1

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

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and problem-solving in that these disciplines typically
seek solutions to specific difficulties, whereas RCA is
directed at underlying issues (bill-wilson.nrt).
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

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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 untuk
Program Keselamatan Pasien (
Institut Manajeme

Institut Manajemen Resiko KliniS)

http://pusdiknakes

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)
Jurnal Universitas http://journal.ui.ac

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.
Pojok Anti Korups

http://pojokantikor

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

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akar penyebab (Root Cause Analysis). RCA adalah
sebuah metode yang terstruktur yang digunakan
untuk menemukan akar penyebab dari masalah
kerusakan poros (LP UNHAS).
LP Universitas Ha

http://w w w .unha

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 masingmasing sebagai cause of failure, mode of failure dan
effect of failure (Mercu Buana).
Mercu Buana
http://74.125.153.

Metode 5 Why dalam Analisis Akar Masalah

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

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ada aktivitas identifikasi mengenai apa saja checkpoint (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 serta duri-durinya digambarkan sebagai penyebab
(cause) suatu permasalahan yang timbul.

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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.

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

Diagram Lingkar Sebab-Akibat:

SISTEM
PERIKANAN
WILAYAH PALABUHANRATU

TANGKAP

DI

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
1

Pelaku
Pemda

Dinas
Perikanan dan
Kelautan

Nelayan

Pengusaha

Pedagang/Bak
ul

Kebutuhan
-Peningkatan pendapatan DaerahPeningkatan Lapangan Kerja-Peningkatan
kesejahteraan nelayan
-Produksi Hasil Tangkapan memenuhi
kebutuhan pasar-Menjaga potensi
sumberdaya perikanan-Peningkatan
sumber informasi perikanan
-Bantuan modal untuk biaya operasiPenambahan unit penangkapan
-Peningkatan jumah alat tangkapTersedianya BBM-Pabrik es
-Bantuan modal-Fasilitas untuk
berdagang-Mutu ikan yang bagus

Formulasi Masalah

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

Identifikasi Sistem
Identifikasi sistem berhubungan dengan kebutuhankebutuhan 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

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dikendaikan, seperti kenaikkan harga BBM, dan hasil
tangkapan yang didapatkan.
Diagram Lingkar Sebab-Akibat
Diagram 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.

Diagram lingkar sebab-akibat (Sumber:

http://akhmadsyahbana.wordpress.com/2011/06/18/sistemperikanan-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 Kebutuhan
Analisis 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.

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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.

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

Formulasi Permasalahan Sistem

Permasalahan 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:

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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.
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 Sistem
Identifikasi 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.

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Diagram lingkar sebab-akibat (cousal-loop diagram) sistem pengendalian

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

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.

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

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

PENGANTAR
ANALYSIS)

METODE

RCA

(ROOT

CAUSE

(= 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

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

16
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

Pokok
Masalah

Banjir
Ht gundul

Akar
Masalah

Pembalaka
n

Tdk
ada
reboisa

Irigasi
Samp
ah

Tdk
terawat

SISTEMIK MASALAH
Berbeda 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

17
3. Menunjukkan SEBAB AKIBAT antar masalah-masalah
tersebut denganmenggunakan TANDA PANAH
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

Sekala Usaha
Kecil

Sekala
Usaha
Sekala
Akses
Kecil
modal
Usaha
lemah
Kecil

Daya
tawar
lemah

Investasi
Kecil

Profit Kecil

18
Analisa akar permasalahan adalah suatu
penyelidikan / pengusutan yang terstruktur yang
bertujuan untuk mengidentifikasi penyebab
sesungguhnya dari suatu masalah, dan tindakantindakan 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 ).
Hal yang penting adalah bukan mempelajari dan
menggunakan semua alat in, tetapi lebih untuk mengenal
alat-alat analisa akar masalah dan mengaplikasikan teknikteknik 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.

19
2. Kejadian yang kritis : Pendekatan yang anggun
digunakan untuk mengeksplorasi / menyelidiki isuisu yang paling kritis dalam suatu situasi.
3. Grafik Laba-laba / Spider Chart : Sebuah grafik
perbandingan untuk menandai sebuah masalahmasalah.
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.
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

20
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 (Relations 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 konsepkonsep yang kelihatannya tidak berkaitan sehingga
mereka semua bisa dieksplorasi / ditinjau lebih
lanjut.

Diagram Hubungan
Diagram 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.
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.

21

Diagram hubungan antara iklim dan tanaman. (Sumber:

http://rudikomarudin.blogspot.com/2011/03/hubungan-antara-iklim-dantanaman.html)

22
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

23
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.

