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The previous article in our blog series described the recommended training strategy for your RCA program development. The next step in achieving a successful RCA program is to ensure leadership understands their role and has the tools in place to ensure the longevity of the program and its effectiveness.

To ensure the success of your root cause analysis program leadership must have a vested interest and take responsibility not only for developing and overseeing the functions of the RCA effort, but also monitoring the status of the individual analyses and associated solutions. This monitoring is typically done by the Steering Committee in conjunction with its other strategic responsibilities.  

The critical elements to track in relation to conducting the root cause analysis include

• Incident date
• RCA assignment date and lead
• Estimated RCA completion date
• Days past due
• Escalation activity
• Actual completion date

The critical elements to track in relation to the solutions that are to be implemented include

• RCA completion date
• Solution assignment date and lead
• Estimated solution completion date
• Days past due
• Escalation activity
• Actual completion date
• Frequency of incident recurrence
• Annual savings/HSE incident reduction

Once a root cause analysis has been completed, a list of potential solutions will be developed by the RCA team and submitted to the Steering Committee via the Program Champion or his/her designee for approval. The Steering Committee then assigns these solutions to individuals for completion and puts them into an action plan format with assigned due dates. These actions should be completed in the shortest time possible, otherwise the process will quickly fade away. The Steering Committee must track the status of open RCAs, the progress of implementing the solutions to ensure timely completion, and the effectiveness of previously implemented solutions (as measured by recurrences of the original incidents). New analyses should not be started if a large number of solutions remain to be implemented. 

An appropriate person needs to be assigned the responsibility of tracking progress and recurrence.  The right person for this responsibility may be different for different organizations. Progress is tracked by showing the number or percentage of completed solutions. Recurrence will be tracked by measuring repetition of the incident. 

Some organization will already have software and methods for tracking tasks, such as a CMMS. If this is the case, it can be considered for RCA and solution tracking as well. However, if a system does not currently exist or does not fulfill all the organization’s RCA tracking needs, then we would recommend considering RCPro^TM enterprise RCA software. It allows for the generation of an action list, due dates, and comments of each analysis to be shared with team members. It will also provide detailed reports on current investigation status, action tracking, outstanding Items, and view systemic issues across the organization. 

This is where the Steering Committee review and support really comes in to play. The leadership team should review RCA status and solution implementation and final results as a regular part of Steering Committee business. The Steering Committee’s main role is to ensure that RCAs are completed in a timely fashion and that resulting solutions are implemented and tracked for effectiveness.

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

RCA Program Development Training Strategy

And, Oversight and Management.

Stay tuned for our next installment on RCA Process Mapping. 

The previous article in our blog series on RCA Program Development described the responsibilities of the six roles required for your program to function well. The next step in achieving a successful RCA program is to develop a comprehensive RCA training strategy that will ensure sustainability of the effort to reduce the frequency and severity of undesirable incidents into the future.

A common mistake is to under-train, primarily RCA facilitators, in relation to the trigger diagram which we discussed in an earlier blog post.  You may recall that in developing the trigger diagram, a 3-year baseline of triggering events is reviewed to ensure an adequate balance of events and trained facilitators. Assuming the RCA facilitation responsibilities will be an addition to the existing position responsibilities, one would expect a facilitator would be leading a triggered RCA on average once per month with a series of less important ad hoc RCAs in between to stay current on skills.

There should be at least one Super User at each facility and at the corporate level. Likewise, all personnel that may be either a first responder to a triggered event or expected to participate in the RCA should be trained to an appropriate level as outlined in the table below (click photo to enlarge).

A “Refresher” course should also be undertaken as needed. An often overlooked element of a training program is the need to maintain optimum skill levels over time, especially if there are prolonged periods where the skill may not be practiced. This can often be the case with triggered events because of their random nature. This creates a danger that skills and knowledge may not improve at the same rate as other jobs skills. This is especially true for Facilitators, First Responders, and Participants. Records should be maintained that track the number of facilitated RCA, first responses, and RCA participations and reviewed at least annually. If Facilitators have gone six months, or Participants/First Responders one year, without using these skills then consideration should be given to the refresher training.

Training is an essential component for all personnel involved with an organizations’ RCA program. Having the right roles with the right skills and ensuring those skills stay fresh over time is important to the overall success of your RCA effort. ARMS Reliability leads world-class training to assist you in every stage of your RCA journey. Learn more about the required and recommended courses, and contact us for more information. 

