As a term, ‘RCA” is useless!! This is because there is no universally accepted definition, so however an organization is solving problems, they will call it ‘RCA’.
At RCI, we define RCA as:
“The establishing of logically complete, evidence-based, tightly coupled chains of factors from the least acceptable consequences to the deepest significant underlying causes.”
It’s not a ‘simple’ definition, but it is a thorough and comprehensive definition. Stay tuned as we’ll dig deeper into what it all means in the future.
Reliability professionals could do RCAs on a napkin, using kraft paper and post it notes, or utilizing fancy software. In the end, the analysis is only as good as the analyst! I have seen some pretty bad ‘RCA’s documented in some really fancy software that had real potential. However, the analyst was not able to unleash that potential simply because they didn’t know how to properly conduct a Root Cause Analysis…they unknowingly were specializing in Shallow Cause Analysis.
That doesn’t make them bad people. They are often the victims of poor organizational systems at their facility. A while back I outlined how such poor systems impact the effectiveness of an RCA effort
If you get a chance, look at his video and let me know if those points hit home for you.
I want to briefly expand on three (3) of them, but in a positive light, showing how you can dramatically improve our RCA bottom-line results by simply focusing on the following:
Table of Contents
1. Set Leadership Expectations.
If site leadership is serious about their RCA system, they will set expectations accordingly.
Ensure the RCA methodology matters. Don’t treat RCA like a commodity where one size fits all. Here are some criteria to consider, the methodology should:
- Be comprehensive and flexible
- Require valid evidence to support hypotheses (not hearsay)
- Be simple, practical and efficient when applied in the field
- Measure its effectiveness using bottom-line results
Ensure that those analysts are qualified to do effective RCA
- Seek out volunteers for being RCA instructors and students. Experience shows that people that WANT to do RCA, are far more successful than those that HAVE to do it.
Ensure that those trained are able to actually implement what they learned in a timely fashion. Set expectations such as:
- When leadership wants to see results (i.e. – X weeks from conclusion of training).
- Make sure students ‘use it, or they will lose it’ ASAP
- What specific results are they looking for (i.e.- > production, < maintenance, < injuries, etc.)
D. Management Support
Ensure your analysts in the field have the environment to succeed. Management support includes:
- Properly communicate performance criteria to those in the field
- Provide analysts proper time to do RCA’s, instead of just adding the task of RCA to already full plates
- Ensure that planners & schedulers set aside a % of proactive resources for addressing the RCA recommendations.
- RCA recommendations tend to be viewed as not urgent.
- In a reactive work order system, without management support, RCA recommendations will never get done and the effort will die on the vine
- Assign a qualified RCA Champion to support the analysts in the field
- Provide analysts in the field access to engineering resources such as metallurgist to read fractured surfaces
2. Analyze Chronic Failures.
Most of the time that RCA’s are conducted, are for serious and costly events. Such RCA’s have hit a pre-defined trigger (i.e. – $, lost units of production, safety incident, etc.).
By then, it’s too late and it’s a reaction to a bad outcome.
A. Identify Proactive RCA Opportunities
It is often very hard to make a business case for conducting an RCA on a serious event. This is because they may happen once every 5 or 10 years. So we would have to wait 5 or 10 years to see if it happens again. Most of us won’t be in our current positions in 5 or 10 years. However, chronic failures are different.
Try finding RCA candidates by doing the following:
- Pick a unit or process that is the one of the worst performers
- Do a query in your CMMS or APM system using the following calculation:
- Recorded ‘failure events’ over the past year (whatever trigger is defined)
- Identify the ‘Frequency of occurrence/Yr x Impact/Occurrence (Labor $ + Material $ + Lost Production) = Total Annual Loss (See Hidden Treasures for more details)
- Take a Pareto Cut (80/20) of the listing and identify the 20% or less of the failure modes costing the organization 80% or greater of the losses.
- These are qualified, proactive candidates for RCA because they are hidden in the system and trapped in the paradigm of ‘a cost of doing business
- Chronic failures are much easier to make a business case for because they have historical trends to fall back on. We are paying for them every year…they even get a cost of living increase.
- By doing an RCA on these types of failures and making them go away, we can return monies already in the budget to address them…right NOW.
- You don’t have to wait 5 or 10 years to make a business case.
3. Learn How to Evaluate an RCA.
Leadership, or whoever listens to the final presentations of the RCA analysts, needs to learn how to properly evaluate and assess the quality of an RCA. Once they possess this skill, they need to reject RCA’s on the basis of poor quality, in order to raise the standards for an acceptable RCA. When an analyst’s RCA has been rejected on a constructive basis, the next time they return, they will come with a much better analysis.
Here are some things that leaders should look for in an effective RCA:
- Is there adequate evidence to support hypotheses?
- Was the RCA team cross-functional?
- Did the analysis start with facts (not assumptions)?
- Did the analysis explore all possibilities (by asking How Can, not just Why), or just what was obvious?
- Did the analysis identify physical, human and latent (organizational) root causes?
- Were team members assigned tasks to validate hypotheses in the RCA?
- Has the team provided ‘metrics to track’ to ensure the company gets the expected ROI for investing in the recommendation?
- Are the support systems in place to be able to track such ROIs?
These 3 RCA suggestions will most definitely improve current RCAs based on demonstrable facts, and not just assumptions.
The proposed pathway is very logical, just like RCA should be:
- Set realistic expectations & provide support systems
- Analyze the right things (high ROI, short-term turnarounds)
- Measure effectiveness based on results and not simply doing tasks
I look forward to hearing of your RCA successes in the field. If you find you are still hitting hurdles, do an RCA on why your own RCA effort is not meeting expectations!
About the Author
Robert (Bob) J. Latino is former CEO of Reliability Center, Inc. a company that helps teams and companies do RCAs with excellence. Bob has been facilitating RCA and FMEA analyses with his clientele around the world for over 35 years and has taught over 10,000 students in the PROACT® methodology.
Bob is co-author of numerous articles and has led seminars and workshops on FMEA, Opportunity Analysis and RCA, as well as co-designer of the award winning PROACT® Investigation Management Software solution. He has authored or co-authored six (6) books related to RCA and Reliability in both manufacturing and in healthcare and is a frequent speaker on the topic at domestic and international trade conferences.
Bob has applied the PROACT® methodology to a diverse set of problems and industries, including a published paper in the field of Counter Terrorism entitled, “The Application of PROACT® RCA to Terrorism/Counter Terrorism Related Events.”
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