material dimension, but also a social one (exclusion, marginalisation) and also a cultural dimension (level of education, means of expression). The material dimension is itself multi-faceted; it includes financial components (income, level of indebtedness, other financial burdens) and non-financial ones (health, housing, rights). Each of these material dimensions is itself more or less composite. Income, for instance, may or may not be monetary. A further point is that the regular or precarious nature of income matters more sometimes than the level of income at any particular time.

Agregasi

Aggregation is the operation consisting in condensing the information contained in each criterion into one single item of information. This supposes that the following questions receive an answer. Should the same weight be given to all the criteria constituting the index? Or should they be given different weights? And if so, how? What is the relationship between the index and the indicators? Is it a sum, a product, or something more complicated? In practice, both questions usually come down to a dilemma between a simple and a weighted average. The question of weighting is a crucial and distinctly difficult one. It consists in attributing a weight, and therefore a specific value to the various dimensions of the concept. For instance, in the case of a poverty index, it could consist in giving more weight to the material dimension than to the social (isolation, exclusion) or cultural dimensions.Dimensions and indicators making up an index can be represented in the form of a tree diagram, the concept being the trunk of the tree and each branch representing one of the dimensions, with each branch breaking down into sub-branches ending up with the leaves representing the actual indicators. At each branching out, a weighting can be attributed to the branches arising there, with at the end the leaves to which is attached a weight equal to the product of the coefficients of the sub-branches and the branches from which they arise.

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Tree diagram of dimensions and indicators (Sumber: http://sapiens.revues.org/166#tocfrom2n3)

It is an example of a tree diagram of this kind where the concept of sustainable development is broken down into three dimensions corresponding to the famous: Economic, Social and Environmental pillars. Only the Economic branch is further developed, with two constituting dimensions, Performance and Resilience. Performance is evaluated with the help of two indicators: two growth rates (GDP and Productivity). The Resilience sub-branch also gives rise to two dimensions: Diversity and Innovation. The cascading weighting process is illustrated by the final weight of each indicator, which is the product of all the previous weights and its own. Thus the GDP growth rate is given a 0.16 weighting, i.e. the product of its own specific weight 0.8, of the 0.6 weight of the "Performance" branch, and the 0.33 weight of the "Economics" branch.

Contoh Penggunaan Diagram Pohon: Analisis Pencemaran Sungai

Analisis akar masalah dan Pohon-Masalah

In order to understand a situation to be influenced by a project, it is essential to be aware of problem conditions which constitute development constraints as well as their causes. Problem analysis identifies the negative aspects of an existing situation and establishes the « cause-effect » relationship between the problems identified. Precise description of problems as deviations between some desired conditions and the status quo, and the major root causes of the situation need to be identified in

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order to devise effective ways of dealing with them. Problems and their inter-relationships can be identified and visualized using the so-called “problem tree”. The problem tree is a diagram showing the cause–effect relationships between problem conditions in a defined contest. How to proceed:

1. Define precisely the situation (sector, subsector, area, and so on.) to be analysed;

2. Define some (approximately five) major problem conditions related to the selected situation;

3. Organize the problem conditions according to their cause –effect relationships;

4. Add additional problems, thus describing causes and effects; and 5. Check the diagram (tree) for completeness (most relevant conditions) and

logical order.

Berikut adalah contoh “Pohon-Masalah” pencemaran sungai menurut pedoman EC PCM:

Analisis Tujuan dan Pohon-Tujuan

It is important to identify, on the basis of the problem analysis, the objectives and results that the project is intended to achieve. If there is no secure commitment from all the parties concerned to the project’s objectives and results, then friction may occur among stakeholders, leading to poor project implementation. The

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problem structure shown in the problem tree can serve as a basis to identify and visualize potential objectives a project might want to achieve. The objective tree is created by transforming the hierarchy of problems into a hierarchy of objectives describing future conditions which are desirable and realistically achievable. The objective tree can form the basis for further decision -making on alternative interventions (projects) that would aim to influence a given situation. Bagaimana proses selanjutnya:

1. Reformulate the problems as objectives; 2. Check the logic and plausibility of the means- to-ends relationship; 3. Adjust the structure wherever necessary and revise statements; 4. Delete objectives that are not desirable; 5. Check whether rewording will lead to meaningless or ethically questionable

statements; in that case, reformulate the objective or indicate that this problem cannot be solved in the given context; and

6. Add new objectives if they appear to be relevant and necessary in order to achieve the stated objective at the next higher level.

Berikut ini adalah contoh Pohon-Tujuan untuk pencemaran sungai dari Pedoman EC PCM:

The situation analysis is concluded with the selection strategy, i.e. the exercise of synthesising a significant amount of information then making a complex judgement about the best implementation strategy (or strategies) to pursue. The figure below summarizes the passage from the situation analysis to planning:

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SEKUENS PROBLEM-SOLVING YANG SISTEMATIK

“Masalah” dapat terjadi sepanjang waktu. How we choose to respond is a major factor in determining how badly we will be affected by any given problem. I would argue that a systematic response is best, and furthermore, It is proposed a 9-stage sequence as discussed in this article.If you are already familiar with other problem-solving methodologies, like 8D or DMAIC, some aspects of the recommended sequence may seem familiar to you. I believe the sequence proposed below is more comprehensive than either of those, but is also compatible with them.

Ada Sembilan tahapan yang berurutan, dan semuanya itu dapat dikelom[pokkan menjadi tiga kelompok, yaitu:

RESPOND MITIGATE ASSESS... (Problem Response)INVESTIGATE ANALYZE DESIGN... (Root Cause Analysis)EXECUTE REVIEW ADJUST... (Corrective Action)

Much more could be written about these groupings, and the problem solving sequence in general, but I'll let it go for now. Just keep in mind the intent of presenting such a thing is to provide a structured framework for solving problems, not to box you in or limit you unnecessarily. Please use this if you think it will be helpful; otherwise, ignore it!

1. RESPOND - Respond to the problem: address injury/damage that has already been caused, make appropriate notifications, preserve/quarantine evidence to the extent possible, initiate cleanup actions.

2. MITIGATE - Mitigate the immediate causes: take action to reduce the production and/or release of the bad thing, enhance protections against it, find a way to eliminate it or minimize it.

3. ASSESS - Assess risk: determine extent of condition, review adequacy of measures in place, assess risk of further harm, decide if deeper analysis required.

4. INVESTIGATE - Investigate the how: track the actual sequence of events, figure out what changes of state took place, determine the script behind the problem.

5. ANALYZE - Analyze the why: break down the script and determine critical points, figure out what should have happened, find the gaps between actual and expected, uncover key forcing factors, determine extent of cause.

