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on Systems Thinking

A listing in reverse chronological order of articles by:
  • JD Solomon — Communicating with FINESSE series
  • Robert (Bob) J. Latino — The RCA series

by Robert (Bob) J. Latino Leave a Comment

Leveraging Foresight via Root Cause Analysis & Defect Elimination

Leveraging Foresight via Root Cause Analysis & Defect Elimination

Most associate the traditional application of RCA, with some type of undesirable outcome, that has exceeded a set threshold or trigger. It is at this point that a formal RCA process will be set into motion. Because of its serious nature, it will likely have the attention and support of leadership. It may also have the attention of external stakeholders like OEM’s, insurance companies and regulators. As a career ‘RCA’ professional, I must say that this traditional perception unfortunately is the norm, and not the exception in my 35+ years in this space. This is unfortunate because it suppresses the methodology’s potential, and the capability of applying a more holistic approach to preventing such undesirable outcomes in the first place. In this article my intent is to provide a different perspective of how to view ‘RCA’ in a much broader and meaningful context and coupling its use with an effective Defect Elimination (DE) strategy. While most are familiar with hindsight-based RCA, we will explore the emergence of foresight approaches as well. We will also contrast these perspectives in an effort to truly understand WHY we even do RCA, and is it worthwhile?

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by JD Solomon Leave a Comment

Synergy: Why Group Effects Matter Most When Facing Complexity and Uncertainty

Synergy: Why Group Effects Matter Most When Facing Complexity and Uncertainty

The utility had an excellent opportunity to implement a green initiative. Energy could be created from excess digester gas at the wastewater treatment plant. There seemed to be a full range of feasible options after an engineering analysis.

“We can convert the gas and use it to either heat the building or reuse it to make the wastewater treatment process more efficient,” explained the chief engineer. “it is a 10- to 15-year payback, but the regulators love it so it is easy to get approved. It will buy us some goodwill too.”

“Can we reduce the payback if we sell the energy to the electric grid?” asked the chief financial officer.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by Robert (Bob) J. Latino Leave a Comment

How Much Money is Wasted on ‘Root Cause Analysis (RCA)’ and Why?

How Much Money is Wasted on ‘Root Cause Analysis (RCA)’ and Why?

Properly conducted RCAs are time and resource consuming, so when we are not getting the expected ROI’s from our efforts, we have to consider why are we wasting so much money doing the same thing over and over again? This article will focus on the commercial and process aspects of RCA, that can take away from their effectiveness on the corporate bottom-line and impact the safety of our co-workers.

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by JD Solomon Leave a Comment

How Do You Want Your Presentation to Be Remembered?

How Do You Want Your Presentation to Be Remembered?

It is easy to get caught in this trap. After months of working on an issue, you are asked to provide an informational update to a group of senior decision makers. You understand that no decision will come from your presentation. And there is not much on the agenda, so you are free to make as much as 30 minutes to provide your update.


Your presentation can be a little less formal and use the entire time, right? Wrong.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by Robert (Bob) J. Latino Leave a Comment

Root Cause vs Shallow Cause Analysis: What’s the Difference?

Root Cause vs Shallow Cause Analysis: What’s the Difference?

Does procedural and/or regulatory compliance with RCA guidelines ensure Operational Reliability? Does it ensure improved Safety? Operational Reliability involves the aggregation of Equipment, Process and Human Reliability methods and techniques.

What is the difference between troubleshooting, problem solving and ‘RCA’? Are the outcomes different when we use The 5-Whys, The Fishbone or a Logic Tree/Causal Factor Type Tree? 

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by JD Solomon Leave a Comment

Why Three Ethics Matter When the Outcomes Are Complex and Uncertain

Why Three Ethics Matter When the Outcomes Are Complex and Uncertain

The Board of Adjustment was having a hard time making a decision. The property owner’s new woodworking shop extends six feet into the required side-lot setback. Even worse, it blocks the scenic view of the neighbor, who paid a premium for the lot.


“So, whose fault is it that the building was built in the wrong place,” asked the board chairman. “Clearly, it was shown on the approved drawing in the right place.”


“I am still trying to figure it out, “replied the property owner.” I hired the best surveyor in town and one of the best contractors. I know it will cost me over $30,000 to move it over six feet. I paid a premium to make it look good like my house, and I am afraid it will look worse after the move. And I don’t have the $30,000 to move it.”


In rebuttal, the neighbor explained, “right is right.” The building location violated the town’s planning and zoning codes. The correct location had been formally approved by town staff, and there was no relief they could provide because this was clearly wrong. Leaving the building in the wrong place would devalue his property much more than $30,000. If the Board of Adjustment did not uphold the ordinance, he would be the victim of something he had no control over.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by JD Solomon Leave a Comment

Does Your Dog Have More Empathy Than You Do?

Does Your Dog Have More Empathy Than You Do?

The comment is a common one.


“It does not surprise me that they do not want to save $60,000,” quipped the second-in-command of the electrical department. “They are more concerned with being popular and helping their friends.”