24
Tabel kumpulan ide hasil brainstorming
Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?
Mengetahui
Menyediakan training
Menerapkan
Mendapatkan
kebutuhan konsumen
pengawasan;
komitmen
pemeriksaan dan
manajemen
pengendalian mutu
Mewawancarai
Mengetahui alat alat
menerapkan tata
melibatkan top
konsumen
pengembangan dan
cara analisa dan
manager dan middle
perbaikan mutu
pengukuran
manager sebagai
steering commitee
Mengidentifikasi
konsumen

Melakukan
investigasi terhadap
usaha usaha tentang
perbaikan mutu
secara terus menerus

Mengembangkan
tata cara koreksi
yang efektif terhadap
penyimpangan

Menerapkan sistem
rewarding yang
konsisten

membuat defenisi
operasional
mengenai pengetian
out-put

Melibatkan karyawan

Menerapkan
pengembangan
berdasarkan project
by project
membuat defenisi
operasional
mengenai pengetian
proses

menyediakan job
security, seperti
freedom to fail

Menghitung process
capability.

membuat program
goals yang jelas

meningkatkan
komunikasi di semua
sektor

menyediakan
waktu bagi middle
manager untuk
berpartisipasi
Membentuk steering
committee dengan
wewenang yang jelas

Menciptakan
keakraban dengan
jalan menghilangkan
penghalang diantara
kariawan

akses yang luas

terhadap informasi

Menyediakan support
staff bagi middle
manager

Tabel Penyaringan dan pengelompokan ide hasil brainstorming ke dalam 5

kelompok
Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?
Pengetahuan
Training
Pemeriksaan
Mendapatkan
Meningkatkan
tentang
perbaikan dan
dan
komitmen dari
komunikasi
konsumen
peningkatan
pengendalian
manajer
mutu
mutu
Mengetahui
Menyediakan
Menerapkan
Mendapatkan
Meningkatkan
kebutuhan
training
pengawasan,
komitmen
komunikasi di
konsumen
pemeriksaan dan manajemen
semua sektor
pengendalian
mutu
mewawancarai
Mengetahui
menerapkan
melibatkan top
akses yang luas
konsumen
alat-alat
tata cara analisa
manager dan
terhadap
pengembangan
dan pengukuran
middle manager
informasi
dan perbaikan
sebagai steering
mutu
commitee

25

Mengidentifikasi konsumen

membuat
defenisi
operasional
mengenai
pengetian
output

melakukan
investigasi
terhadap
usahausaha
tentang
perbaikan mutu
secara terus
menerus

mengembangka
n tata cara
koreksi yang
efektif terhadap
penyimpangan

menerapkan
system
rewarding yang
konsisten

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
Menyediakan
waktu bagi
middle manager
untuk
berpartisipasi
membentuk
steering
committee
dengan
wewenang yang
jelas

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

26
c. Melakukan klarifikasi terhadap ide-ide yang tidak
jelas, sehingga dengan demikian dapat digolongkan
ke dalam salah satu kelompok.
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.

27
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 aspekaspek 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 1
Write down the effect to be investigated and draw the 'backbone' arrow to it.
In the example shown below the effect is 'Incorrect deliveries'.

Step 2
Identify 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:

28

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.

29

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

30

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

31
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 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.)

32
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.
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 sumbersumber.
Akar adalah primer dan fundamental.
Roots are established and entrenched.

33

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 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.

34

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.

35
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.

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:

36

Sumber: http://syque.com/quality_tools/toolbook/causeeffect/example.htm

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

37
these phases Investigation, Analysis, and Decision. Read on
to see why.

Tahap 1: Investigation
The 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: Analysis

38
The 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.
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: Decision
The 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.

39
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 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.

40

Diagram Pohon Keputusan dalam pengendalian bising (Sumber:

http://www.dot.ca.gov/ser/vol1/sec3/physical/ch12noise/chap12noise.htm

Catatan Penutup
Hopefully, 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.

41

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-DoCheck-Adjust" cycle (PDCA). Hopefully, what I've written here
will help you Plan better!

Implementtation of the PDCA

PDCA cycle (Plan-Do-Check-Adjust) is broken down into 7
steps.
1. Problem Statement
The 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 Statement
The 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 Cause
Think 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
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 5Why Analysis and other PDCA tools.
5. Counter Measures

42
Counter 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 Up
This 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
goal statement. If the counter measures were successful,
standardize. If the problem still exists which happens
then adjust. That may mean simply modifying the

43
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. Standardization
Standardization 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)

44
Menindaklanjuti hasil untuk membuat perbaikan yang
diperlukan. Ini berarti juga meninjau seluruh langkah
dan memodifikasi proses untuk memperbaikinya
sebelum implementasi berikutnya.

