An RCA myth shared by many managers is that RCA methods are all the same, when in fact they are NOT. The range of what constitutes an effective RCA method is vast. Here's how the PROACT Approach is different:
An RCA myth shared by many managers is that RCA methods are all the same, when in fact they are NOT. The range of what constitutes an effective RCA method is vast. Some RCA techniques have minimal emphasis on establishing all the ways a problem can occur. Others provide a more comprehensive set of reasons a problem occurred. Verification of each possibility can also range from someone saying it happened (weak verification) to re-construction and testing of each possibility (strong verification).
RCA methods can be shallow, or they can be robust, it depends on what the management wants to accomplish. Here are some analytical methodologies that are often grouped into the category of RCA:
When something ‘fails’ in our workplaces, do faces come to mind of the people that we immediately turn to, to make everything alright? These are our ‘heroes’ who get us back to normalcy quickly, and they get a fair amount of recognition for doing so. However, these individuals are being provided positive recognition for being great responders. They are rarely doing any analytics to understand root causes, but they are great at implementing temporary solutions. A progressive management team, under these conditions, would be asking, “Why is this person getting so much practice at responding?” That's where the meat is. This approach is normally attractive because it is quick, inexpensive (in the short-term) and demonstrates immediate action.
We can all relate to this analytical technique. When something bad happens, we tend to put very smart people in a room who listen to a summary of what we know happened (the bad outcome). Oftentimes this description embeds hearsay as fact, and the group is accepting of this hearsay, as they move on to solutions. So many bright people throw out disconnected ideas as to what they think happened, and then they move on to corrective actions. Usually this approach focuses on speed to demonstrate activity, and as a result, is weak on evidence and deep analysis down to true root causes. Chances are this team will be meeting again because the failure will recur. This approach takes a little longer because we are not dealing with an individual, we are dealing with several individuals so this requires more give-and-take in discussions.
This approach is very common and it is essentially brainstorming plus a structured analytical tool like 5-whys or a fishbone diagram. The ‘tool’ provides a degree of discipline as it has a series of steps and a structure to follow. This is certainly more progressive than troubleshooting and brainstorming. This approach, when applied properly, could be effective. However, in my 35+ years of this business, I find this approach is rarely applied properly. People are usually time constrained to hurry up, and therefore the time to collect evidence is expensed. So we run with hearsay and assumption, treating them as facts. We develop and implement recommendations accordingly. Dick Swanson (Owner, Performance Management Initiatives, Inc.) says, “The irony of this association is rooted in the fact that the 5-Why approach was developed by Toyota as a tool for assembly floor supervisors to keep production moving, and not as a tool to identify deep, underlying causes of complex events”.
I will add another potential form of RCA, used by many, which is ‘trial and error’. I do not list it with the others because I really don’t consider it an analytical process. This approach just supports the paradigm of ‘if it ain’t broke, don’t fix it!’ This is more akin to applying a crisis maintenance strategy. There really is no analytics going on, we just fix things when they break.
Our approach is different, and we call it PROACT®.
PROACT® is a robust Root Cause Analysis (RCA) process that can drive incredible business results for your company. Since its inception in the mid-80’s, the PROACT® approach has helped hundreds of companies do tens of thousands of successful RCAs, resulting in large financial returns for the business.
The PROACT® approach helps to identify and conduct RCAs on those events that are 'hidden in plain site.' These failures happen every day, on every shift; yet their individual occurrences do not meet the threshold to trigger a formal RCA process. These failures are hidden in plain sight and often viewed as 'a cost of doing business'. These ‘chronic failures’ are the underserved of the organization and they are truly what is eating the corporation’s lunch (bottom-line). On an annual basis, they are an organization’s most costly failures!
The PROACT® acronym stands for the following basic, investigative process steps:
Just like any of your favorite detective/investigative shows on TV, STEP #1 is to preserve the scene and to collect evidence in a very disciplined manner. In the PROACT® methodology we collect evidence based on the 5-P’s, which are data categories. They are Parts, Position, People, Paper and Paradigms. These categories make it easier to remember the types of data/evidence we have to collect.
This step is about organizing an ideal team to analyze a specific failure. This deals with roles and responsibilities of team members and more importantly, minimizing the potential of any bias between the team and the nature of the Event.
At this point in the investigative process we should have ample data/evidence to start with and a team who has nothing to lose or gain by the outcome of the analysis (unbiased). Now comes the critical step of Event reconstruction. PROACT® utilizes a logic tree to graphically express the event reconstruction. Proper application of a logic tree will utilize both deductive and inductive reasoning, evidence-based validation of hypotheses and identification of Physical, Human and Latent Root Causes. Proper use of a logic tree will combine the physical sciences (physics of Event) and the social sciences (the systems and human contributions to the Event).
Theoretically at this point we have done a lot of work to identify our actionable root causes. This is about 50% of the effort to complete an effective RCA. It is at this point that we must develop and implement effective solutions to counter our identified root causes. Determining accurate and comprehensive root causes is useless, if we do not act to prevent their recurrence.