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

And, RCA Program Development Training Strategy.

Stay tuned for our next installment on RCA Effort Oversight and Management. 

This is our sixth installment in our blog series on Root Cause Analysis Program Development. Earlier in the series we introduced the six necessary functions within an RCA program and then outlined a recommended team structure to fulfill those functions. In this article, we’ll provide a detailed description of the part each of the six roles plan within an effective RCA program.

Let’s dive right in.

It is the responsibility of the Steering Committee to develop and oversee the strategic functions of the RCA effort.  Steering Committee members should collectively have the authority to assign RCA roles and responsibilities, allocate resources to the effort, and most importantly, have a vested interest in the success of the program.  

Leadership teams of this nature usually already exist in almost all organizations and as such, can double as the Steering Committee by simply adding RCA program status review to regularly scheduled routine meetings as an agenda item. This avoids the creation of more bureaucracy and duplicate meetings.   Steering Committee responsibilities and functions are as follows.

Strategic Responsibilities:

• Define the scope and breadth of the RCA effort
• Assign RCA roles and responsibilities
• Review and approve RCA resource requirements for annual budgeting purposes
• Set and adjust program KPI’s (at least annually) to reflect improvements in the organization’s performance
• Set and review threshold criteria (at least annually) to ensure proper balance between trained RCA facilitators and formal RCA demand
• Sponsor a human change management plan where needed to ensure support from affected positions and departments.

 Tactical Responsibilities:

•  Approve (or not) recommended RCA solutions for implementation including prioritization and resource allocation
• Monitor status of open RCAs
• Monitor and ensure timely implementation of approved RCA solutions
• Monitor the effectiveness of implemented solutions

The RCA Champion

The Champion serves as a primary sponsor of the RCA effort.  The Champion’s key functions are to promote the RCA effort through sustained advocacy and to make recommendations to the Steering Committee for the resources necessary for the tactical maintenance of the program.  Primary responsibilities include the following.

Advocacy:

• Monitor RCA solution impact on the program KPIs and regularly communicate these results throughout the organization
• Promote a spirit of success by recognizing and celebrating specific RCA team’s accomplishments and contributions to the organization
• Attract individual interest in having a role in the RCA effort by communicating its career enhancement value and benefits to the organization   

Tactical Resource Recommendations:

• Make recommendations to the Steering Committee for RCA program resource requirements for the budgeting process (man hours, positions, training, etc.) necessary to sustain a successful RCA effort
• Manage the organization’s overall RCA training schedule
• Regularly track the status of open RCAs and solution implementation
• Ensure the Steering Committee has accurate and up-to-date RCA and solution status data to make informed decisions regarding allocations of resources and action item prioritization.

The Super User

Depending on the size and structure of the organization, the role of Super User may be beneficial. The Super User is the level above Facilitator in terms of formal RCA training, experience, and expertise with both the RCA methodology and any supporting software. They will also have advanced group facilitation skills and should also be the most experienced facilitator on site.  It is not uncommon to combine the roles of Super User and RCA Champion. Super User responsibilities include the following.

• Facilitate, or assisting in facilitating, the more significant events and complicated analyses for the organization
• Performing critical quality assurance reviews of other facilitators’ analysis
• Act as a mentor to new facilitators
• Ensure that all facilitators use the proper RCA methodology
• Deciding, in conjunction with the Champion, when to recommend bringing in facilitation assistance from impartial third-party experts.

The RCA Facilitator

The RCA Facilitators, or methodology practitioners, are fundamental to leading the RCA team in discovering the causes of the incident under review and associated preventative measures or solutions. The Facilitator needs to be neutral in the process. Too often facilitation duties are assigned to positions or individuals because of their technical skills, which can be a mistake. Facilitation skills and technical expertise are two distinctly different talents. Quality RCA facilitators have a naturally engaging personality, logical thought processes, superior group management techniques, and mastery of the RCA methodology. They must create effective RCA team dynamics by ensuring that all team participants are heard, keeping dominate personalities in check, and avoiding group think. Technical responsibilities include ensuring the RCA methodology is accurately followed which includes:

• Creating a clear and precise problem definition
• Ensuring that all incident causes are identified and documented in the proper causal relationships
• Encouraging “out of the box” thinking of the team members during the solution identification process
• Summarize the results of the RCA with recommended solutions for submittal to appropriate personnel