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 FaktorPenyebab
...

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 wellknown, a wide variety of tools have been developed, and the
strengths and weaknesses of specific approaches are

45
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.
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, posthoc 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.

46
Contoh Analisis Faktor
Dalam 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 hubunganhubungan kovarian antara beberapa variabel yang
mendasari tetapi tidak teramati, kuantitas random yang
disebut faktor. Vektor random teramati X dengann p
komponen, memiliki rata-rata dan matrik kovarian. Model
analisis faktor adalah sebagai berikut :

X 1 1 11 F1 12 F2 .... 1m Fm 1

X p p p1 F1 p 2 F2 .... pm Fm p
Atau dapat ditulis dalam notasi matrik sebagai berikut :

X pxl ( pxl) L( pxm) F( mxl ) pxl

Fj

Dimana: i rata-rata variabel i ; i

faktor spesifik ke i;
i j
common faktor ke- j; dan
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 :

hi2 2i 1 2i 2 .... 2i m

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.

47

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 :
p

r
i 1 j1

KMO =

r
i 1 j 1

2
ij

2
ij

a ij2
i 1 j 1

i = 1, 2, 3, ..., p dan j = 1, 2, ..., p

rij = Koefisien korelasi antara variabel i dan j
aij = 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.

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 : = I
H1 : I
Statistik Uji :

rk

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

48

2
rik
p ( p 1) i k

( 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

(n 1)

p
2

(
r

r
)

(r k r ) 2 2 ( p 1) ( p 2) / 2;

2 ik
(1 r ) i k
k 1

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.

49
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

50
Diagram CED Degradasi mangrove (Sumber:
http://thesisondisastermanagement.blogspot.com/2011_04_01_archive.htm
l

51
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 tree

52
CRT 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 whywhy 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
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).

53

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 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.

54

Sumber: http://www.pinnacle-strategies.com/ Theory%20of

%20Constraints%20Jonah%20Thinking%20Processes.htm

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.

55

Sumber: http://www.pinnacle-strategies.com/ Theory%20of

%20Constraints%20Jonah%20Thinking%20Processes.htm

56
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

57
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

58

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 Way
One 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.

59
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.

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?)

60
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? *
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

61

2.

3.

4.

5.

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 dont 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.
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.
Simplistis: 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 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,

62
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
dont 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.
Unrelated: We often have more than one problem to deal
with, and it can be tempting to tie one problem to another in

63
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!

64

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. its protective nature is inherent to its structure,
and no additional action on the part of any agent is required
to afford this protection.

65
Control: A mechanism intended to prevent undesired effects
to the target. A control is often active, i.e. its 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.
Diskusi
At 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 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,

66
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 Perubahan
The 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, 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

67
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 changebased 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

68
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 the possibility of commonmode 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;
and
if the overall risk of undesired change was acceptable.
Kelemahannya
The
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

69
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.

70

ANALISIS PERUBAHAN (CHANGE ANALYSIS)

Deskripsi
Change 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.

71
DEVIASI: A situation in which actual results or actual
performance differed from what was expected.
Diskusi
As 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
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

72
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 nondeviated 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 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.

73

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.

74

ANALISIS POHON-PENYEBAB (Causal Factor Tree Analysis)

Deskripsi
Causal factor tree analysis is an investigation and analysis
technique used to record and display, in a logical, treestructured hierarchy, all the actions and conditions that were
necessary and sufficient for a given consequence to have
occurred.
Pros and Cons
Pros

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.

75

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 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).

76

Diagram Pohon untuk identifikasi penyebab (Sumber:

http://www.vertex42.com/ExcelTemplates/fishbone-diagram.html)

Diskusi
Tree 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 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

77
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.
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

78
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/creativeroot-cause-analysis-terminology/

Creative: A new and different approach through insight

and intuition
Team:

Two or more people working together to accomplish

a common goal

Surface Problem: Obstacle that blocks the expectation

79
Root Causes: Factors that fuel (feed) the surface problem
Analysis:

Logical, rational, viable inquiry

Solution: The course of action chosen to address causes

and eliminate the problem.

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.

80
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:

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.

81

The construction of indicators: The successive phases - From

concept to indices

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.

82

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.

83

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:

84

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 order to devise
effective ways of dealing with them. Problems and their interrelationships 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

menurut pedoman EC PCM:

pencemaran

sungai

85

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 projects objectives and results, then friction may occur among
stakeholders, leading to poor project implementation. The 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;

86
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

87
strategy (or strategies) to pursue. The figure below summarizes the
passage from the situation analysis to planning:

88

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.