6. DESIGN - Design the solution: find the weaknesses, pick the points of most leverage, develop solution options, decide on best combination of actions, validate the plan, get buy-in and funding.

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7. EXECUTE - Execute the plan: develop timeline, obtain materials, marshall resources, initiate action, monitor performance, verify completion.

8. REVIEW - Review effectiveness: check for recurrence of original problem, check for instances of related problems, verify actions taken still relevant, assess continued risk.

9. ADJUST - Adjust the plan: address deficiencies in execution, assess effects of changes from outside the plan, identify new/revised actions needed to ensure effectiveness.

Stages 4 - 6 above are discussed more thoroughly in Phases of Root Cause Analysis... however, note that the phase previously referred to as Decide is now designated Design. I just thought Design captured the intent better.

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METODE RCA - PERISTIWA BESAR ATAU KECIL ?

Root Cause Analysis (RCA) can be applied to events of any size or significance. However, it's usually applied to large events, i.e. those with serious consequences. Even so, it can and should be applied to smaller events as well. Statistically, smaller events are more likely to occur than larger events. Thus, application of RCA to small events may identify many significant opportunities for improvement.Given that smaller events are more likely to occur, should we focus our RCA efforts solely on smaller events? This would have the advantage of ensuring that we have a statistically significant sample from which to draw learning opportunities. Why, then, do we expend so much effort applying RCA to large events if we can get the same (or better) benefits by focusing on small events? This idea could be expressed as follows:Little events happen all the time. We should analyze each little event. After we have enough observations, we will have a statistically significant sample. This should be the basis for our learning.Instead, we analyze the big events because they catch our attention. Big events come around only once in a while. We spend a lot of time investigating them. However, we have only one sample point. Therefore, our results have little statistical significance.By emphasizing investigation of the big events, we are potentially learning the wrong things because we may be placing too much emphasis on issues that have very little statistical significance.Is this a valid idea? Should we emphasize RCA of small events, and perhaps do away with RCA of large events altogether? I'll try to answer that question in this article.There is a common belief that large events and small events have the same causes. Therefore, it is assumed that by analyzing small events and applying lessons learned from them, we prevent large events as well. However, using this strategy, do we limit the severity of potential future events? Suppose we analyze only small events. We'll have a lot of data on common event initiators and latent conditions. As we'll have a lot of data, we'll develop a very good understanding of the events and our corrective actions will be very good. We'll knock down the frequency of these events by a significant amount, perhaps even eliminate them completely. Again, we have to ask the question, have we limited the severity of potential future events? If we assume that all events, large and small, have the same root causes, then the answer is yes. Is this true though? What makes a small event different from a large event?

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Speaking very generally, it's the interaction of various latent conditions. Some of these latent conditions may be deeply embedded in the operations of our systems. They may be very subtle conditions that will not be activated very often. With a low probability of occurrence, we won't have much data on them and we may not have any protections against them. They may be very simple conditions that, under ordinary circumstances, cause no problems for us. Its when circumstances change in unexpected ways that these kinds of conditions become a real danger. An event that might ordinarily terminate with very low consequences could, under less common circumstances, terminate with very serious consequences.Consider a condition like grinder kickback. This can occur when using a grinder because the grinder "catches" on whatever's being worked on, and the rotational force of the spinning grinder wheel causes the entire tool to kick back toward the operator. Standard safety precautions while using such a tool include maintaining a proper stance and appropriate distance from the grinder. Kickback is a known condition, and under most conditions, is easily compensated for.Now, throw in a twist. A worker decides that, in a standing or kneeling position, he can't get a good angle on whatever he's grinding. He decides that the best, fastest way to get the job done is to lie down on the floor, and hold the grinder above him to get at the bottom of the piece he's grinding. He has every intention of being very careful. However, he has just removed his ability to avoid a kickback if it occurs. The weight of the grinder is now working against him, as well.The job starts out fine. Then the grinder catches on something. It kicks back. The worker can't avoid it. The mechanics of the event are such that the grinder moves laterally towards the worker's head. The worker receives an extremely serious laceration to his face. This is a "large" event. You would never have expected it to happen. The circumstances of the event were unusual. The probability of the event happening again appears to be low. Should we subject this event to a detailed root cause analysis?Of course we should! We should investigate and analyze the heck out of this event. However, we must not limit ourselves to the question of "why did the worker use the grinder that way." We must instead find out "what is it about the way we do business that: set up this situation, forcing the worker to make this choice; convinced the worker that he needed to do the job this way; kept him from taking more time to get a different tool or to rotate the piece he was working on."I'm not making this up. It actually happened two years ago. The worker required extensive reconstructive surgery to one side of his face. It was pure luck that he didn't lose his nose or one of his eyes.

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In conclusion, my belief is that we must investigate and analyze the sporadic, large events. So what if the probability of occurrence is low? Remember that risk is probability times consequences. If the potential consequences are high, we must do what we can to prevent those consequences from occurring -- even if it is a low probability event. Sometimes, a sample of one is more significant than a sample of thousands.

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MODEL DALAM RCA

Model merupakan representasi dari realita. Model ini dapat rinci atau abstrak, komplex atau sederhana, akurat atau misleading. Whether we realize it or not, everything we perceive is processed using models. Therefore, it is important for us to understand how models can help us to understand reality, yet may also mislead us if not used with appropriate care and attention.

Model digunakan secara luas dalam analisis akar masalah. Probably the most fundamental of these is the model of causation. There are models based on manipulability, probability, counterfactual logic, etc. This is an area of considerable complexity, as no single model seems to address all possible situations.

The counterfactual logic model of causation is used most often in root cause analysis, as it is the easiest to grasp and is generally the most useful. It is the model that gives us the necessary and sufficient test, and for this alone, it's usefulness to the investigator or analyst is boundless. However, even this model fails under certain circumstances.

Consider the statement "smoking causes cancer" -- can this statement be proven (or disproved) using the necessary and sufficient test? Not really. However, despite it's difficulties in certain areas, the counterfactual logic model of causation is sufficient in the overwhelming majority of cases. This is because it:

easily guides our thought processes in a predictable way, provides rules that can be applied unambiguously and repeatably, helps us ensure completeness in causal reasoning, and becomes unworkable in those special cases where it does not

provide good answers.

This last point might initially seem to be a disadvantage. How can a model that becomes unworkable ever be beneficial? Consider it this way -- what if we used an alternate model that happily gave us answers, well outside it's range of applicability? We might very well continue using the model without realizing that it no longer applied.

