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Author: Jack Jager

While there are three main reasons organizations typically perform Root Cause Analysis (RCA) following an issue with their asset or equipment, there are a whole host of other indicators that RCA should be performed. 

Odds are, you’re recording a lot of valuable information about the performance of your equipment - information that could reveal opportunities to perform root cause analysis, find causes, and implement solutions that will solve recurring problems and improve operations. But are you using your recorded information to this extent?

First, let’s quickly talk about three reasons why root cause analysis is typically performed. 

1. Because you have to

There may be a regulatory requirement to demonstrate that you are doing something about a problem that’s occurred.                                    

2. You have breached a trigger point

Your own company has identified the triggers for significant incidents that warrant root cause analysis. 

3. Because you want to

An opportunity has presented itself to make changes for the better. Or perhaps you’ve decided you simply don’t want to lose so much money all the time.

At the core of all industry is the desire to make money. Anything that negatively impacts this goal is usually attacked by performing root cause analysis.

I was having a conversation with a reliability engineer at an oil and gas site, and I asked him what lost opportunity or downtime might cost that company over the course of a year. He said it was in the vicinity of three quarters of a billion dollars. $750,000,000. Is this a good enough reason to perform root cause analysis? Even a 10% change would have a huge impact on bottom line figures.

The monetary impact to the business was of course not due to any single event, but to a multitude of events both large and small.

Each event presents itself as an opportunity to learn and to make any changes necessary to prevent its reoccurrence. Once can be written off as happenstance… things happen, serious or minor, and that’s life. But to let it happen continuously means that something is seriously wrong.

While these are all valid reasons to perform root cause analysis, there are at least ten more tell-tale equipment-related clues that an RCA needs to happen – most of which can be identified through the information you’re probably already recording.

Here are ten tell-tale signs that your organization needs to perform Root Cause Analysis:

1. Increased downtime to plant, equipment or process.
2. Increase in recurring failures.
3. Increase in overtime due to unplanned failures.
4. Increase in the number of trigger events.
5. Less availability of equipment.
6. High level of reactive maintenance.
7. Lack of time… simply can’t do everything that needs doing.
8. Increase in the number of serious events… nearing the top of the pyramid.
9. Longer planned “shut” durations.
10. More frequent “shut” requirement.

These indicators imply that we need to be doing more in the realm of root cause analysis before these issues snowball.

If you can identify with some of these pain points, download our eBook “11 Problems With Your RCA Process and How to Fix Them” in which we provide best practice advice on using RCA to help eliminate some of these problems.

Author: Kevin Stewart

Audit is defined in the Merriam-Webster dictionary as:  “a methodical examination and review.” When we talk about auditing your Root Cause Analysis (RCA) investigations, we mean just that -- a methodical examination and review. This is easier said than done, especially without some sort of standard to gauge against. If we establish a standard by which we gauge the quality of an RCA, the audit then becomes a simple matter of checking the RCA against the accepted standard and then determining how well it meets that standard. This post is all about helping you establish a standard, and we’ll even give you a free score sheet template to get you started.

Could you have the worst-looking RCA in the world and meet none of the criteria, but have an effective solution that: 

• prevents reoccurrence,
• meets our goals and objectives,
• is within our control, and
• doesn’t cause other problems?

Sure, and it is hard to argue with success. I doubt anyone would say: “Even though this solution will prevent the problem from recurring, it comes from an RCA that doesn’t meet our stringent, high-quality metrics so we can’t use it.” This scenario is entirely possible, though the odds of it are unlikely. If we have a set of measures to check an RCA against to ensure it meets some quality standards, the probability of an effective solution coming from that RCA is greatly increased. 

So what characteristics of an RCA are important?

Here are some questions to consider: 

(If you need a refresher on some of these points, I’ve included the relevant page numbers from the eBook “RealityCharting™: Seven Steps to Effective Problem-Solving and Strategies for Personal Success” by Dean L. Gano.)