89
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.
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.

90

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

91
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?

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

92
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.
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.

93

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

94
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 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/simplemodel-human-behavior)

95
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.

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 largescale, 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

96
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.

97
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.

98

Some components of
illustrated using boxes

graphical

forest

ecosystem

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 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 = clayvery 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.

99

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. 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

100
or nutrients are represented. You will see why this is
important a little later.
Now lets 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.

101
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 doesnt heat up too much or cool down too
much because the earths energy balance is in a relatively
stable equilibrium, meaning that the amount of energy being
input and output are about equal.

102

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, lets examine some potential inputs and outputs of

nutrients & energy to our forested ecosystem (see Figure 5
below).
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.

103

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 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

104
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 dont have full understanding of how their forest
works and they may go back to try to improve their model.

105

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

nutrients.

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ANALISA AKAR MASALAH DENGAN WHYWHY ANALYSIS

(Riyantono Anwar. 2011.
http://belajarlean.blogspot.com/2011/09/analisa-akar-masalahdengan-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 breakdown
1. Mengapa? Komponen automator tidak berfungsi
2. Mengapa tidak berfungsi? Usia komponen sudah
melebihi batas lifetime 12 bulan
3. Mengapa tidak diganti? Tidak ada yang tahu
4. Mengapa tidak ada yang tahu? Tidak ada jadwal rutin
maintenance
5. 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 masalahnya
2. Mengumpulkan team untuk brainstorming sehingga
kita bisa memiliki berbagai pandangan, pengetahuan,

107

3.
4.
5.

6.
7.

pengalaman, dan pendekatan yang berbeda terhadap

masalah
Melakukan gemba (turun ke lapangan) untuk melihat
actual tempat, actual object, dan actual data
Mulai bertanya menggunakan why why
Setelah sampai pada akar masalah, ujilah setiap
jawaban dari yang terbawah apakah jawaban tersebut
akan berdampak pada akibat di 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?
Pada umumnya solusi tidak mengarah pada
menyalahkan ke orang tapi bagaimana cara melakukan
perbaikan sistem atau prosedur
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 Corganik, 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.

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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.

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.

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Sumber: http://meelaisme.wordpress.com/2011/10/19/analisis-masalahdan-akar-masalah-penanaman-padi-sawah-irigasi-oryza-sativa-pada-tanahseri-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

111
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.

Diagram Tulang Ikan untuk mencari penyebab dari suatu

perubahan atau permasalahan (Sumber: http://www.bizdevelopment.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

112
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 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 Pendidikan
Berdasarkan 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.

113
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 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.

114

Kerangka Implementasi Fishbone Diagram dalam inovasi

Pendidikan
2. Fishbone Diagram
Diagram 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 langkahlangkah penggunaan diagram Fishbone:
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.

115
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.

116

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?

117
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 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 Utama
Sebab 1 (Sb1): Guru/Dosen
Sebab 2 (Sb2): Siswa
Sebab 3 (Sb3): Masyarakat
Sebab 4 (Sb4): Kurikulum
Five Why: Why Sebab 1 Sebab 2 Sebab 3 Sebab 4
1. 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

118
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.
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 belajar
Sb1-2:
Guru/Dosen mengajar ditempat lain atau
sibuk mencari uang tambahan
Sb1-3:
Kesejahteraan kurang
Sb1-4:
APBN tidak mencukupi
Sb1-5:
Pajak banyak hilang korupsi merajalela
(temuan...)
Sb2-1:
Siswa input (lulusan sekolah sebelumnya)
kurang berkualitas
Sb2-2:
Unit pemroses rendah (guru, fasilitas, dll)
Sb2-3:
Anggaran APBN Rendah (BOS tidak
normal)
Sb2-4:
Pajak negara terserap sedikit
Sb2-5:
Korupsi dan sadar pendidikan moral
rendah
Sb3-1:
Masyarakat kurang peduli kualitas lulusan
siswa
Sb3-2:
Masyarakat sudah menganggap biasa
atau terbiasa dengan KKN
Sb3-3:
Rekruitmen siswa dan SDM tidak bersih
atau transaparan
Sb3-4:
Ada ketidak sesuaian penerapan
kebijakan
Sb3-5:
Korupsi dan sadar pendidikan moral
rendah
Sb4-1:
Kurikulum kurang tepat atau salah arah
Sb4-2:
Ada kepentingan tidak etis dalam
penyusunannya
Sb4-3:
Tidak ada akses kontrol untuk masyarakat
atau pemerhati pendidikan
Sb4-4:
Sistem demokrasi anomali yang sarat
akan KKN