What other types of models do we employ in root cause analysis? In some cases, we may develop engineering models for physical processes, in order to understand how a failure occurred. In others, we might model an industrial processes to show where bottlenecks are constraining throughput. These types of models are used quite frequently, and generally require

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specialized knowledge to use properly. However, the difficulty of developing and using such models may actually pale in comparison to the modeling of human behaviour.

The Three B Model of Human Behavior The three B model of human behavior has three components that coincidently start with B. Beliefs, Behaviors and Benefits.

Sumber: http://www.reallysimplebusinesstools.com/content/simple-model-human-behavior)

Beliefs - Beliefs are determined by an individuals past experiences - the past positive and negative benefits that have been recieved - or by the expected future benefit. For example I believe that I will get a bonus if I work very hard because I did last time (or the negative I believe I will be ignored and no one will care if I work hard because that is what happened last time). There are very strongly held beliefs (values) and weaker ones. You aren't going to change someone's core beliefs without momentous effort, so you should focus on the weaker held beliefs. Hire for the strong beliefs and coach and guide someone to change the weaker ones such as the example above. Behaviors - Behaviors are beliefs in action. These actions are visible, and can be observed. For example Sue stays late to get a project done and completed to high quality. Benefits - Benefits can be either positive or negative. The more immediate the benefit, the more powerful the impact on beliefs and future behaviors. It is important to note that benefits can be intrinsic or extrinsic and that the benefit is only what the person persieves the benefit to be. So if you give someone a bonus but this person doesn't value money as much as praise they won't get the benefit you intended them to get. Also people can get intrinsic benefits such as feeling proud for their work.

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We need models of human behaviour because humans are so incredibly complicated. Such models must account for information input and processing, communication, motivation, learning, decision, fatigue... the list goes on and on. Then, on top of models for individual human behaviour, we must add models for group, organizational, and societal behaviour and interaction. The problem seems intractable. Nonetheless, several generalized models do exist.One step above the models of human and organizational behaviour are models of accident initiation and propagation. The driver for research interest in this area is obvious, as industrial accidents are potentially the most damaging events that can occur. Death and destruction, possibly on a large-scale, are the consequences. It is hoped that by understanding how accidents occur, we can find strategies to reduce the risk of such events.Accident models, in fact, tend to be models of human and organizational behaviour. What makes accident models different is the sharp focus on failure propagation. The underlying assumption tends to be that accidents start as relatively simple, minor events that eventually spiral out of control. In fact, most recently developed accident models tend to be system models that focus attention on complex interactions between multiple, lower-level failures or infractions.

In the end, we are left with models upon models upon models... each with their own rules and assumptions, strengths and weaknesses. As stated previously, models are useful because they help us abstract away unimportant data so we can increase our focus on useful information. This is the strength of using models; unfortunately, it is also the main weakness. If models are used without knowledge of their assumptions and limitations, we could end up discounting potentially important facts and misdirecting our investigations.There is no single "model of everything" we can rely upon to provide good answers in all cases. However, we shouldn't be fooled into thinking that the various models can't help us achieve better root cause analysis results. Models can guide us to possibilities we might have missed, and provide insights that we might not have seen. The key success strategy may well be to have knowledge of a wide variety of models that can be used in a variety of situations. Then, as with anything else in life, we must simply ensure that we understand the tools we use, before we use them.

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MODEL: What is an Ecosystem?An ecosystem is a group of living and non-living components interacting together on a given physical landscape. The size of an ecosystem is arbitrary and could be as small as a few square centimeters if you are looking at a soil microbial ecosystem; as large as thousands of square kilometers if you are looking a biome like the Great Plains ecosystem; or a few hectares if you are looking at a single forest stand ecosystem.

One way to learn more about how a forested ecosystem works is to build a model. An ecosystem model is an accurate but simplified representation of an ecosystem that can be very useful in thinking about or simulating the actions of a real ecosystem. Because any ecosystem has many different but interrelated components, the best way to understand the system is to break it down into its component parts. To get an introduction to a very simplified forest model, see our Forest Ecosystem Gamewhich gives participants and introduction to how a hardwood forest ecosystem works before and after exotic earthworms invade.

Step One: The first step in building a graphical model of a hardwood forest ecosystem is to identify its major components. The components of any ecosystem are those physical things that contain energy and nutrients. In a graphical Forest Ecosystem, these components are often illustrated using boxes like in Figure 1 below.

Some components of a graphical forest ecosystem illustrated using boxes

A forested ecosystem, by definition contains trees, so that is our first component. In addition to the various species and layers of trees in a forest, there are other distinct ecosystem components. For example, the

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understory contains most of the visible plant life found between the sapling layer and forest floor. The forest floor is where one would find most of the plant roots, bulbs, fungi, seeds, years of accumulated leaves and twigs. The soil is the “dirt” under the forest floor and is composed largely of minerals of various grain size (very small grain size = clay…very large grain size = sand) and organic material that has been mixed in with the mineral component. In addition, there are numerous animals that live in the forest, and of course we cannot forget people. We will add those two components to our forest ecosystem model later.

Step Two: Once you have identified the components of your ecosystem model, you need to define the processes that connect the components. This is graphically done by using arrows to indicate the flow of nutrients or energy among the different ecosystem components.

The components of our ecosystem model are now connected by processes that result in the movement of energy or nutrients among the components.

One thing to notice in our ecosystem model is that there is no process connecting the trees component with the understory plants component.

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This is because there are no substantial processes that result in the flow of nutrients directly from a tree to an understory plant or visa-versa (the flow of nutrients always goes through the forest floor first!). In a conceptual diagram, there would be important relationships between the trees and understory plants. For example, trees provide shade to the understory plants. But remember, in an ecosystem model, only processes that result in flow of energy or nutrients are represented. You will see why this is important a little later.Now let’s add the animals and the people components to our ecosystem. You can see in Figure 3 below that energy & nutrients flow from the trees and understory plants to the animals when they eat the leaves, twigs and buds of trees or graze on understory plants; and when the animal excrete waste products or die, energy & nutrients are returned to the forest floor component. Since people are really just a special kind of animal, you can see that energy & nutrients flow from the trees to people when they eat something from a tree, like maple syrup… Read more.

We have added two components (people & animals) to our ecosystem model, along with some processes connecting them to other components.

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Step Three: Determine the major inputs and outputs of your ecosystem. As you are building your ecosystem model, one thing to think about is whether your ecosystems could be opened or closed. A closed ecosystem is one that has no inputs of energy or nutrients from outside the ecosystem and no outputs of energy or nutrients leaving the system. The earth is an example of a closed ecosystem with respect to nutrients and an open ecosystem with respect to energy (see figure 4 below). All the nutrients that have ever been on earth are here and simply continue to cycle, there are no additions or losses. However, the earth is constantly getting inputs of energy from the sun and simultaneously radiating energy back. The earth doesn’t heat up too much or cool down too much because the earth’s energy balance is in a relatively stable equilibrium, meaning that the amount of energy being input and output are about equal.