The RCA Participant

The Participants' primary role is to be an RCA team member when called upon to do so. They can be anyone from hourly employees, to upper level managers and every position in between. Participants need to receive a level of training on the RCA methodology such that they understand the terminology and the steps involved. Although the level of training is significantly less than that of the Facilitators, Participants often comprise the bulk of the trainees because of the diversity of the personnel requirements for the various RCA incidents. Responsibilities often include the following:

• Maintain a fundamental understanding of the RCA methodology employed
• Participate as an RCA team member when called upon
• Apply their own specific knowledge, skills, and expertise in identifying incident causes
• Assist in identifying and gathering incident evidence as directed
• Participate in the solution identification process

The First Responders

The role of a First Responder is to gather as much information and preserve as much evidence as reasonably possible when a trigger incident occurs.  This role is especially important for 24/7 manufacturing operations. Since response time is often critical to preserving evidence, it is important that First Responders be readily available to serve in this role.  For such operations, typical First Responders are shift supervisors, lead hands, shift maintenance personal, etc. Activities of the First Responders primarily include:

• Notifying appropriate personnel that a triggered RCA event has occurred
• Securing incident information and evidence for the RCA team which may include:
  • Taking photographs if applicable
  • Identifying eye witnesses for debriefing by the RCA team
  • Securing electronic data related to the incident in question
  • Preserving any physical evidence relative to the incident

By understanding the responsibilities of each of these roles, you can ensure that the appropriate personnel are assigned to the proper roles, while at the same time, balancing existing position duties with any added RCA responsibilities. 

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

And, descriptions of each of the six roles within an RCA program.

Next up – Training Strategy and RCA Effort Oversight and Management. Stay tuned for more.

Our previous article in this RCA Program Development blog series introduced the six roles required in your root cause analysis team in order cover all of the necessary functions. This installment in the series goes into more depth on the team structure and provides some important considerations for deciding whom should be involved.  

The RCA effort in any organization will require a number of participants at various levels of the organization having distinct roles with very specific responsibilities.  Once the workflow processes are established it is time to assign these roles and responsibilities to specific individuals, determine training needs, and decide if a formal human change management plan will be desirable to assist employees in assuming their new assignments.  These responsibilities must be clearly understood to ensure that the appropriate personnel are assigned to the various roles which include the following:

To assist in the above, it is helpful to review the nature and dynamics of a functioning RCA team.

The role of an analysis team is to apply the RCA methodology to a particular incident.  A predetermined set of conditions or triggers is used in determining what incidents qualify for a formal RCA.  The RCA Champion in collaboration with a designated Facilitator then decides through the problem definition process how much effort is to be expended on the analysis i.e. what skills participants will be on the team and how many of each, based upon the severity of the incident.  As a general rule, the cost of the resources expended should be significantly less than the potential benefit of a successful outcome.  In other words, the effort should yield a favorable ROI or greatly reduce the risk of a safety or environmental incident recurrence.  It is often useful to define threshold levels, or break points for minor, significant, or major RCA efforts to provide guidance.

The Facilitator leads the analysis process.  Teams should be cross functional and consist of 6 to 8 members depending upon the nature, complexity, and severity of the incident under investigation. When assembling an RCA team, the Champion or Facilitator has the option of including people directly involved in the incident being analyzed on the team, or involve them as interviewees only.  It is often beneficial to include a team member with no firsthand knowledge of the incident, but having familiarity with the process, equipment, etc. in order to help bring objectivity to the group and avoid "group think". These members need to be carefully selected to ensure they add value. Having people assigned to the analysis team because they are available will only waste time. The team should also have at its disposal all the facts, evidence, and a timeline surrounding the incident. 

Certain points in the analysis may require additional information that is not available within the organization.  For example, it may be necessary to contact suppliers or vendors concerning design issues. The incident owner will need to understand and encourage the follow-up on this type of information gathering.

When the RCA program is launched, it is recommended to focus on the quality of the analysis and not quantity. A few quick-wins are important to building momentum and confidence in the process.

