on Systems Thinking

Guest post by Mark Latino

If managers knew what the overall power of a well supported Root Cause Analysis (RCA) effort meant for their bottom-line, they would be breaking down doors to implement the process.

Unfortunately, this is often not the case, so this paper is an attempt to educate such individuals about the characteristics of an effective RCA methodology. The paper focuses on three aspects of RCA:

1. What is RCA?
2. What it takes to implement an effective RCA process as a way of conducting business rather than a finite ‘program’ that will eventually end
3. How does RCA contribute to a company’s bottom-line? [Read more…]

Guest post by Mark Latino

This case history takes place in a packaging facility in Virginia. The packer on module E5 was checked for vibration integrity during a pre-machine care evaluation. A problem was detected in the folding arm gearbox. The frequency characteristics indicated a bearing was deteriorating.

This seems very straight forward but let’s put the reality of the situation into the problem detected. The gearbox is located in a section of the packer that is not easily accessible. To do the necessary repairs it will require separating the two sections of the machine. When the packer is split it will take an additional two days of work before the unit can be restored to service. [Read more…]

Guest post by Charles J. Latino

At the root of most mechanical and system failures lurks a human cause. Insights into what to look for when solving human-caused failures are essential. Human error is generally described as behavior that goes beyond the norm. A proper definition in the context of this article is, “an action planned but not carried out according to the plan”. To find a means of minimizing human error, one must first understand its characteristics: [Read more…]

In order to know if all RCA is the same, we first have to define ‘What is RCA?’ On the surface this seems quite simple, but unfortunately it is quite complex. When I train or present speeches around the world, I often poll my audiences about how they define ‘RCA’. The fact is I will get as many answers, as I have people that I ask. This is unfortunate because there is no universally accepted definition of what ‘RCA’ actually is. Are there definitions out there, absolutely! There are hundreds of them. Various regulatory agencies have their own such definitions, as do corporations and companies. However, when definitions differ between agencies, corporations and industries, it is hard to measure the effectiveness of ‘RCA’ across the board, because everyone considers whatever they are doing, as ‘RCA’.

[Read more…]

No matter where we work, we will experience failures or ‘undesirable outcomes’ of some kind. As long as we work with other humans, this will indeed be the case. These failures may surface in the form of production delays, injuries, customer complaints, missed deadlines, lost profits, legal claims and the like.

In order to prevent recurrence of any such undesirable outcome, we have to truly understand the causes that led up to that bad outcome. In many of our worlds, the process used to analyze and understand what went wrong is called Root Cause Analysis or RCA. However, for the sake of this article, call this process whatever you want; problem solving, brainstorming, troubleshooting, etc. The common denominator of these terms, is they desire to resolve a failure and ensure it does not happen again.

Let’s get away from labels and specific industries and focus on the anatomy of a ‘failure’. Where does a failure come from? Think about this no matter where you work and see if it applies. [Read more…]