• Do the causes pass the noun-verb test? (page 83)

• Do the causes have a lot of unnecessary words or descriptors?
• Do the causal elements pass all logic tests? (page 108)
  • Space-Time Logic Check 
    • Do the causes of this effect exist at the same time? 
    • Do the causes of this effect exist in the same place?
  • Causal Logic Check
    • If you remove this cause, will the effect still exist?
      If the answer to this question is no, then the cause is necessary for the causal relationship and should stay on the chart. If the answer is yes, it should be removed or repositioned.
• Are there any rule violations? If so, what are they and do they pass the minimum standards? Rules to be included are:
  • Are any of the cause boxes empty?
  • Are there any unconnected causes floating around in the chart?
  • Has each cause been identified as an action or condition?
  • Does each effect meet the 2nd principle (causes exist in an infinite continuum – there is an action and a condition for each effect)?
  • Have all conjunctions been eliminated? Remember that “and” is often interpreted to mean “caused,” which can leave too much room for misunderstanding and error. (pages 67-68)
  • Does each cause have the appropriate supporting evidence to justify its inclusion in the chart?
  • Does each branch have some type of stop identified for it? Below are the five potential stops: (pages 88-89)
    • Question Mark – more information needed; an Action Item is created.
    • Desired Condition – there is no need to keep asking why.
    • Lack of Control – something over which you or your organization have no control, for example “laws of physics.”
    • New Primary Effect – a separate analysis is required.
    • Other Cause Paths More Productive – continuing down this path would be a waste of time.
• Does the solution matrix fall into a typical mix such as:

• Have the solutions been judged against a standardized set of criteria with standard ranges to minimize the possibility of favorite solutions being chosen? (page 118-120)
• Has each solution been assigned to a team member and given a due date?
• Does the chart meet all of the four principles of causation? (page 36)
  • Causes and effects are the same thing.
  • Causes exist in an infinite continuum.
  • Each effect has at least two causes in the form of actions and conditions.
  • An effect exists only if its causes exist in the same space and time frame.
• Does the problem definition establish a clear dollar value significance that will let management make informed choices and approvals?
  • If a dollar value is not appropriate (safety near miss or potential fatality) does the problem definition establish a significant value?
• Have all of the action items been resolved? (Action items can include areas where more information is needed, there are evidence issues, or any manually entered items need to be resolved and deleted.)

The next step in developing an audit is to generate a checklist that your RCA will be gauged against.

This list can come from the items above, your own list, or a combination of the two. Once you have a list of items to audit against, you need to generate a ratings scale. This can be a pass/fail situation or a scale that gives a rating from 0 to 5 for each item. This can allow you to give partial credit for some items that may not quite meet the full standard.

Develop a score sheet with each item listed and a place to put a score for each one. Don’t forget to leave a space for notes from the reviewer to explain the reasons for partial credit. It’s handy to add some guidelines with each item to give the reviewer a gauge to score the item against. A sample of such guidelines might look like:

0 = Does not exist
1 = Some are in place but not correct
2 = Many are in place and some are correct
3 = All are in place but only some are correct
4 = All are in place and most are correct
5 = All are in place and correct

With guidelines like these easily available as a reference on your score sheet, it helps ensure consistency in the scoring, especially if multiple people will be scoring an RCA.

Now all you have to do is review an RCA against your list, score it, and have some sort of minimum for passing.

This will ensure that each RCA is measured against a consistent standard that can be repeated by multiple people, though there will always be differences if multiple people are auditing RCAs. Differences can be minimized by either having only one person doing the audit or calibrating the audit, or by bringing all personnel together and scoring several as group so that all auditors understand the scoring nuances.

While I’ve provided a pretty thorough list of what to check for when auditing an RCA, my experience is that an RCA can meet all of the requirements above and still have some issues. The biggest one is that the logic may be correct but the causes may not, so the RCA can pass the tests but it won’t actually fix the issue. The fact is, humans are involved and we make mistakes. Sometimes the errors can be caused by inexperienced investigators that need more practice. Other reasons for error are some of the filters that we talk about, such as time constraints, preconceived notions or biases, language issues, etc. This means that there is still a component that needs to be reviewed by someone for general integrity and for things that a computer just can’t look for. This person can be an external corporate person, a contractor, or an internal resource.

RealityCharting™ has tools that are available to the reviewer to assist them in critiquing the analysis such as rules check, action item report, causal element view, and most importantly there is a dashboard.

FREE Instant Download

To assist you in creating your RCA score sheet, we’re offering a free template.

Author: Kevin Stewart

Oftentimes our differences can be a source of conflict and confusion, but in this article I’d like to explore how they can be harnessed to solve problems rather than create them.