“By ‘they,’ I assume you mean the Board and me as the interim Town Manager?” I asked.“Well, not really you, but them – yes,” came a frustrated response.


I decided to move to a more productive line of discussion.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by Robert (Bob) J. Latino Leave a Comment

Defect Elimination 101

Defect Elimination 101

In recent years, “Defect Elimination” has become a hot topic in the reliability world. But what exactly does defect elimination mean? How does it differ from other maintenance practices? Is it more than just a new way to describe planned and predictive maintenance? This article will seek to answer these questions in a very practical manner.

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by Robert (Bob) J. Latino Leave a Comment

Top 5 Keys to a Proactive RCA Culture Shift…

Top 5 Keys to a Proactive RCA Culture Shift…

From a holistic RCA perspective…

“What are the top 5 keys to focus on when trying to change a Root Cause Analysis (RCA) culture from one of a reaction to proaction?”

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by JD Solomon Leave a Comment

Communicating with FINESSE: How to Avoid Putting a Stench in Someone’s Ear

Communicating with FINESSE: How to Avoid Putting a Stench in Someone’s Ear

“So, what did you think about the most recent five-year management assessment?” asked the Agency Director.

I knew it was a loaded question. If the executive team had agreed with the assessment, the chief operating officer would not have asked me to review it before the report was presented to the Board of Directors.

“I had some issues with the report,” I responded. “Out of the gate, they lost me and will probably lose your Board with that multi-colored, busy graph.”

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by JD Solomon Leave a Comment

Communicating with FINESSE: This Is How to Make Your Graphics More Powerful, Understandable

Communicating with FINESSE: This Is How to Make Your Graphics More Powerful, Understandable

“I have a question,” stated the Chief Financial Officer. “The second data point from the right end of the line the drastically different than the others. How do you know that the line should be straight? Should not the cost line be curved between the last two data points?”


“Well, when we look at the correlation of the best-fit line with and without the point you reference, we obtain a nearly ideal fit when we treat the second point from the end as an anomaly,” stated the highly educated, high-brow consultant was discussing the agenda item before mine. His second sentence was equally long as he started launching into details about correlation and how the computer program cyphered through all of the data.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by Robert (Bob) J. Latino Leave a Comment

RCA Principal Analysts vs Subject Matter Experts: What’s the Difference?

RCA Principal Analysts vs Subject Matter Experts: What’s the Difference?

An undesirable event occurs (fancy term for unexpected failure) a Root Cause Analysis (RCA) is triggered. This usually means what occurred is a severe event as triggers are often set pretty high (i.e. – reportable injury/fatality, equipment damage in excess of x-thousands of dollars, production losses in excess of x-thousands of dollars, regulatory violation, etc.). Since there is urgency and visibility, how do I decide who will lead the investigation/RCA? Our natural tendency is to identify the technical ‘expert’ in the nature of whatever the undesirable event was. But does that typically produce the most effective outcome for the organization and its employees? This article will focus on which skills are needed most, under such conditions, and why

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by Robert (Bob) J. Latino Leave a Comment

‘Facebook’ Maintenance & Reliability: The Illusion of Performance

‘Facebook’ Maintenance & Reliability: The Illusion of Performance

I used to be on Facebook many years ago in an effort to keep up with old friends. However, I began to realize the forum was often used to create an illusion that someone wanted their community to have about them. I knew many of these people creating such illusions, that is how I know they were ‘illusions’. Their ‘Facebook Family’ simply was not their reality. 

This is not a paper about the pro’s and con’s of social media forums such as Facebook, but more about our propensity to create illusions, or prisms in which we want others to view our work initiatives. While I could apply this concept to many personal and business situations, I’m going to limit it to our general views of Reliability, Maintenance and to a degree Safety (as a by-product of effective Maintenance and Reliability). 

[Read more…]

Filed Under: Articles, on Systems Thinking, The RCA

by JD Solomon Leave a Comment

Communicating with FINESSE: Why is Framing So Important?

Communicating with FINESSE: Why is Framing So Important?

“I just got through with a telephone call,” stated a concerned voice on the other end of the line. “We addressed the wrong issue. I am not saying you. It was collectively all of us. They wanted to sell all parts of the business unit and completely get out of that aspect. We addressed them retaining ownership but having someone else operate it.”


“That is not right,” I replied. “We solved the problem they wanted us to solve, and they bought off on it. “We can develop some solutions for the other problem, but that will take some time and effort.”


“How do you know we solved the right problem?” my client asked. “They have gone over everyone’s head and say we didn’t.”

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

by JD Solomon Leave a Comment

These Three Acts Improve Your Ability to Lead Others with Better Facilitation, Communication

These Three Acts Improve Your Ability to Lead Others with Better Facilitation, Communication

Every written or verbal communication needs a structure. The three-act structure stands the test of time because it is a straightforward, efficient structure that works effectively with our human thinking processes. An example of the three-act structure is the series “Communicating with FINESSE” on Accendo Reliability.


There is still time to jump into the second act if you have not followed from the beginning.

[Read more…]

Filed Under: Articles, Communicating with FINESSE, on Systems Thinking

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