The RCA

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

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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). 

WE LOVE OUR POST-ITS!

When I’m asked who our primary competitors are, I quickly and simply reply ‘Post-Its’ (full-disclosure, ‘Post-Its’ are a registered trademark of the 3M corporation)!

It’s hard to imagine anyone who hasn’t been in a conference room at some point in their career, utilizing colorful, adhesive post-its to help express some form of a logical thought process. Whether it be for brainstorming, process mapping, Reliability Centered Maintenance (RCM) or some form of Root Cause Analysis (RCA), we have become avid fans of post-its to help us produce graphical expressions of our thoughts…WE LOVE POST-ITS!

Most of us have all worked at places with some degree of an ‘RCA’ effort. They likely all defined and practiced ‘RCA’ differently, but nonetheless they had something called RCA.

What made one facility better at it than another? Why was one facility’s RCA more effective than another?

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 the three aspects of RCA we believe leadership teams need to understand the most. [Read more…]

Safety is often directly correlated with system or component reliability. Is that really the case?

Find out what the experts and their data really says.

During a recent webinar I presented with SMRP, entitled “Root Cause Analysis: It’s a Money Maker, Not a Money Taker”, I was fortunate to have many deep thinkers in my virtual audience. 

They floated some questions related to conducting ‘RCA’s on non-mechanical situations. To my fellow veterans in this RCA space, this is a relatively easy question to properly address, but it did get me to thinking. I think those of us who do this for a living, take for granted that we know a properly facilitated RCA, can apply to any undesirable outcome, no matter the industry or the bad outcome.

When we look at the widely used and misunderstood tool of Root Cause Analysis (RCA), we should reflect its interpretation in our own environments. Think about it: when is RCA typically requested and applied in our environment? Based on my experience, it is typically requested and applied when:

• Someone is injured
• There is a catastrophic damage
• There is an environmental incident
• There is a “near miss” with high severity potential
• There is public scrutiny over an issue that makes the news
• There is a quality issue that a valued customer is complaining about

Author: Mark Latino

RCA and How to Understand the Basics of Component Failure 

When performing a PROACT® Root Cause Analysis (RCA) there is a data collection step called ‘Preserve’ (or the PR in the PROACT acronym) which requires the team to collect failed parts, conduct interviews, obtain paper data and positional information after an undesirable event occurs.

So what does it mean to be ‘safe’? Is a company ‘safe’ because they have not had an OSHA recordable injury in say over a one year period? Does that mean they will continue to be ‘safe’ in the next year? Does it mean they are at a higher risk of an incident in the near term, because they weren’t safe…but lucky? These are the debates I read about online and as an outsider, I can see both sides. But there has to be a practical middle ground as Safety and Reliability depend on each other for their individual successes, they are interdependent.

Author: Mark Latino

Oftentimes, Production may not know the value of using Reliability tools such as Opportunity Analysis (OA) and Root Cause Analysis (RCA) to gain more consistent predictable production runs.

Most production leadership has never spent time in Maintenance and/or Reliability roles; therefore, they see a different big picture. The pieces of the big picture are interconnected like a puzzle and most production people see the puzzle assembled one way, while the Maintenance and Reliability people see the puzzle assembled another way.

In my travels over the past 35+ years talking to RCA analysts around the world, as well as those outsiders who look into our ‘RCA’ bubble, I find many misconceptions about RCA. This happens in every space, just think about RCM, RBM, APM, CBM and the like; everyone experiences how other people view their craft.

The following article was published in Plant Services earlier this year with the title, “Don’t get stuck in reactive mode – The world of fantasy maintenance is calling you”. The alias of the author is Captain Unreliability, so all credit should go to the Captain:-).

To the veterans in the field, you will connect with this article in a heartbeat. You will be laughing all along the way. In the end, I will add a commentary about while this may appear comical, it sadly is reality in many places that we all work (or have worked). But I’ll leave that up to you, to be the judge. In the end, please relate your own experiences and let me know if this is B.S. in your world or not!

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A Little History About How I Came Across Learning Teams.

A little over three years ago I was asked to speak at a conference that was entitled, Human Performance, Root Cause and Trending or HPRCT (great conference BTW and I encourage you to attend). This was a different world for me as I typically attended and spoke at Reliability and Maintenance trade conferences, but I was interested to see what it was all about (plus a good friend of mine was the one who invited me).

Put another way, Can RCA be successful without the incorporation of system’s thinking? What prompted this question was that according to Drs. Leveson and Dekker in their 2014 paper Get To The Root of Accidents, systems thinking is not currently utilized in the application of RCA.

In this paper they cite:

 “An often-claimed ‘fact’ is that operators or maintenance workers cause 70–90% of accidents. It is certainly true that operators are blamed for 70–90%”.