Specific RCA team responsibilities include the following:

• Review the facts, evidence, and timeline surrounding the incident  
• Interview eye witnesses or others that may have useful knowledge of the incident at hand but are not on the analysis team
• Interview subject matter experts
• Provide the technical expertise for problem solving including action and condition recognition and possible solution proposals
• Perform an RCA analysis. The Apollo Root Cause Analysis methodology includes:

• Validating the problem definition as previously determined by the Champion and Facilitator
• Creating the cause and effect diagram using RealityCharting® software
• Identifying conditions and actions that precipitated the incident under investigation
• Proposing effective solution to eliminate selected conditions and actions that are realistic and under the control of the facility’s management

• Summarize the findings in a report to the Champion to be presented to the Steering Committee. Be available to answer any question the Steering Committee may have regarding the report.

Once the roles and responsibilities are assigned, a comprehensive training plan covering the RCA methodology and any identified change management needs must be developed with a targeted timeline. 

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

And, Recommended RCA Team Structure.

The next edition will review the specific responsibilities of the six RCA roles. Stay tuned for more.

For the fourth installment in this blog series on the key steps of RCA program development we are covering step #5 – RCA and Solution Tracking Systems and #6 – Roles and Responsibilities. Remember, to have a successful implementation and adoption of your new (or redesigned) RCA program, it’s crucial to have all the elements of an effective and efficient program clearly identified and agreed upon in advance. 

Here’s what we’ve covered in this blog series so far:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

Now we’ll dive into the important aspects of tracking your RCA solutions and the responsibilities of each role that must be played within your RCA processes.         

RCA and Solution Tracking Systems

It is very important that the status of outstanding RCAs and solutions be monitored for two basic reasons: To assure timely completion of the tasks, and to measure their effectiveness in preventing recurrence of the undesirable incident.

When a formal RCA is triggered and assigned to a facilitator, the assignment should also include a reasonable completion date that is agreed upon with the facilitator. I emphasize the word “reasonable” because human nature is to cut ourselves short on schedule time leading to rushing and taking short cuts, which in turn can result in an inferior work product.  I’ve not known anyone that has ever been admonished for completing a task ahead of time, so be sure the due date is readily achievable.

Once an RCA has been completed, a list of possible solutions will be submitted for approval.  As with the RCAs, solution implementation should have a realistic due date and a responsible party for completion. Progress towards meeting the due dates must be tracked to ensure timely completion. In addition, solution effectiveness, as measured by incident recurrence (or hopefully the lack thereof), should be monitored as well in order to demonstrate the value of both the individual RCAs and the RCA program as a whole.

When discussing action tracking, often the first thought is to create a new system. However, I suggest thinking about your existing systems and technology first and whether there is an opportunity (and if it makes sense) to integrate action tracking into those. Solution and action item lists can be exported from RealityCharting® to Excel® and then imported into your current action tracking system. If you don’t have an existing tracking system that will serve all your needs, then consider an enterprise RCA tool, such as RC Pro^TM.

Roles and Responsibilities

An effective, efficient, and sustainable RCA effort will require a number of functions to be fulfilled at various levels of the organization. There must be distinct RCA program roles to accomplish this, each with either a unique set of responsibilities or, in some cases, shared duties. The responsibilities of each role must be clearly understood to assure that the appropriate personnel are assigned to the proper roles while at the same time balancing existing position duties with any added RCA workload.

Here are the necessary functions:

1. Steering committee – What existing management team will oversee the RCA effort?
2. Program Champion – Who will be the RCA sponsor that brings legitimacy to the effort?
3. RCA Methodology Expert – Who will quality-check completed RCAs or facilitate the most difficult ones?
4. RCA Facilitators – How many and who will be trained as standard RCA facilitators?
5. First Responders – When a triggered event occurs, who will be responsible for preserving evidence?
6. Skills Participants – What people will participate in RCAs?

We will go into more depth on each of the above in our next blog installment.

Learn more about our recommended facilitated workshop that covers all 11 of the key steps, and contact us for more information.

Stay tuned for the next article in this series!

As outlined in our previous blog article, “RCA Program Development: The Key Steps of Designing Your Program”, there are 11 key steps to a successful RCA program. Last month we introduced the first two steps – Defining Goals and Current Status. In this article we’ll break down steps 3 and 4 – Setting KPIs for your RCA program and establishing trigger thresholds to initiate an RCA.