The earth ecosystem and has no inputs or outputs of nutrients which are constantly recycled within the global ecosystem, while the earth has both inputs

and outputs of energy that are in a relatively stable equilibrium.

Now, let’s examine some potential inputs and outputs of nutrients & energy to our forested ecosystem (see Figure 5 below).

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Just as the Earth ecosystem is closed with respect to nutrients, unmanaged earthworm-free hardwood forest ecosystems are often very nearly closed nutrient ecosystems that there are very few inputs or outputs of nutrients. Rather the nutrients are constantly recycled among the various ecosystem components. In contrast, most agricultural ecosystems require nutrient inputs from outside to function properly.

Some typical inputs and outputs of nutrients and energy for forested ecosystems include evapotranspiration, nutrient leaching, sunlight and rain.

Step Four: Once you have identified the components, processes and major inputs and outputs in your ecosystem model, then you can begin to add the actual values to these parts of your ecosystem by measuring them. For example, you could measure the amount of litter that falls to the forest floor each year (a process), what the biomass of trees is in a given forest (a component), how much light reaches the forest over a growing season (an input), or how much nitrogen leaches from the forest (an output). Needless

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to say, some of these things are easier to measure than others and for most of these things it would be very hard to directly measure the value for a whole forest. For example, it would be hard to catch every single leaf that fell from the trees in a given year and weigh them all! So, researchers estimate these values taking samples of the given measurement they want to know. In the case of leaf litter, you can put out trays in the forest and after all the leaves have fallen for the year, dry and weight the leaf liter in your trays. They you can use that value to calculate an estimate of the total leaf litter for your forest.

Step Five: Use your ecosystem model to think about how changes can cascade through an ecosystem or to ask specific questions that can be answered with further research. When the major components, processes and inputs and outputs of an ecosystem are understood, then you can use the model to see how changing one part of the ecosystem affects other parts. For example, if you harvest trees from your forest, that will decrease the amount of leaf litter reaching the forest floor each year which may lead to decreases in available nutrients for understory plants. This is the type of thing forest ecology researchers often study. For example, researchers may monitor soil nutrient levels for many years after trees have been harvested to see how the real forest behaves compared to what they thought might happen based on their forest model, their understanding of how the forest works. If the results in the real forest are very different than those predicted by their model, then they know that they don’t have full understanding of how their forest works and they may go back to try to improve their model.

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An ecosystem that is in equilibrium doesn't gain or lose nutrients.

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ANALISA AKAR MASALAH DENGAN WHY-WHY ANALYSIS (Riyantono Anwar. 2011. http://belajarlean.blogspot.com/2011/09/analisa-akar-masalah-dengan-why-why.html)

Why why analysis (analisa kenapa kenapa) adalah suatu metode yang digunakan dalam root cause analysis dalam rangka untuk problem solving yaitu mencari akar suatu masalah atau penyebab dari defect supaya sampai ke akar penyebab masalah. Istilah lain dari why why analysis adalah 5 whys analysis. Metoda root cause analysis ini dikembangkan oleh pendiri Toyota Motor Corporation yaitu Sakichi Toyoda yang menginginkan setiap individu dalam organisasi mulai level top management sampai shopfloor memiliki skill problem solving dan mampu menjadi problem solver di area masing-masing.

Metoda yang digunakan oleh why why analysis adalah dengan menggunakan iterasi yaitu pertanyaan MENGAPA yang diulang beberapa kali sampai menemukan akar masalahnya. Contohnya sebagai berikut:

Masalah: Mesin breakdown1. Mengapa? Komponen automator tidak berfungsi2. Mengapa tidak berfungsi? Usia komponen sudah melebihi batas

lifetime 12 bulan3. Mengapa tidak diganti? Tidak ada yang tahu4. Mengapa tidak ada yang tahu? Tidak ada jadwal rutin maintenance5. Mengapa tidak ada jadwal rutin? Inilah akar masalahnya

Terkadang untuk sampai pada akar masalah bisa pada pertanyaan kelima atau bahkan bisa lebih atau juga bisa bahkan kurang tergantung dari tipe masalahnya. Metoda root cause analysis ini cukup mudah dan bisa sampai pada akar masalahnya, bukan hanya di permukaan saja. Dan mencegah masalah tersebut terulang lagi.

Tahapan umum saat melakukan root cause analysis dengan why why analysis:

1. Menentukan masalahnya dan area masalahnya2. Mengumpulkan team untuk brainstorming sehingga kita bisa

memiliki berbagai pandangan, pengetahuan, pengalaman, dan pendekatan yang berbeda terhadap masalah

3. Melakukan gemba (turun ke lapangan) untuk melihat actual tempat, actual object, dan actual data

4. Mulai bertanya menggunakan why why5. Setelah sampai pada akar masalah, ujilah setiap jawaban dari yang

terbawah apakah jawaban tersebut akan berdampak pada akibat di

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level atasnya. Contoh: apakah kalau ada jadwal rutin maintenance maka akan mudah buat maintenance untuk melakukan penggantian komponen secara rutin. Apakah hal tersebut paling masuk akal dalam menyebabkan dampak di level atasnya. Apakah ada alternatif kemungkinan penyebab lainnya?

6. Pada umumnya solusi tidak mengarah pada menyalahkan ke orang tapi bagaimana cara melakukan perbaikan sistem atau prosedur

7. Jika akar penyebab sudah diketahui maka segera implementasikan solusinya

Monitor terus performancenya untuk memastikan bahwa masalah tersebut tidak terulang lagi.

Contoh Analisis Akar Masalah:ANALISIS MASALAH DAN AKAR MASALAH PENANAMAN PADI SAWAH IRIGASI (Oryza sativa) PADA TANAH SERI TLOGOREJO

Berdasarkan evaluasi kesesuaian lahan tanah di kawasan Dadapan, Tlogorejo terhadap tanaman padi, dapat diketahui bahwa tanah tersebut memiliki kelas kesesuaian lahan s3 dengan faktor pembatas tekstur, persentase C-organik, dan kelerengan. Faktor-faktor pembatas tersebut menyebabkan kurang optimalnya pertumbuhan tanaman padi, sehingga produktivitasnya juga akan berkurang. Berikut ini adalah analisis permasalahan dalam penanaman tanamanan padi sawah di tanah di kawasan Dadapan, Tlogorejo yang dijabarkan dalam pohon permasalahan.

