Think of errors as a chain of events or series of linked holes…
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Root cause failure analysis interprets the features of a system or a component to determine why it doesn’t perform as intended. This could be a part, machine, operating area or entire plant. Using detective skills and a team of involved people, the key is to understand the physical, human and latent root causes of the inability to meet those goals.
Two influential authorities in root cause failure analysis are Charles Latino, one of the pioneers of industrial reliability engineering movement, and Dr. James Reason, a recognized expert in the area of human re-liability.1 Different practitioners of root cause failure analysis in industry might use different terms, but the approaches are generally similar.
Untrained people rarely recognize there is always a chain of events with multiple contributors that leads to a failure or accident. There is a common tendency to solve the physical root of the problem and then wonder why the failure recurs. Errors can be thought of as the result of a chain of events or a series of linked holes. Latino created chains of errors that lead to a failure or accident. Reason uses the ex-ample of rotating slices of Swiss cheese—the pieces represent errors and when the holes line up, there is an incident.
The most important aspect of root cause failure analysis is that there can be no guess-work or opinions as to causes. Concrete facts have to support every decision that leads to the roots.
This article is based on a Webinar presented by STLE Education on April 4, 2018.
Neville W. Sachs, P.E., is a partially retired professional engineer. He graduated from Stevens Institute of Technology in Hoboken, N.J., with majors in mechanical and chemical engineering. Sachs was on the ground floor of the industrial Reliability Engineering effort. He formed SS&A in 1986 with a partner where he worked extensively with the Reliability Center, Inc. He is an active member of ASME, NSPE, NACE and STLE and holds the STLE CLS certification.