3. Key Performance Indicators

Key Performance Indicators, or KPIs, are the benchmarks used to measure the success of a program or effort. They can generally be divided into two categories: leading indicators and lagging indicators.  Both of these measure the degree to which progress is being made in achieving a specific goal.  Leading indicators tend to be objectives that progress you towards achieving the ultimate goal. They can be measured over a short period and act as mileposts to gauge how you’re tracking towards your goal. Lagging indicators are often the goals themselves.  If the relationship between the two is correctly defined, then achieving the short-term (leading) indicators virtually guarantees achieving the long-term goals. 

To provide perspective in measuring progress using KPIs, a baseline must first be established.  Baselines for the selected KPIs should be at least 3 years of historical performance. Once these are established, then goals or targets for improvement should be set for a period of time, say 3 years, going forward. This process should be reviewed at least annually with baselines and targets adjusted accordingly.

4. Formal RCA Threshold Criteria

An effective incident prevention program will have RCAs being performed at two levels: 1) On an informal or ad hoc basis for smaller, nuisance-level problems that may be specific to individuals or departments; and 2) on a formal level where challenges to the organization’s goals exist.

Leaders must communicate the organizational trigger criteria but they should also encourage and support teams and individuals to set their own trigger criteria as well.  When your employees can solve smaller day-to-day problems more effectively, your organization will realize the benefits of pro-active problem solving because many smaller problems will be rectified before they can manifest themselves into larger organization-level problem.

For RCA to be a core competency at all levels of the organization, and for people to be proactively preventing organizational problems, it is important to have clear guidance for formal RCAs. This is the function of the Trigger Criteria diagram. High-level challenges should be formally identified and assigned a threshold that when exceeded will automatically trigger a formal RCA.  Triggers should generally be leading indicators of some form or another and derived from specific organizational goals, or KPIs.  They are the trip wires to engage the RCA process for finding solutions to problems that are inhibiting organization goal achievement.  

Organizations at higher levels of maturity will most often have triggers for multiple categories including safety, environmental compliance, revenue loss, unbudgeted costs, production loss, and sometimes repeat incidents. 

For a deeper dive into the topic of trigger thresholds and scaling your RCA investigation, check out our whitepaper “Matching the Scale of Your RCA Investigation to the Significance of the Incident”.

In this blog series, we’ve now covered:

• The Key Steps of Designing Your Program
• Defining Goals and Current Status

And

• Setting KPIs and Establishing Trigger Thresholds

But of course, there is more to setting up your RCA program for success. ARMS Reliability’s RCA experts can assist you with designing your complete RCA program or reinvigorating your current one. This of course includes assisting with determining the status of your current RCA effort, walking you through the process of establishing and aligning goals, helping you set KPIs for your program, and establishing trigger thresholds that make sense for your organization. Learn more about our recommended facilitated workshop that covers all 11 of the key steps, and contact us for more information.

Stay tuned for the next article in this series.

In our previous blog article, “RCA Program Development: The Key Steps of Designing Your Program”, we provided a high-level outline of the eleven key elements that need to be defined in order to have an effective root cause analysis program in your organization. Now, in a series of articles, we’ll break down each of those eleven key elements into further detail expanding on the important considerations that need to be taken under account, starting here with your goals and your current status. 

1. RCA Goals and Objective Alignment

So, the first question is, “What are we trying to achieve with the RCA effort?” The answer from an overarching perspective can be found in the organization’s goals and objectives. Every organization, and individual for that matter, has a set of goals and objectives that are used as yardsticks to measure both short and long term performance. It is critically important that the RCA effort be in complete alignment with the organization’s and individuals’ goals and objectives. We do this by using the goals and objectives to guide us in identifying the Key Performance Indicators (KPIs) of the RCA effort and setting the Threshold Criteria (Trigger Diagram) for determining when a formal RCA must be performed. (Learn more about setting Threshold Criteria.) If the alignment is true, then there will be tangible, measurable improvement in goals and objectives achievement over time.

2. Status of Current RCA Effort

Every organization will have some form of RCA in practice whether it is formalized, or ad hoc. It is worthwhile spending some time assessing the status, or maturity level, of the existing RCA process. Maturity level can be categorized in one of four general categories.

• Level 1: Learning and Development
• Level 2: Efficient
• Level 3: Self-Actualizing
• Level 4: Pro-Active

Level 1, Learning and Development, is where most organizations without a formalized RCA program find themselves.  Management recognizes a need for a formal problem solving method but the focus is primarily on training. There is little or no structure in place to support the trained facilitators and no well-defined KPIs or threshold criteria guidance. At this stage the organization will usually gain some organizational improvements from the elimination of problems, but in an inefficient "learn as you go" manner.