Permasalahan utama yang ditemukan pada lahan tersebut apabila ditanami dengan tanaman padi sawah adalah produksi tanaman padi akan tidak optimal dan tidak stabil.

Penyebab ketidakoptimalan dan ketidakstabilan produktivitas tanaman padi tersebut adalah rendahnya ketersediaan unsur hara, ketersediaan air yang terbatas, serta gangguan fungsi penunjang mekanik tanah tersebut. Ketersediaan unsur hara yang rendah dapat disebabkan oleh erosi, maupun karena rendahnya keragaman mikroorganisme di dalam tanah tersebut. Penyebab utama erosi ialah kelerengan yang cukup curam dan terjadinya pencucian hara akibat runoff. Hal ini disebabkan oleh kurangnya penutup tanah, baik itu berupa pohon maupun seresah, di permukaan tanah. Sedangkan rendahnya keragaman mikroorganisme dalam tanah disebabkan oleh kandungan C-organik dalam tanah yang rendah pula. Rendahnya kandungan C-organik tanah dapat disebabkan oleh pencucian hara, kurangnya bahan organik dalam tanah, serta pengolahan tanah yang terlampau intensif.

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Sedangkan ketersediaan air yang terbatas disebabkan oleh tekstur tanah yang kasar. Tekstur tanah yang kasar memiliki permeabilitas yang tinggi sehingga air mudah mengalami infiltrasi. Hal ini akan menjadi tidak optimal bila ditanami dengan tanaman padi sawah. Tanaman padi sawah memerlukan penggenangan selama masa tanamnya, sehingga membutuhkan tanah yang memiliki permeabilitas tidak terlalu tinggi sehingga tidak banyak air yang hilang.

Sumber: http://meelaisme.wordpress.com/2011/10/19/analisis-masalah-dan-akar-masalah-penanaman-padi-sawah-irigasi-oryza-sativa-pada-tanah-seri-tlogorejo/)

Berdasarkan analisis akar masalah yang digambarkan dengan pohon masalah di atas, dapat dilihat bahwa terdapat tiga akar masalah yang menyebabkan tidak optimal dan tidak stabilnya produktivitas tanaman padi sawah bila ditanam di lahan di kawasan Tlogorejo. Ketiga akar masalah tersebut ialah kelerengan yang cukup curam, kurangnya penutup lahan, serta tekstur tanah yang agak kasar.

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DIAGRAM TULANG IKAN: PERANGKAT ANALISIS AKAR MASALAH

Dalam zaman globalisasi dan turbulensi seperti sekarang ini, segala sesuatu yang berhubungan dengan perilaku manusia dan hubungan antara manusia seakan-akan dapat berlangsung tanpa batas. Dimana sepanjang zaman hingga sekarang dan masa yang akan datang semakin cepat berubah. Ungkapan presiden RI pertama dalam salah satu pidatonya “jika kita tidak mengikuti perubahan maka kita adalah sejarah.” Setiap perubahan senantiasa ada penyebabnya, dan akar-penyebab inilah yang harus dapat diungkapkan.

During the Fishbone Diagram analysis, group causes in two groups: 1. External ( economy, weather, legislation ) just list them in Fishbone

Diagram, but do not focus too much about them, since it is hard or impossible to influence them.

2. Internal ( productivity, discipline, high costs, ... ) are causes that you can influence. Branch further the Fishbone Diagram for every cause.

Based on Route Cause Analysis ( Fishbone Diagram ) owner of the KPI (Key Performance Indicator ) need to prepare Action plan with a purpose of returning the result of process back on track, meaning to be on Target with that specific KPI next time.

The action plan is focused on defining a 4 key points that are defines by simple questions: Who - The owner of the KPI is responsible for conducting the action plan What - Action plan, specifying activities that will lead to achieving target When - Time frame, deadline for the activities How - Resources required for Action plan

The Fishbone Diagram is the practical tool for route causes analysis during daily environmental management.

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Diagram Tulang Ikan untuk mencari penyebab dari suatu perubahan atau permasalahan (Sumber:

http://www.biz-development.com/PerformanceManagement/2.10.Ishikawa-Fishbone-Diagram.htm)

Konteks tersebut di atas mengarahkan pemikiran bahwa subjek dan objek ada pada diri manusia. Hal ini bermakna bahwa manusia menciptakan perubahan dan perubahan itu sendiri mengkreatur manusia itu sendiri. Demikian hal dengan pendidikan sebagai apresiasi dari setiap perubahan manusia dan hal yang mampu mengubah manusia. Oleh sebab itu tidak sedikit para ahli yang mengungkapkan bahwa sekolah sebagai wahana pendidikan merupakan agen perubahan.

Satu hal yang patut dipikirkan adalah bahwa pendidikan pun demikian pada diri manusia. Yaitu sebagai objek dan subjek dari perubahan manusia bahkan bisa mempercepat, mengoptimalkan setiap perubahan itu sendiri. Pendidikan mampu mengubah manusia dan manusia itu sendiri yang mampu mengubah pendidikan. Oleh sebab itu tidak sedikit kini muncul berbagai paradigma baru dalam sistem pendidikan sebagai bukti nyata bahwa pendidikan berubah seiring dengan perubahan manusia. Dan manusia pun berubah seiring dengan perkembangan sistem pendidikan itu sendiri.

Manusia senantiasa akan berupaya mengeksplorasi segala sumber daya yang dimilikinya. Dengan cara mencurahkan segala daya dan kemampuanya untuk selalu berinovasi menemukan sesuatu yang baru yang dapat membantu hidupnya menjadi lebih baik. Jika manusia tidak menggali segala kemampuanya maka ia akan tertinggal bahkan tergerus oleh zaman yang selalu berkembang.

Dalam dunia penelitian dan pendidikan, Inovasi merupakan hal yang mutlak dilakukan karena tanpa inovasi akan terjadi kemandekan pada dunia

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pendidikan yang kemudian berimbas pada pada elemen-elemen kehidupan yang lain seperti politik, ekonomi, sosial dan lain-lain. Pertanyaan yang terbentuk kini adalah realisasi prinsip dasar inovasi untuk pemecahan masalah atau kebermaknaan inovasi itu sendiri. Hal ini berangkat dari bahwa segala macam proses berawal dari perencanaan yang matang “if you fail to plan, you plan to fail” sehingga konteks analisis akar masalah lebih kentara pada proses perencanaan inovasi demi memunculkan solving, perubahan dan memunculkan inovasi. Meskipun tidak sellu “inovasi” adalah perubahan, namun diyakini bahwa perubahan merupakan bagian dari inovasi.

