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60 I ICT TODAY 3. Determine the Root Cause There are many roots because most problems have multiple causes. However, there is one "main" causal root to address the problem stated in Step 1. Remember, it is vital to be sure that members in a team are not trying to solve forest problems, just one individual tree's problem. RCA is a team activity, and RCA project leads must stifle no one. People need to be able to contribute without fear of condemnation or retribution. 4. Find Corrective or Preventative Actions This brainstorming step should have significant involve- ment from the corrective team, including those respon- sible for the first-step identification. This step may bring in more people outside of the core RCA team as part of the brainstorming activities; the more, the merrier. But, again, no opinion or possible solution should be stifled or belittled. Sometimes a little bit of one person's idea combined with another makes all the difference! At this point, the corrective actions are a suggestion toward a solution. The recommended solution may change and will not be set in stone until the testing and verification round(s) in Step 6. 5. Draft and Train on Corrective Actions At this time, the plan of attack needs to be communi- cated to all stakeholders. Steps and improved measures will include the knowledge transfer and any upstream or downstream implications. It is important to set the path for monitoring the solution to verify if it is working. Communication is vital. All affected people need to be in the proverbial loop. There needs to be clear direction as to how to report any unforeseen circumstances. 6. Monitor and Measure While all of the steps previously outlined are important, this step could be the most critical. This step determines if the identified solutions are working. It is also likely to identify other areas of improvement that could positively impact operations. As in Step 5, open lines of communication are paramount. This step can be a bit of lather, rinse, iterate, and repeat, but that is fine. The team is working on a solution that will improve operations long term. SOME HELPFUL TOOLS FOR RCA EXERCISES The Five Whys of Root Cause or Decision Making One methodology of RCA is referred to as the Five Whys. The why exercises are designed to a fixed set of five drill-down why questions. Suppose there is a building that is never supposed to go without power, but it has a power failure, and security systems shut down. In a smart building, this could impact a variety of services, such as environmental controls, security, cybersecurity, doors, and lighting. Q: Why did the building security system fail? A: Because the power went out, and the generator did not come online. Q: Why? A: Because it was on manual bypass Q: Why? A: It stayed in manual mode after maintenance testing. Q: Why? A: Human error; a person forgot to switch it back after testing, and the controls need to be set to notify someone if the transfer switch is in manual mode for more than six hours. Q: Why? A: The procedures were not explicitly listed, and the person doing the testing was new. This is the first time this problem occurred. The Fishbone Diagram does a great job of looking at a more in-depth problem analysis, such as a more complex problem occurring in a smart building environment.