By Bob Latino, CEO, Reliability Center, Inc.
Abstract: If we have heard it once, we have heard it a million times – “let’s do an RCA on that failure”. The problem here is that phrase will mean something different to everyone who says it. What is an RCA? That is a question even the notable experts cannot agree on. With all of this RCA “chaos”, how do we make any progress?
What is RCA?
Think about whenever you hear the mention of the term Root Cause Analysis (RCA). What is an RCA? Is it a tool, or is it a process? Is all RCA the same? These are very legitimate questions and there are no consensus answers unfortunately.
As an RCA provider, we participate with our peers on various discussion forums. We discuss such questions and issues that cause frustration to the RCA end-users. I would like to say that we make more progress than we do, however I would not be telling the truth if I did so. RCA providers, like any other type of vendor, have their business interests to protect. Sometimes trying to obtain a consensus on those questions, may have an adverse impact on such business interests.
However, I believe I have a different view. RCA is a process, a public domain term. RCA is a term that is not able to be trademarked because of its generic use in the public domain (some have tried). When you hear about the various RCA proprietary methodologies in the marketplace such as our PROACT® or Apollo® or Kepner-Tregoe®, these are all merely different brands of RCA. Each one has their own merits and each go about solving a problem differently. All will also have successful users to say good things about their approach (or they would not be able to survive as a business). However, they are all equally considered ‘RCA’ from the perspective of the public.
Are There Common Elements to an Investigative Process?
I believe there are common elements to the basic investigative process. These common elements are required in order for such processes to be called RCA. Think about any investigative occupation, be it an NTSB investigator, a police detective or a doctor; their thought processes are essentially the same.
- Preserve, collect and analyze data/evidence associated with the event being analyzed
- Organize an unbiased team with diverse backgrounds to be able to help review the data
- Analyze the data with the team to try and reconstruct the cause-an-effect relationships leading up to what happened, and use evidence to support hypotheses
- Communicate the findings and recommendations to Leadership to obtain approvals for recommendations (or convictions in the detective’s case) and actually implement them
- Track or monitor specific metrics to measure the effectiveness of the effort on the bottom-line and correlate to KPI’s/Corporate Dashboards
Do these reflect more than what the term RCA usually connotes? Most likely. RCA to most would be the simple graphical expression of cause-and-effect relationships. This usually takes the form of a logic tree, fault tree, fish bone diagram, event and causal factor diagram and/or a comparative time line to name a few. Most do not consider the other items in my list to be the responsibility of the RCA analyst. In some cases, neither do I.
However, what we must realize is all the elements must be successfully completed if we are to see an improvement based on our work. Just because we complete a magnificent RCA and identify causes, does not mean the problem at hand goes away. We could make recommendations that will not work. We could make good recommendations that do not get approved. We could make recommendations that get approved and do not get implemented. You get the hang of it. I do not care if you call it RCA or not, as long as the work gets done and something measurable gets better.
What is an “RCA Method”?
RCA methodologies like the brands I mentioned earlier represent the various proprietary methodologies in the marketplace to conducting RCA. Remember, RCA is merely a defined process flow. It is a way of thinking through why things go wrong. It is applicable anywhere and under any circumstances. It does not matter if you are trying to figure out why Crude Unit catches fire in an oil refinery or why packages are delivered late to the customer.
Each RCA brand has their own method. These methods have various rules embedded in their approaches. These rules provide the discipline for following their RCA methodology in the hopes for achieving a successful outcome.
What are “RCA Tools”?
Many users associate the RCA tools as BEING the RCA method. That is typically not the case. The tools are merely vehicles to express the methodology. These tools, be it manual (paper-based) or electronic (software-based), embed the rules from the different methodologies.
Without proper training and experience in the method, the tools are usually a bunch of screens or forms. I often use the analogy that Microsoft Word has a ton of capability, but if you do not know proper English (or whatever language) and grammar, it does not help you much.
Many who look to RCA tools are looking for what I call “auto-RCA” solutions. In other words, the easy way out. They are looking for something to give them the answer so that they do not have to think it through themselves. Do such tools exist? Sure. Do such tools have all the answers? No. Do many users think these tools have all the answers? Yes. There lies the danger. Some people do “RCA by the numbers” by picking from a drop down list and then saying they have done an RCA. In actuality, they may have missed some key contributing factors, which should cause a safety concern, as the risk of recurrence is greater.
RCA tools without methodology training is a waste of money to me. An analysis is only as good as the analyst. A car is a transportation tool. If you do not know how to drive, should you be behind the wheel? Same with RCA, it is dangerous to have a person ‘behind the wheel’, who is not trained in how to uncover the truth about undesirable outcomes and then ensure something is done about making sure it does not happen again.
About Reliability Center (RCI)
RCI is an international leader in bringing Reliability Engineering principles to the field of solving problems, correcting failures and preventing future human errors in the workplace. RCI has been a leader in successfully applying these skills to the industrial, government and health care field fields for over 44 years. For more information, visit www.reliability.com
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."