Implementasi Fishbone Diagram (Kaoru Ishikawa) dalam Merencanakan Inovasi Pendidikan.

1. Merencanakan Inovasi PendidikanBerdasarkan pada 6 prinsip dasar inovasi pendidikan maka

setidaknya kita tidak akan semena-mena dalam merencanakan inovasi. Kembali ketitik awal bahwasanya proses inovasi dapat bermula dari munculnya kesenjangan (GAP), ketidaksesuaian sehingga diperlukan pembaharuan, perubahan atau tindakan korektif atau kebijakan baru yang sifatnya inovatif, meskipun setiap perubahan belum berarti inovasi namun setiap inovasi meski di dalamnya adalah perubahan. Singkatnya langkah langkah secara global sebagai berikut di bawah ini:

1. Dokumentasi gap atau kesenjangan dan ketidaksesuaian (proses). Baik secara kuantitatif maupun kualitatif. Hingga terbentuk prosses flowchart.

2. Identifikasi kebutuhan (demand) pelanggan dalam hal ini pengguna jasa pendidikan.

3. Menganalisis gap dan kesenjangan dan ketidaksesuaian (analisa proses) tersebut.

4. Pengembangan tindakan korektif (root causes analysis)5. Implementasi inovasi.6. Validasi.

Tahapan tersebut di atas menunjukkan bahwa root causes analysis memegang peranan penting dalam menentukan kebijakan selanjutnya (korektif/pembaharuan/inovasi).Gejolak, Penomena, Gap, Ketidak sesuian yang terjadi dalam proses pendidikan atau berbagai permasalahan yang aktual baik teoritis maupun paraktis, baik dalam tatanan makro maupun mikro, bahkan skup yang lebih kecil seperti permasalahan di dalam kelas dijadikan sandaran dalam berinovasi di dunia pendidikan. Namun untuk kebermaknaan suatu inovasi tetap harus mengusung prinsip-prinsip inovasi itu sendiri. Untuk itu salah

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satunya, masalah yang diungkap haruslah terlebih dahulu dinalisis (akar masalah) sehingga inovasi betul-betul berkenaan dan bermakna (mainfull).Berikut di bawah ini adalah diagram framework dimana esensi analisis akar masalah demi mewujudkan inovasi pendidikan yang penuh makna.

Kerangka Implementasi Fishbone Diagram dalam inovasi Pendidikan

2. Fishbone DiagramDiagram ”Tulang Ikan” atau Fishbone diagram sering pula disebut Ishikawa diagram sehubungan dengan perangkat diagram sebab akibat ini pertama kali diperkenalkan oleh Prof. Kaoru Ishikawa dari Jepang.

Menurut Gasversz (1997), ”Diagram sebab akibat ini merupakan pendekatan terstruktur yang memungkinkan dilakukan suatu analisis lebih terperinci dalam menemukan penyebab-penyebab suatu masalah, ketidaksesuaian, dan kesenjangan yang ada. Selanjutnya diungkapkan bahwa diagram ini bisa digunakan dalam situasi:

1) Terdapat pertemuan diskusi dengan menggunakan brainstorming untuk mengidentifikasi mengapa suatu masalah terjadi,

2) diperlukan analisis lebih terperinci terhadap suatu masalah, dan 3) terdapat kesulitan untuk memisahkan penyebab dan akibat.

Berikut disarikan dari Gasversz (1997) tentang langkah-langkah penggunaan diagram Fishbone:

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1. Mendapatkan kesepakatan tentang masalah yang terjadi dan diungkapkan masalah itu sebagai suatu pertanyaan masalah (problem question).

2. Membangkitkan sekumpulan penyebab yang mungkin, dengan menggunakan teknik brainstorming atau membentuk anggota tim yang memiliki ide-ide berkaitan dengan masalah yang sedang dihadapi.

3. Menggambarkan diagram dengan pertanyaan masalah ditempatkan pada sisi kanan (membentuk kepala ikan) dan kategori utama seperti: material, metode, manusia, mesin, pengukuran dan lingkungan ditempatkan pada cabang-cabang utama (membentuk tulang-tulang besar dari ikan). Kategori utama ini bisa diubah sesuai dengan kebutuhan.

4. Menetapkan setiap penyebab dalam kategori utama yang sesuai dengan menempatkan pada cabang yang sesusai.

5. Untuk setiap penyebab yang mungkin, tanyakan ”mengapa?” untuk menemukan akar penyebab, kemudian daftarkan akar-akar penyebab masalah itu pada cabang-cabang yang sesuai dengan kategori utama (membentuk tulang-tulang kecil dari ikan). Untuk menemukan akar penyebab, kita adapat menggunakan teknik bertanya mengapa lima kali (Five Why).

6. Menginterpretasikan diagram sebab akibat itu dengan melihat penyebab-penyebab yang muncul secara berulang, kemudian dapatkan kesepakatan melalui konsensus tentang penyebab itu. Selanjutnya fokuskan perhatian pada penyebab yang dipilih melalui konsensus itu.

7. Menerapkan hasil analisis dengan menggunakan diagram sebab-akibat itu dengan cara mengembangkan dan meng-implementasikan tindakan korektif, serta memonitor hasil-hasil untuk menjamin bahwa tindakan korektif yang dilakukan itu efektif karena telah menghilangkan akar penyebab dari masalah yang dihadapi.

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Fishbone Diagram (Gasversz, 1997)

Pada langkah ketiga 3 tersebut di atas kategori utama dapat kita ubah menjadi sebab satu (Sb1) atau sebab 2 (Sb2) dan selanjutnya hingga menjadi cabang-cabang kecil sebab Sb1a, Sb1b dan seterusnya. Kita sepakati konteks korektif dalam hal ini adalah produk atau proses perbaikan dalam bidang pendidikan sehingga menghasilkan suatu pembaharuan/ inovasi pendidikan baik dalam bentuk discovery maupun invention baik dalam tatanan mikro maupun makro.

Fishbone Diagram (Gasversz, 1997)

Pertanyaan Why? Bercabang hingga mencapai lima yang menggambarkan sub tulang ikan itu sendiri. Dimana kategori utama Manusia, Pengukuran, Metode, Materia, Mesin dan Lingkungan dapat diganti sesuai kebutuhan misalkan, dalam

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konteks permasalahan penurunan kualitas lulusan bisa diganti dengan: Sarana Belajar, Orang tua, Teman Sekolah, Kurikulum, Guru, Kepala Sekolah, Lingkungan Belajar, dll.

3. Implementasi Root Cause Analysis menggunakan Fishbone Diagram dalam Perencanaan Inovasi Pendidikan

Penerapan atau implementasi Fishbone Diagram dalam analisis akar masalah dalam berinovasi di bidang pendidikan, berikut di bawah ini langsung disajikan dalam bentuk contoh root cause analysis dalam bidang pendidikan.