119
Sb4-5:

Korupsi dan sadar pendidikan moral

rendah

Fishbone Diagram Kegagalan Inovasi Kualitas SDM Indonesia

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 Utama
Sebab 1 (Sb1): Guru
Sebab 2 (Sb2): Siswa
Sebab 3 (Sb3): Masyarakat
Sebab 4 (Sb4): Kurikulum
Sebab 5 (Sb5): Sarana
Five Why

120
1. 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
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 kompeten
Sb1-2:
Fasilitas pendidikan dan pelatihan kurang
Sb1-3:
Tidak ada waktu dan cana dukungan
Sb1-4:
Pendanaan pribadi, pemerintah dan
komite sekolah kurang
Sb1-5:
Alokasi dana pemerintah dan siswa
terbatas
Sb2-1:
Siswa kurang antusias belajar
Sb2-2:
Teacher center
Sb2-3:
Kurangnya referensi atau buku sumber
dan praktek
Sb2-4:
Kurangnya fasilitas
Sb2-5:
Alokasi dana pemerintah dan siswa
terbatas
Sb3-1:
Masyarakat kurang peduli kualitas jasa
pendidikan

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Sb3-2:

Masyarakat hanya berpikir tentang lulus

dan tidak lulus
Sb3-3:
Terlalu percaya pada sekolah
Sb3-4:
Membatasi diri berpikir tentang
kelangsungan perekonomian
Sb3-5:
Ekonomi lebih untuk kehidupan (sekolah
pun untuk perbaikan ekonomi)
Sb4-1:
Membutuhkan banyak praktek dan
referensi
Sb4-2:
Indikator atau tujuan terlalu luas dan
banyak
Sb4-3:
Materi yang harus disampaikan banyak
Sb4-4:
Tuntutan lulusan untuk melanjutkan ke
jenjang pendidikan yang lebih tinggi
Sb4-5:
Perbaikan pendidikan untuk jenjang yang
lebih tinggi.
Sb5-1:
Referensi dan praktek kurang memadai
Sb5-2:
Alat dan bahan serta buku sumber kurang
memadai
Sb5-3:
Keterbatasan dana
Sb5-4:
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 forecast
d. 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. Income
a. Same level of income over the years while loans keep on
going up
b. Limited opportunity to increase personal income
c. People are surviving on disposable income making them
vulnerable to interest rates fluctuations
d. Reduced income specially when a person becomes less
marketable in a competitive labor market
e. Saving too little or none at all.
3. Culture and Lifestyle
a. 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-ups
d. Financial Illiteracy

124

4. Cost of Living
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 fare
e. GST hike
f. Rising cost of housing
g. Needs for broadband connection to gain access to the
World Wide Web.
5. Employment
a. Automation displaces human labor.
b. Company mergers and acquisition causing lay offs on
redundant workforce.
c. Underemployment
d. Downsizing of companies
e. Managerial jobs are taken over by intelligent systems.
f. Job losses
g. 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).

125

Penggunaan Diagram Tulang ikan dalam Metode RCA (Sumber:

http://www.reproline.jhu.edu/english/6read/6pi/ppt/maqpi/gifs/slide1
6.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 everyones 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 itemsperformance
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 isnt
happening as desired. It cannot replace empirical testing
of these hypotheses. The diagram alone does not tell
which is the root cause.

126

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DAFTAR PUSTAKA
Danim, Sudarwan. 2010. Manajemen dan Kepemimpinan
Ytransformasional Kekepala Sekolahan. Jakarta: Rineka
Cipta.
Danim, Sudarwan. 2010. Inovasi Pendidikan Dalam Upaya
Peningkatan Profesionalisme Tenaga Kependidikan.
Bandung: Pustaka Setia.
Gaspersz, Vincent. 1997. Manajemen Kualitas Penerapan
Konsep-Konsep Kualitas Dalam Manajemen Bisnis Total.
Jakarta: PT. Gramedia Pustaka Utama.
Harsono, Ari. 2008. Metode Analisis Akar Masalah dan Solusi.
MAKARA, SOSIAL HUMANIORA, VOL. 12, NO. 2,
DESEMBER 2008: 72-81
Kusmana, Suherli. 2010. Manajemen Inovasi Pendidikan,
Ciamis: PascasarjanaUnigal Press.
Mulyasa, E. 2008. Menjadi Guru Profesional Menciptakan
Pembelajaran Kreatif dan Menyenangkan. Bandung:
Rosda.
Suud, Udin Syaefudin. 2010. Inovasi Pendidikan. Bandung:
Alfabeta.