Root Cause Analysis, 5th Edition

Book description

This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach.

This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results.


  • Outlines in detail every aspect of an effective RCA ‘system’
  • Displays appreciation for the role of understanding the physics of a failure as well as the human and system’s contribution
  • Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system
  • Explores the correlation between Reliability Engineering and Safety
  • Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA

Table of contents

  1. Cover
  2. Half Title
  3. Title Page
  4. Copyright Page
  5. Dedication Page
  6. Table of Contents
  7. Foreword
  8. Preface
  9. How to Read This Text
  10. Acknowledgments
  11. Introduction/Reflections
  12. Authors
  13. 1 Introduction to the PROACT® Root Cause Analysis (RCA) Work Process
    1. Strategize
    2. Execution
    3. Evaluation
      1. Mean-Time-Between-Failures
    4. Number of Failure/Repair Events
    5. Maintenance Cost
    6. Availability
    7. Reliability
    8. Balanced Scorecard
    9. The RCA Work Process
  14. 2 Introduction to the Field of Root Cause Analysis
    1. What Is Root Cause Analysis?
    2. The Error-Change Phenomenon
    3. The Stigma of “RCA”
    4. Why Do Undesirable Outcomes Occur? The Big Picture
    5. Are All RCA Methodologies Created Equally?
    6. Attempting to Standardize RCA—Is This Good for the Industry?
    7. What Is Not RCA?
    8. How to Compare Different RCA Methodologies When Researching Them?
    9. What Are the Primary Differences between Six Sigma and RCA?
    10. Obstacles to Learning from Things That Go Wrong
    11. What Are the Differences between an “RCA,” a Legal Investigation and a Safety Investigation?
  15. 3 Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP®)
    1. The Role of Executive Management in RCA
    2. The Role of an RCA Champion (Sponsor)
    3. The Role of the RCA Driver
    4. Setting Financial Expectations: The Reality of the Return
    5. Institutionalizing RCA in the System
    6. Sample PROACT RCA Procedure (RCI)
  16. 4 Failure Classification
    1. RCA as an Approach
  17. 5 Opportunity Analysis: “Mindfulness”
    1. Step 1—Perform Preparatory Work
      1. Define the System to Analyze
      2. Define Undesirable Event
      3. Drawing a Process Flow Diagram or Block Diagram (Use the Contact Principle)
      4. Describe the Function of Each Block
      5. Calculate the “Gap”
      6. Develop Preliminary Interview Sheets and Schedule
    2. Step 2—Collect the Data
    3. Step 3—Summarize and Encode Data
    4. Step 4—Calculate Loss
    5. Step 5—Determine the “Significant Few”
    6. Step 6—Validate Results
    7. Step 7—Issue a Report
  18. 6 Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process
    1. Determining Our Event Data Elements
    2. Establish a Work Process to Collect the Data
    3. Employ a Comprehensive Data Collection System
    4. Analyze the Digital Data
  19. 7 Preserving Event Data
    1. The PROACT® RCA Methodology
    2. Preserving Event Data
    3. The 5P’s Concept
    4. Parts
    5. Position
    6. People
      1. People to Interview
      2. Interview Preparation
      3. Observe the Body Language
    7. Paper
    8. Paradigms
  20. 8 Ordering the Analysis Team
    1. Novices versus Veterans
    2. The RCA Team
    3. What Is a Team?
    4. Team Member Roles and Responsibilities
      1. The Principal Analyst
      2. The Associate Analyst
      3. The Experts
      4. Vendors
      5. Critics
    5. PA Characteristics
      1. Unbiased
      2. Persistent
      3. Organized
      4. Diplomatic
    6. The Challenges of RCA Facilitation
      1. Bypassing the RCA Discipline and Going Straight to a Solution
      2. Floundering of Team Members
      3. Acceptance of Opinions as Facts
      4. Dominating Team Members
      5. Reluctant Team Members
      6. Going Off on Tangents
      7. Arguing among Team Members
    7. Promote Listening Skills
      1. One Person Speaks at a Time
      2. Don’t Interrupt
      3. React to Ideas, Not People
      4. Separate Facts from Conventional Wisdom
    8. Team Codes of Conduct
    9. Team Charter/Mission
    10. Team CSFs
    11. Team Meeting Schedules
    12. PROACT RCA Process Flow
    13. Process Flow and Chronic versus Sporadic Events
    14. Team Approach to Chronic Events
  21. 9 Analyzing the Data: Introducing the PROACT® Logic Tree
    1. Categorical versus Cause-and-Effect RCA Tools
    2. Analytical Tools Review
    3. The Germination of a Failure
    4. Constructing a Logic Tree
    5. The Event