Contoh 1.

Masalah: Mengapa Kualitas Lulusan SDM Rendah?Kategori UtamaSebab 1 (Sb1): Guru/DosenSebab 2 (Sb2): SiswaSebab 3 (Sb3): MasyarakatSebab 4 (Sb4): Kurikulum

Five Why: Why Sebab 1 Sebab 2 Sebab 3 Sebab 41. Why 1. Guru/Dosen kurang kompeten/tidak banyak belajar.

Siswa input (lulusan sekolah sebelumnya) kurang berkualitas. Masyarakat kurang peduli kualitas lulusan siswa. Kurikulum kurang tepat atau salah arah.

2. Why 2. Guru/Dosen mengajar ditempat lain atau sibuk mencari uang tambahan. Unit pemroses lembaga pendidikan sebelumnya berkualitas rendah (guru, fasilitas, dll). Masyarakat sudah menganggap biasa atau terbiasa dengan KKN Ada kepentingan tidak etis dalam penyusunannya

3. Why 3. Kesejahteraan kurang. Anggaran APBN Rendah (BOS tidak normal). Rekruitmen siswa dan SDM tidak bersih atau transaparan . Tidak ada akses kontrol untuk masyarakat atau pemerhati pendidikan

4. Why 4. APBN tidak mencukupi Pajak negara terserap sedikit. Ada ketidak sesuaian penerapan kebijakan. Sistem demokrasi anomali yang sarat akan KKN

5. Why 5. Pajak banyak hilang korupsi merajalela (temuan...). Korupsi dan sadar pendidikan moral rendah. Korupsi dan sadar pendidikan moral rendah. Korupsi dan sadar pendidikan moral rendah.

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Atau tampilan deskripsi dapat berupa catatan demikian yang jika diterapkan dalam fishbone diagram memunculkan gambaran tulang besar dan tulang kecil ikan. Sebagai berikut:

Sb1-1: Guru/Dosen kurang kompeten/tidak banyak belajarSb1-2: Guru/Dosen mengajar ditempat lain atau sibuk mencari

uang tambahanSb1-3: Kesejahteraan kurangSb1-4: APBN tidak mencukupiSb1-5: Pajak banyak hilang korupsi merajalela (temuan...)Sb2-1: Siswa input (lulusan sekolah sebelumnya) kurang berkualitasSb2-2: Unit pemroses rendah (guru, fasilitas, dll)Sb2-3: Anggaran APBN Rendah (BOS tidak normal)Sb2-4: Pajak negara terserap sedikitSb2-5: Korupsi dan sadar pendidikan moral rendahSb3-1: Masyarakat kurang peduli kualitas lulusan siswaSb3-2: Masyarakat sudah menganggap biasa atau terbiasa dengan

KKNSb3-3: Rekruitmen siswa dan SDM tidak bersih atau transaparanSb3-4: Ada ketidak sesuaian penerapan kebijakanSb3-5: Korupsi dan sadar pendidikan moral rendahSb4-1: Kurikulum kurang tepat atau salah arahSb4-2: Ada kepentingan tidak etis dalam penyusunannyaSb4-3: Tidak ada akses kontrol untuk masyarakat atau pemerhati

pendidikanSb4-4: Sistem demokrasi anomali yang sarat akan KKNSb4-5: Korupsi dan sadar pendidikan moral rendah

Fishbone Diagram Kegagalan Inovasi Kualitas SDM Indonesia

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Pertimbangkan tentang kejujuran, konseptual yang kuat untuk mewujudkan jawaban-jawaban, ”Mengapa?” sebanyak lima kali. Oleh sebab itu dianjurkan untuk melaksanakan Brainstorming dengan kekuatan Tim, jadi lebih dari satu orang pemikir. Dari contoh tersebut di atas, dapat diinterpretasikan bahwa akar masalah adalah masalah perilaku negatif KKN terutama korupsi dan pendidikan moral yang rendah sehingga untuk meningkatkan kualitas SDM kita adalah memberantas perilaku KKN terutama korupsi melalui perbaikan pendidikan moral atau penegakan positif moral apapun caranya (jalur pendidikan maupun supremasi hukum).

Contoh 2.Masalah: Mengapa Siswa SMA Kesulitan Menyerap Pelajaran Kimia ?

Kategori UtamaSebab 1 (Sb1): GuruSebab 2 (Sb2): SiswaSebab 3 (Sb3): MasyarakatSebab 4 (Sb4): KurikulumSebab 5 (Sb5): Sarana

Five Why1. Why 1. Guru kurang kompeten. Siswa kuarang antuasias belajar.

Masyarakat kurang peduli kualitas jasa pendidikan. Membutuhkan banyak praktek dan referensi. Referensi dan praktek kurang memadai

2. Why 2. Fasilitas pendidikan dan pelatihan kurang. Teacher center dan pembelajaran sering konvensional. Masyarakat hanya sekedar berpifikir tentang lulus dan tidak lulus. Tujuan kurikulum banyak . Buku, Alat dan bahan kurang memadai

3. Why 3 Tidak ada waktu dana pendukung. Kurangnya referensi atau buku sumber dan praktek. Terlalu percaya pada sekolah. Materi yang harus disampaikan banyak. Keterbatasan Dana

4. Why 4 Pendanaan dari pribadi, pemerintah dan komite sekolah kurang lancar Kurangnya fasilitas. Membatasi diri hanya berpikir tentang kelangsungan pendidikan siswa (ekonomi). Tuntutan kelulusan untuk melanjutkan kuliah Keterbatasan bantuan dari pemerintah maupun komite sekolah

5. Why 5 Alokasi dana pemerintah dan siswa terbatas. Alokasi dana pemerintah dan siswa terbatas. Angapan ekonomi lebih utama untuk kehidupan dibanding lainnya. Perbaikan pendidikan untuk perbaikan ekonomi. Alokasi dana pemerintah dan siswa terbatas

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Atau tampilan deskripsi dapat berupa catatan demikian yang jika diterapkan dalam fishbone diagram memunculkan gambaran tulang besar dan tulang kecil ikan. Sebagai berikut:

