Appendix E -Change Analysis

Change Analysis looks at a problem by analyzing the deviation between what is expected and what actually

happened. The evaluator essentially asks what differences occurred to make the outcome of this task or

activity different from all the other times this task or activity was successfully completed.

This technique consists of asking the questions: What? When? Where? Who? How? Answering these

questions should provide direction toward answering the root cause determination question: Why?

Primary and secondary questions included within each category will provide the prompting necessary to

thoroughly answer the overall question. Some of the questions will not be applicable to any given

condition. Some amount of redundancy exists in the questions to ensure that all items are addressed.

Several key elements include the following:

Consider the event containing the undesirable consequences.

Consider a comparable activity that did not have the undesirable consequences.

Compare the condition containing the undesirable consequences with the reference

activity.

Set down all known differences whether they appear to be relevant or not.

Analyze the differences for their effects in producing the undesirable consequences. This

must be done with careful attention to detail, ensuring that obscure and indirect

relationships are identified (e.g., a change in color or finish may change the heat transfer

parameters and consequently affect system temperature).

Integrate information into the investigative process relevant to the causes of, or the

contributors to, the undesirable consequences.

Change Analysis is a good technique to use whenever the causes of the condition are obscure, you do not

know where to start, or you suspect a change may have contributed to the condition.

Not recognizing the compounding of change (e.g., a change made five years previously combined with a

change made recently) is a potential shortcoming of Change Analysis. Not recognizing the introduction of

gradual change as compared with immediate change also is possible.

This technique may be adequate to determine the root cause of a relatively simple condition. In general,

though, it is not thorough enough to determine all the causes of more complex conditions.

Figure E-1 shows the six steps involved in Change Analysis. Figure E-2 is the Change Analysis worksheet.

The following questions help identify information required on the worksheet.

WHAT?

What is the condition?

What occurred to create the condition?

What occurred prior to the condition?

What occurred following the condition?

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