“Everything will be fine if you’ll just do it my way.” At some point we have all probably said or thought something like this. Or maybe you’ve heard it from someone else (quite possibly your significant other). What is the underlying feeling or issue here? What we’re really saying is: “If everyone was just like me and thought the way I did, everything would be fine.” Of course, this is impossible. Neuroscience research tells us that no two brains are exactly alike, and to quote an article from Scientific American on this topic, “…if the apparatus that senses the world differs between two individuals, then the conscious experience of the brains wired to these sensors cannot be the same either.”[1] 

Good problem solvers need to be aware of this so they don’t fall into the trap of assuming that everyone knows what everyone else knows, or that everyone interprets information in the same way. I was channel surfing one day and spotted an interesting show about conjoined twins who share one body and most organs, but have completely separate heads (and therefore brains). When the interviewer posed a question, each twin responded in turn with different answers. This caused an ensuing disagreement between them.

These two people had as identical an upbringing and exposure to life and environmental factors as is humanly possible and yet they still thought differently.  If that doesn’t convince you that it’s impossible for two different brains to share the same perspective, I’m not sure what will!

Here’s an example of how two people can be having a conversation about the same thing and yet not be talking about the same thing at all. During a common exercise in one of my classes, a rousing discussion started about cleaning fish. Everyone except one bright student seemed to be on the same page. Everyone else got the feeling that this person was just being difficult, but something inside reminded me to get more information. After a few probing questions we discovered that we did not have the same perspective on the issue. This person had never been fishing and did not understand that “cleaning fish” implied gutting and preparing it for consumption. She couldn’t understand the exercise because her perspective of cleaning was to wash and in general clean the outside, so what did a knife have to do with it!

One more personal observation to cement this issue is a discussion I had with colleagues about the “Hierarchy of Controls” (pictured below for reference). 

One colleague stated that another must understand this concept since he has an engineering background, and all engineers would know this. I had to inform them that I also have a 30-year background in engineering, maintenance, and reliability but actually had never been exposed to the term either. So once again, the impossible situation of everyone’s perspective being identical rears its head.

While doing your root cause analysis, keep the perspective issue in mind. Ensure that you formulate the problem definition so that each perspective has a chance to be heard, and that the problem is a reflection of all of the perspectives of the team. While doing the root cause analysis, some may not speak up in the meeting but will have a different perspective, so as a facilitator it is your job to draw it out and ensure it gets voiced.

In my experience it can have a significant impact on a team’s understanding of a particular cause. Though sometimes we might wish everyone saw things exactly as we do, allowing for others’ alternate realities is actually key to building a more complete picture of your problem, thereby allowing you to find the best solution.

[1] http://www.scientificamerican.com/article/think-different-jan-11/

The lion and gazelle have to be at the top of their game each and every day. If they get lazy, they lose.

The Apollo Root Cause Analysis methodology can help you maintain a competitive advantage, but only if you use it completely and consistently.

How are you ensuring that you maintain and improve your lead?

Can you measure what you have achieved since your Apollo Root Cause Analysis methodology training, or has it become just another initiative that didn’t work?

You spent the time and effort learning a proven methodology that solves event-based problems every time, and perhaps it has become a company standard tool. But the creation of the reality chart and incident report are only steps on the journey. We also need to focus on creating an effective problem-solving culture (for alumni: page 109 in your manual). The culture part of the equation can be easy to overlook, but it is this holistic approach that will help you get the most out of the Apollo Root Cause Analysis^TM method.

If we do nothing after the initial implementation of the Apollo Root Cause Analysis methodology, entropy kicks in and the system begins to unravel. Any shortfall from the potential gain becomes considered “normal” and root cause analysis just gets accepted as another initiative that didn’t work.

With this in the back of our minds, we have to put supports in place to develop a solid platform on which incremental change can be applied to achieve ever greater gains.

To help enhance your company’s problem-solving culture and get maximum benefit from your Apollo Root Cause Analysis program:

1) Ensure your senior leadership team is fully aware of your efforts.

Try to get an influential sponsor to regularly mention root cause analysis in group communications. Remember that everyone’s reality is different, so time and energy spent with this team creating that common reality is going to pay dividends.

2) Implement Leader Standard Work.

(See chart below for an example) This ensures the ball is kept rolling from leadership down the chain. Developing formal, measured business processes can really help with this, along with good visual management tools.

*HOD = Head of Department

3) Increase awareness of the benefits and gains brought about by your successes.

4) Involve union and safety reps.

If this is done correctly, these folks can be your biggest evangelists. You can then use them as a resource. The “No Blame” approach of the Apollo Root Cause Analysis methodology should make it easier to sell.