Finally, just because we developed recommendations does not mean 1) that we implemented them and 2) that they worked. An effective RCA system will close the loop by demonstrating a benefit on the bottom-line. Each recommendation should have a performance metric tied to it, demonstrating proof that something got better. As often as possible, RCA’s effectiveness should be tied to ROI and corporate dashboards.
The PROACT® Approach is designed to help mitigate risk, optimize cost, increase performance, and contribute to exceeding Reliability goals. Whether we’re in a manufacturing setting, hospital, or school; the PROACT® process remains the same. It allows us to drill down to the root causes and implement the correct and needed changes.
PROACT® OnDemand is our easy to use, RCA Investigation Management System that allows analysts to conduct RCAs on any undesirable event or incident. Once we properly identify our root causes, we can make the appropriate corrective actions in the system, and communicate with our entire team.
Logic Trees are tools that help us recreate the event backwards in time, allowing us to understand the root causes of our undesirable outcomes. Our PROACT Software includes easy to use logic trees to help us think through events and drill down to the root causes behind them. Our logic trees allow analysts to fill in their Event and eventually uncover the Latent Roots of the event (or the underlying reasons for the improper decisions that were made that day).
Event = Undesirable Outcome
Mode = Factual Observation that Needs to be Explained.
Hypothesis = Educated Guesses
Physical Root = Physical, Observable Consequence of Decision
Human Root = Decision Error
Latent Root = Reasoning or Rationale for Decision
These are warehouses of cause-and-effect relationships aggregated from past analyses inside and outside the company, available OEM troubleshooting flow diagrams and other public domain resources. There are Industrial and Healthcare templates available that adapt to whichever RCA process the team is currently using (i.e. cause & effect, form-based, fishbone diagram, 5-whys, logic tree). Search templates for hypotheses that you might have missed and easily incorporate them into your current analysis. Such libraries consist of templates for Mechanical, Electrical, Quality, Safety, Human Error/Human Performance.
This allows our team to easily record all the costs associated with performing an RCA and compare numbers with the benefit realized as a result of our corrective actions to calculate our ROIs.
We developed the PROACT® ROI Calculator to enable those on the front lines to quickly make a business case for conducting an RCA on a chronic failure. This calculator can instantly produce a line item justification based on the simple calculator of FREQUENCY OF OCCURRENCE/YR x IMPACT/OCCURRENCE (Manpower $ + Material $ + Downtime $).
These emails are sent to team members upon assignment of task, and the appropriate management owner is copied on overdue alerts.
Customizable Company Branded Reports can be created at any time for printing or saving as a pdf for implementation and future use. Customizable reports can be made for reporting to team members or for the Board of Directors, as each is interested in different information.
Are we reporting our RCA ROI’s back to our leaderships to justify the existence of our RCA system? Our documented average ROI for our case study database is over 600%. Here are a few specific examples showing the financial impact the PROACT® approach can have on real businesses. These cases were published in our text entitled ‘Root Cause Analysis: Improving Performance for Bottom-Line Results' (https://www.amazon.com/Root-Cause-Analysis-Performance-Bottom-Line/dp/1138332453).
This means that in order for us to be able to publish these cases, the company legal department had to approve. For these reasons I would consider these numbers conservative! I also want to reiterate that these are NOT our successes, they are the successes of these teams and their corporations. In the end, ‘an analysis is only as good as the analyst’!!!
During a two year period, there were 19 failures on thick stock pumps on A and B units in the Bleach Room. Several attempts had been made to implement corrective actions for the pumps but ultimately failures were still occurring. Thick stock pumps are a big ticket item ranging from $60,000 to $120,000 per rebuild due to the tight clearances and amount of material it takes to machine the pumps. It was determined by maintenance that the pumps could be rebuilt in-house in the bleach room maintenance shop. This has been very successful and has cut the cost of maintenance dramatically and has proven to have had greater reliability. Performing the rebuild by internal millwrights has brought ownership and pride of the repairs and operations of the thick stock pumps. Although production loss was not used in the Opportunity Analysis (OA) for these failures, it would have been a significant factor in the loss equation for these events.
There are substantially less failures on these critical pumps and defects are caught before they cause catastrophic problems. In-house rebuild of pumps has resulted in greater ownership and pride on the performance of the pumps. Maintenance costs today are approximately $25,000 compared to roughly $500,000 during the previous two year time frame.
Eastman Chemical senior management realized their level of customer complaints had not shown significant reduction during the past few years. This was troubling, given that Eastman had a strong history of continual improvement performance in their processes. Furthermore, one of the key objectives of Eastman’s Customer Complaint Handling Process was to investigate and identify the cause of complaints – evidently the complaint investigations were not as effective as expected.
Recurrent failures of vacuum column bottom pumps. Both pumps came on-line at the same time. The Mean Time Between Failure (MTBF) was very poor at three (3) months. Failures of mechanical seals, thrust bearings, impellers and case wear rings were very common. Most of the failures occurred at start-up. The system operates with one pump as a primary pump and the other as a spare pump. Different attempts to correct the above problems failed. There was not a good understanding of the causes of these failures and most important how they correlated to each other. At times, both pumps would not be available. The impact on production and the excessive maintenance costs resulted in management appointing a Root Cause Analysis (RCA) team to find and implement final solutions to these problems.
About the Author
Robert (Bob) J. Latino is 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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