At Level 2, Efficient, formal RCA triggers and KPIs are in place and are aligned with business goals and objectives in advance of RCA training. This would include clear definitions of RCA roles and responsibilities as well as identification of supporting infrastructure such as RCA status tracking, effectiveness of implemented corrective actions and the like. 

In the Self-Actualizing level, the effectiveness of the trained problem-solvers has matured through experience. Thus, their ability to solve organizational problems has resulted in a documented achievement of the program KPIs and resulting improvements to the organization’s goals and objectives. The organization is now in the continuous process of tightening the bandwidth of the KPIs to yield greater return to the bottom line. The RCA facilitators are now highly confident, efficient, and effective in eliminating impediments to achieving goals and objectives. 

In the Pro-Active level, your organization has now integrated the RCA process into its core culture. Effective problem elimination is the norm and expected at all levels of the organization. People no longer look to place blame for problems but instead are focused on prevention and elimination. Return on investment for both monetary as well as health/safety/environmental issues is extremely high acting both as gratification and motivation. RCA has become a core competency within your culture whereby people are intolerant of ineffectively solving problems the first time and are finding pro-active ways to use RCA to prevent problems from occurring in the first place.  

There are existing methods or surveys that can be used to determine an organization’s maturity level. Why is this important? Determining your current maturity level draws a line in the sand showing where you started, or took a renewed focus, in this journey of developing your RCA program. You can set goals around where you want to be over a period of time and look back to see how your program has actually evolved.

This article has given you a glimpse into the first two key elements but of course, there is more to setting up your RCA program for success. ARMS Reliability’s RCA experts can assist you with designing your complete RCA program or reinvigorating your current one. This of course includes assisting with determining the status of your current RCA effort and walking you through the process of establishing and aligning goals. Learn more about our recommended facilitated workshop and contact us for more information. 

Stay tuned for the next article in this series.

Author: David Wilbur, CEO - Vetergy Group

To begin we must draw the distinction between error and failure. Error describes something that is not correct or a mistake; operationally this would be a wrong decision or action. Failure is the lack of success; operationally this is a measureable output where objectives were not met. Failures audit our operational performance, unfortunately quite often with catastrophic consequences; irredeemable financial impact, loss of equipment, irreversible environmental impact or loss of life. Failure occurs when an unrecognized and uninterrupted error becomes an incident that disrupts operations.

Individual Centered Approach

The traditional approach to achieving reliable human performance centers on individuals and the elimination of error and waste. Human error is the basis of study with the belief that in order to prevent failures we must eliminate human error or the potential for it. Systems are designed to create predictability and reliability through skills training, equipment design, automation, supervision and process controls.

The fundamental assumptions are that people are erratic and unpredictable, that highly trained and experienced operators do not make mistakes and that tightly coupled complex systems with prescribed operations will keep performance within acceptable tolerances to eliminate error and create safety and viability.

This approach can only produce a limited return on investment. As a result, many organizations experience a plateau in performance and seek enhanced methods to improve and close gaps in performance.

An Alternative Philosophy

Error is embraced rather than evaded; sources of error are minimized and programs focus on recognition of error in order to disturb the pathway of error to becoming failure. 

Slight exception notwithstanding, we must understand people do not set out to cause failure, rather their desire is to succeed. People are a component of an integrated, multi-dimensional operating framework. In fact, human beings are the spring of resiliency in operations. Operators have an irreplaceable capacity to recognize and correct for error and adapt to changes in operating conditions, design variances and unanticipated circumstances.

In this approach, human error is accepted as ubiquitous and cannot be categorically eliminated through engineering, automation or process controls. Error is embraced as a system product rather than an obstacle; sources of error are minimized and programs focus on recognition of error in order to disturb its pathway to becoming failure. System complexity does not assure safety. While system safety components mitigate risk, as systems become more complex, error becomes obscure and difficult to recognize and manage.

Concentrating on individuals creates a culture of protectionism and blame, which worsens the obscurity of error. A better philosophy distributes accountability for variance and promotes a culture of transparency, problem solving and improvement. Leading this shift can only begin at the organizational level through leadership and example.

