Step 3: Select the Best Solutions
Once the Cause Map is built to a sufficient level of detail with supporting evidence, it can be used to develop solutions. The Cause Map is used to identify all the possible solutions for a given issue so that the best solutions can be selected. It is easier to identify many possible solutions from the detailed Cause Map than the oversimplified high 
level root cause analysis of “VALDEZ hit the reef because they were outside the traffic lanes.”
Solutions can also be documented directly on the Cause Map. Solutions are typically placed in a green box directly above the cause the solution controls. At this stage, all solutions are considered and put on the Cause Map. After the analysis is complete, the best solutions are selected based on the impacts to the organization’s goals.
Below is an example of some solutions added to the VALDEZ oil spill Cause Map.
There are causes to every issue. The VALDEZ oil at a high level has only two causes. At a more detailed level it has 4 causes, 11 causes, 41 causes and 117 causes. All of the levels of the Cause Map are accurate – some simply have more detail that others. An issue should be worked to a sufficient level of detail to prevent the incident, meaning to reduce the risk of the incident occurring to an acceptable level. This is why solutions and work processes at a coffee shop are not as thorough or detailed as an airline or nuclear power facility. The risk or impact to the goals dictates how effective the solutions should be. Lower risk incidents will have relatively lower detail investigations while significantly high risk to an organization’s goals requires a much more through root cause analysis.
Shown below is the VALDEZ oil spill Cause Map with 41 causes, evidence and solutions.
Once the best solutions are selected, they are recorded in the action items list, and assigned an owner and due date. Shown below is the Action Items list containing the solutions from the Cause Map above.
Some of the actual solutions implemented by ExxonMobil after the oil spill are as follows:
- Modified tanker routes
- Instituted drug and alcohol testing policies for safety-sensitive positions
- Restricted safety-sensitive positions to employees with no history of substance abuse
- Implemented more extensive periodic assessment of ExxonMobilvessels and facilities
- Strengthened training programs for vessel captains and pilots
- Applied new technology to improve vessel navigation and ensure the integrity of oil containment systems
Another solution that was implemented to mitigate the effects of the spill on the environment was extensive cleanup. The results of the cleanup of an affected island are shown below. (The photos are courtesy of the NOAA’s National Ocean Service Office of Response and Restoration.)
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
Resources
The information used to make this Cause Map was obtained from the Exxon Valdez Oil Spill Trustee Council, NOAA’s Office of Response and Restoration, ExxonMobil and the National Transportation Safety Board.
Go to:
Step 2. Identify the Causes (The Analysis) – Page 1 – Page 2
Step 3. Select the Best Solutions (Reduce the Risk)
Download the one-page PDF summary of the EXXON Oil Spill Root Cause Analysis.
This example was made using our root cause analysis template.