Sb1-1: Guru kurang kompetenSb1-2: Fasilitas pendidikan dan pelatihan kurangSb1-3: Tidak ada waktu dan cana dukunganSb1-4: Pendanaan pribadi, pemerintah dan komite sekolah kurangSb1-5: Alokasi dana pemerintah dan siswa terbatasSb2-1: Siswa kurang antusias belajarSb2-2: Teacher centerSb2-3: Kurangnya referensi atau buku sumber dan praktekSb2-4: Kurangnya fasilitasSb2-5: Alokasi dana pemerintah dan siswa terbatasSb3-1: Masyarakat kurang peduli kualitas jasa pendidikanSb3-2: Masyarakat hanya berpikir tentang lulus dan tidak lulusSb3-3: Terlalu percaya pada sekolahSb3-4: Membatasi diri berpikir tentang kelangsungan

perekonomianSb3-5: Ekonomi lebih untuk kehidupan (sekolah pun untuk

perbaikan ekonomi)Sb4-1: Membutuhkan banyak praktek dan referensiSb4-2: Indikator atau tujuan terlalu luas dan banyakSb4-3: Materi yang harus disampaikan banyakSb4-4: Tuntutan lulusan untuk melanjutkan ke jenjang pendidikan

yang lebih tinggiSb4-5: Perbaikan pendidikan untuk jenjang yang lebih tinggi.Sb5-1: Referensi dan praktek kurang memadaiSb5-2: Alat dan bahan serta buku sumber kurang memadaiSb5-3: Keterbatasan danaSb5-4: Keterbatasan bantuan dana dari pemerintah dan komite

sekolah.Sb5-5: Alokasi dana dari pemerintah dan siswa terbatas.

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Diagram tulang-ikan: Rendahnya IPK mahasiswa (Sumber: gkm1.blogspot.com)

Akar masalah dari suatu system pendidikan adalah keterbatasan pendanaan baik dari pemerintah maupun komite sekolah untuk menunjang proses belajar baik tingkat profesional/komptensi guru maupun siswa. Sehingga solusinya adalah penggalangan dana atau pengalokasian/pendistribusian dana yang diterima sekolah untuk menutupi kekurangan tersebut. Konteks tersebut di atas tidak mutlak, artinya hasil analisis akar maasalah bergantung pada individu/Tim melaksanakan Brainstorming. Bahkan kajian seperti di atas (kesulitan belajar) bisa dipersempit skupnya dalam konteks materi, metode mengajar, media, guru, siswa, dll, bergantung pada sudut pandang Tim analisis akar masalah.

Analisis akar masalah sangat membantu dalam merencanakan tindak lanjut atau tindakan pemecahan masalah. Dimana outcome-nya adalah dapat dalam bentuk perubahan atau perbaikan bahkan inovasi baik discovery maupun invention. Setidaknya hal ini membantu mahasiswa dalam upaya membuat inovasi melalui jalur skripsi atau thesis, untuk guru membantu dalam memperlancar penilitian tindakan kelas. Selain itu lembaga pendidikan baik pusat maupun daerah serta sekolah itu sendiri sebagai wujud organisasi dimana di dalamnya terjadi proses manajemen sudah selayaknya berinovasi yang berbasis pada 6 prinsip inovasi untuk lebih bermakna setidaknya dapat menjauhi untuk mengeluarkan kebijakan-kebijakan pendidikan yang tidak bijaksana.

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Diagram Tulang-Ikan Consumer Debts (http://zenduse2.blogspot.com/2007/12/causes-of-consumer-debt.html)

Causes of Consumer debt and their categories: 1. Economic and Investment Climate

a. Uncertainty in financial market causes interest rates hike and in effect affects interest on personal loans and various lines of credit.

b. Overconfidence in the economy encouraging people to borrow more.c. False hope from the economic growth and forecastd. Supply of finance where banks are more willing to lend people with bad

credit histories.e. Lower interest rates induce people to borrow more.

2. Incomea. Same level of income over the years while loans keep on going upb. Limited opportunity to increase personal incomec. People are surviving on disposable income making them vulnerable to

interest rates fluctuationsd. Reduced income specially when a person becomes less marketable in a

competitive labor markete. Saving too little or none at all.

3. Culture and Lifestylea. No money communication skills. Spouses have differences in the way

they spend their money. Most of the time spouses are hiding from each other their expenditures.

b. Addicted to entertainment including but not limited to watching movies, playing games, video-karaoke, and other form of entertainment.

c. Divorce and marital break-upsd. Financial Illiteracy

4. Cost of Living

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a. Hand phones, which in fact are becoming more fads and crazes instead of necessity.

b. Rising cost of healthcare as reflected in medical expenses.c. Rising cost of education.d. Hike in transport faree. GST hikef. Rising cost of housingg. Needs for broadband connection to gain access to the World Wide Web.

5. Employmenta. Automation displaces human labor.b. Company mergers and acquisition causing lay offs on redundant

workforce.c. Underemploymentd. Downsizing of companiese. Managerial jobs are taken over by intelligent systems.f. Job lossesg. Retrenchment

6. Behavior (Psychological)a. Financial phobia where people keep on denying their

indebtedness.b. Banking on windfall.Compulsive shopping.

Perubahan zaman sekarang menjadikan perubahan kehidupan dunia yang semakin kompleks permasalahannya dimana “ekonomi” sebagai sebuah sistem mangghasilkan permasalahan dari subsistem-subsistem pendukungnya dari mulai tatanan kebijakan hingga empris praktis, baik dari level makro hingga mikro. Hal ini mampu mengaburkan inti permasalahan sehingga diperlukan analisis akar masalah untuk menghasilkan tindakan korektif, pembaharuan bahkan inovasi baik discovery maupun invention.

Root Causes Analysis melalui perangkat Fishbone Diagram (Diagram Ishikawa) membantu inovator untuk menginventarisir, menghindari keragaman masalah dan menemukan akar masalah untuk berinovasi, sehingga inovasi itu sendiri manifull (sangat bermakna).

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Penggunaan Diagram Tulang ikan dalam Metode RCA (Sumber: http://www.reproline.jhu.edu/english/6read/6pi/ppt/maqpi/gifs/slide16.gif)

The fishbone diagram, is an example of one technique for graphically organizing ideas by category for root-cause (cause-and-effect) analysis. The fishbone can broaden thinking about potential causes and facilitate further examination of individual causes. Causes are usually brainstormed by a group. A place can be found on the diagram for everyone’s suggestions. The “effect” or performance problem is written on the right. Here, the category labels are performance factors. Note that ”information” is broken out into two items—performance feedback and job expectations. The group should choose the categories of cause that are most relevant to them and can add or drop categories as needed. For each cause ask, “Why does it happen?” and list responses as branches off the major causes. Push the causes back as far as possible.It is important to remember that the diagram is a structured way of expressing hypotheses about the causes of a performance problem or about why something isn’t happening as desired. It cannot replace empirical testing of these hypotheses. The diagram alone does not tell which is the root cause.

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