The Operational Juncture™

In contrast to the individual-centered view, a better approach to creating Operational Resilience is formed around the smallest unit of Human Factors Analysis called the Operational Juncture™. The Operational Juncture describes the concurrence of people given a task to operate tools and equipment guided by conflicting objectives within an operational setting including physical, technological, and regulatory pressures provided with information where choices are made that lead to outcomes, both desirable and undesirable.

It is within this multidimensional concurrence we can influence the reliability of human performance. Understanding this concurrence directs us away from blaming individuals and towards determining why the system responded the way it did in order to modify the structure. Starting at this juncture, we can preemptively design operational systems and reactively probe causes of failure. We view a holistic assignment of accountability fixing away from merely the actions of individuals towards all of the components that make up the Operational Juncture. This is not a wholesale change in the way safety systems function, but an enhanced viewpoint that captures deeper, more meaningful and more effective ways to generate profitable and safe operations.

A practical approach to analyzing human factors in designing and evaluating performance creates both reliability and resilience. Reliability is achieved by exposing system weaknesses and vulnerabilities that can be corrected to enhance reliability in future and adjacent operations. Resilience emerges when we expose and correct deep organizational philosophy and behaviors.

Resilience is born in the organizational culture where individuals feel supported and regarded. Teams operate with deep ownership of organizational values, recognize and respect the tension between productivity and protection, and seek to make right choices. Communication occurs with trust and transparency. Leadership respects and gives careful attention to insight and observation from all levels of the organization. In this culture, people will self-assess, teams will synergize and cooperate to develop new and creative solutions when unanticipated circumstances arise. Individuals will hold each other accountable.

Safety within Operational Resilience is something an organization does, not something that is created or attained. A successful program will deliver a top-down institutionalization of culture that produces a bottom-up emergence of resilience.

These days, many enterprise-level organizations are likely to have similar operations in multiple locations regionally or even worldwide. When a piece of equipment fails or a safety incident occurs at one site, the company investigates the problem and identifies solutions or corrective actions. Naturally, the team wants to capture the lessons learned and share them with other sites that have similar equipment, processes and potential incidents. 

Advanced tools like the RealityCharting® software enable teams to share results of an Apollo Root Cause Analysis (RCA) across multiple layers of stakeholders. However, a large multinational enterprise might have dozens of different investigations going on at any given time. At the highest levels, decision-makers don’t necessarily want to see granular information about specific causes at any given plant. They need a top-down perspective of problems and patterns that are affecting the entire organization.

At ARMS Reliability, many of our clients have expressed a similar need. Our solution? Using classification tags to create and apply a consistent taxonomy to all root cause analyses performed for a given organization. Rolled up into a composite report, these tags reveal enterprise-wide trends and issues, allowing management to create action plans for tackling these systemic issues. For example, classification tags might uncover a large number of problems related to a lack of preventative maintenance on a certain type of pump, or a systemic non-compliance with a required safety process.

A classification taxonomy can be scalable and configured to an organization's goals and processes. Think of these classifications like buckets that can be applied at any level of the RCA — e.g., to the root causes or solutions, to individual contributing causes, or simply to the RCA investigation in general.

 Keep in mind: The Apollo Root Cause Analysis method is centered around a free-thinking approach to solving problems. That’s what makes the methodology so powerful — it doesn’t lead you down any generic predetermined pathways by asking leading questions or categorizing various causes or effects in any way. At ARMS Reliability, we advocate applying classification tags only after the root cause analysis investigation is completed, so you keep the free-thinking causal analysis and organize it later, for the purpose of rolling the findings up into a deeper systemic view.

Taxonomies can range from 5–20 categories into the hundreds. For example, here we’ve used a human factors taxonomy to tag causes as organizational influences and other people-centric issues.

 (Click to enlarge)

Reports can provide a summary of how many causes were classified under the various tags:

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In another example, an organization bases its taxonomy of reliability issues on the ISO 14224 - Collection and exchange of reliability and maintenance data for equipment.

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The taxonomy options are endless. Most organizations we work with have their own unique systems of classifications. It’s really all about codifying the types of information your organization most needs to capture.

If adding classifications to your Root Cause Analyses would be useful for your organization, contact ARMS Reliability. We’d be glad to show you more about what we’re doing with other clients and help you develop a taxonomy that works best for your needs.