People: The fact that People data is extremely fragile often surprises would-be investigators. Due to this perception, valuable failure data is lost. The problem is that as time passes following an incident, the raw sensory data that was taken in by people who were at or around the failure scene starts to become distorted. People start to evaluate what they heard, saw, smelled or felt and draw conclusions based upon this input. If something they sensed doesn’t fit their mental models of what the scene should contain, they may discount it and only inform the failure investigators of their conclusions about what happened, as opposed to providing them with the raw data.
It is imperative that the people who were at the scene be debriefed prior to their leaving the facility. At the very least, they should fill out a generic failure data collection sheet documenting what they sensed at the time of failure and anything unusual that was being done at the time of the incident. Preferably, each person should spend 15-20 minutes being debriefed by a failure investigator. This provides the failure investigator with much more meaningful data because they gather it firsthand.
Priority 2: Parts
Parts: Following Position and People, Parts should be bagged and tagged, and taken to a secured staging area for analysis at some future point. Here we have to ensure that parts critical to the investigation do not grow legs and run away, or they are thrown in the trash because of production pressure to hurry and get back online. ‘Positional’ data was to quickly note where the parts were located on a failure scene map. That is very time sensitive as people want to clean the scene up quickly for production. But we have to be sensitive to where the parts go, once their location is noted on the failure scene map.
Priority 3: Paper
Paper: Paper data (which includes electronic data which might be manipulated/altered or disappear) such as shift logs, sensitive DCS data, should be gathered and stored for later review. Such information is usually static, so we have some time to get it after the time-sensitive data described above is properly collected and preserved.
Priority 4: Paradigms
Paradigms: Finally, Paradigm data is the least fragile of the 5 P’s. The fact of the matter is that they are deeply ingrained within the organization and revealed as people are interviewed. RCA investigators should always be on the lookout for restraining paradigms that may have contributed to the failure. These restraining paradigms are considered latent root causes. We wish that paradigms would change faster than they do, but we will have plenty of time to capture people’s paradigms (their perceptions of their world).
Doing a good job of “PRESERVING FAILURE DATA” is a key step in conducting an effective RCA. Unfortunately, it is also the step that is usually second in priority to getting the process or the piece of equipment back online as quickly as possible.