5) Create a robust, visible, and measured action tracking system.

Unlike work orders that are in a CMMS, these actions have a tendency to fade away. Ideally you would create one place for all actions, making them easy to prioritize. 

Ultimately, you have to use it or lose it and these five tactics have the potential to help a great deal towards establishing a problem-solving culture and embedding it into an organization. 

Author: Kevin Stewart

At some point, most companies will want to see quantifiable metrics showing that their Root Cause Analysis (RCA) program has resulted in a positive return on investment (ROI).

ROI is relatively easy to calculate as a dollar value when it comes to tangibles such as equipment or production time. Things can seem trickier when trying to assign a dollar value to safety improvements resulting from an RCA program. Try to keep it simple.

This formula -

Cost of the Problem x Likely Recurrence / Cost of the Fix = ROI

is a straightforward way to begin quantifying the ROI of your RCA program, including its effects on safety.

Let’s look at how we might calculate these costs. 

Cost of the Fix

• Cost of an RCA investigation (you may need to include the initial training, though this should drop off as it is amoritized out over the program, as well as whatever time, resources, and people are required to conduct the investigation itself).

• Cost of whatever resources are needed to implement a solution. Don’t forget to include new equipment, parts, additional training, and anything else that is directly attributable to the implementation.

When you eliminate a problem, calculating what you have saved depends a lot on the problem itself and what its rate of reoccurrence is. For instance, if you figure out what was causing a particular machine to fail at a rate of once/year, you won’t see the benefits of your solution for another year. It can take several years and solving many different problems to see the total value of an RCA program. 

Improved safety isn’t as impossible to quantify as it might seem. While most companies don’t publicly discuss this type of equation because it can seem insensitive, chances are your company does calculate the monetary cost of an injury or death on the job. These figures may be a bit outdated, but the Mine Safety and Health Administration at the US Department of Labor offers an online calculator, which takes into account both direct costs (like workers’ comp claims) and indirect costs (like training a new worker and lower morale), as one example.

Cost of the Problem Reoccurring

Cost of the initial problem in equipment, production delays, man hours, workers’ comp claims, medical costs, absenteeism, turnover, training new employees, lower productivity, decreased morale, legal fees, increased insurance costs.

At first glance the equation doesn’t quite make sense for a safety “near miss.” If it missed then what did it cost? Is the answer nothing? So the ROI is:  0 x likely recurrence/cost of the fix = 0? The answer obviously must include the potential cost. The cost to the business if the issue was on target and hadn’t missed. It all becomes subjective then. How do you put a cost on maybes? 

It might help to look at the statistics of how an incident occurs. Take the cost to the business if a single major accident occurred (every business has this unspoken cost locked away somewhere) and then very simply do the math. One near miss will be worth 0.003 of that cost. Tally up your near misses and now go back to the formula.

As an example, say your data indicates you have 3000 near misses in two years, or 4.1 incidents per day. Then you put a program in place and now you have 3000 near misses in four years, or 2.1 incidents per day. This translates to 3000 fewer near misses in two years time. Per the above calculations, this would generate 3000 x 0.003 or nine fewer major incidents at whatever cost your company assigns to that type of incident. This becomes the savings for your ROI (or the Cost of the Problem in our equation) and can be attributed to the safety program of which the RCA process is a part.

This formula will assist in calculating an ROI on an individual RCA, which is necessary to show that the process is working and providing value so you can justify the program. However, since most safety programs track TRIR (Total Recordable Injury Rate) or something to that effect, you will also need to show that the RCA program affects this, too. This will be difficult because the safety program is in place and doing other things to prevent safety incidents before they happen. How do you attribute a reduction in near misses to preventive programs versus items put in place from an RCA?

You may never be able to separate these items. Even with detailed records, it is not always clear why people do what they do. The best thing you can do is to track when an RCA program was incorporated and then show the improvement in your safety metric, in TRIR, or near misses. 

You can use this information to justify the program with the argument that the RCA process is part of the overall safety program and it really doesn’t matter which gets the credit as long as we have continued to drive safety improvements. The RCA program should be a small part of the overall safety program costs since there are usually several full time safety people involved, committee meetings, safety initiatives, programs, etc.

It doesn’t matter how you slice and dice it, the return on investment for your RCA program boils down to: What will it cost me to fix the problem now? – versus – What is the cost if this problem happens again?