    6. The Mode(s)
    7. The Top Box
    8. The Hypotheses
    9. Verifications of Hypotheses
    10. The Fact Line
    11. Physical Root Causes/Factors
    12. Human Root Causes/Factors
    13. Latent Root Causes/Factors
    14. Breadth and All Inclusiveness
    15. The Error-Change Phenomenon Applied to the Logic Tree
    16. Order
    17. Determinism
    18. Discoverability
    19. Finding Pattern in the Chaos
    20. Verification Techniques
    21. Confidence Factors
    22. Exploratory versus Explanatory Logic Trees
    23. Using the Logic Tree for Storytelling
    24. Putting It All Together: A Basic Case
  22. 10 Communicating Findings and Recommendations
    1. The Recommendation Acceptance Criteria
    2. Developing the Recommendations
    3. Developing the Report
    4. The Executive Summary
      1. The Event Summary
      2. The Event Mechanisms
      3. The PROACT® Investigation Management System Description
      4. The Root Cause Action Matrix Summary
    5. The Technical Section (The Explanatory Description)
      1. The Identified Root Cause(s)
      2. The Type of Root Cause(s)
      3. The Responsibility of Executing the Recommendation
      4. The Estimated Completion Date
      5. The Detailed Plan to Execute Recommendation
    6. Appendices
      1. Recognition of All Participants
      2. The 5P’s Data Collection Strategies
      3. The RCA Team’s Charter
      4. The RCA Team’s CSFs
      5. The Logic Tree
      6. The Verification Logs
      7. The Recommendation Acceptance Criteria (If Applicable)
      8. Glossary of Terms
      9. Investigation Schedule
      10. Figure and Table Listings
    7. Report Use, Distribution, and Access
    8. The Final Presentation
    9. Have the Professionally Prepared Reports Ready and Accessible
    10. Strategize for the Meeting by Knowing Your Audience
    11. Have an Agenda for the Meeting
    12. Develop a Clear and Concise Professional Presentation
    13. Coordinate the Media to Use in the Presentation
    14. Conduct “Dry Runs” of the Final Presentation
    15. Quantify the Effectiveness of the Meeting
    16. Prioritize Recommendations Based on Impact and Effort
    17. Determine Next Step Strategy
  23. 11 Tracking for Bottom-Line Results
    1. Getting Proactive Work Orders Accomplished in a Reactive Environment
    2. Sliding the Proactive Work Scale
    3. Developing Tracking Metrics
      1. Process Measures
      2. Outcome Measures
    4. Exploiting Successes
    5. Creating a Critical Mass
    6. Recognizing the Lifecycle Effects of RCA on the Organization
    7. The Pros and Cons of Using Zero Harm as a Safety Metric
    8. Conclusion
  24. 12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior
    1. Ineffective Supervision
    2. Improving Your Listening Skills
    3. How to Use This Information
    4. Lack of an Accountability System
    5. Distractive Environment
    6. Low Alertness and Complacency
    7. Work Stress/Time Pressure
    8. Work Stress
    9. Time Pressure
    10. Overconfidence
    11. First-Time Task Management
    12. Imprecise Communication
    13. Vague or Incorrect Guidance
    14. Training Deficiencies
    15. New Technology
  25. 13 Do Human Performance “Learning Teams” Make RCA Obsolete?
    1. Is RCA “Old School and Obsolete?”
    2. Aligning RCA Dictionaries between HPI and Reliability—The Criticality of Defining Terms
    3. Are the HPI Myths about RCA True?
    4. The Concept of Learning Teams
  26. 14 Is There a Direct Correlation between Reliability and Safety?
    1. Why Explore This Potential Correlation?
    2. An Ironic LinkedIn Post Caught Our Attention
    3. The Safety Research Perspective
    4. The Reliability Practitioner’s Perspective
    5. So, Does a Correlation Exist?
    6. Conclusion
  27. 15 Automating Root Cause Analysis: Introducing PROACTOnDemand®
    1. Customizing PROACT for Our Facility
    2. Setting Up a New Analysis in the New PROACT RCA Module
    3. Automating the Preservation of Event Data
    4. Automating the Analysis Team Structure
    5. Automating the RCA—Logic Tree Development
    6. Automating RCA Report Writing
    7. Automating Tracking Metrics
  28. 16 Case Histories
    1. Case Study No. 1: North American Paper Mill
    2. Case Study No. 2: PEMMAX Consultants, Waterloo, Ontario, Canada
    3. Case Study No. 3: PSEG, Jersey City, New Jersey
    4. Case Study No. 4: MotorDoc® LLC, Lombard, IL USA
  29. Index

Product information

  • Title: Root Cause Analysis, 5th Edition
  • Author(s): Mark A. Latino, Robert J. Latino, Kenneth C. Latino
  • Release date: June 2019
  • Publisher(s): CRC Press
  • ISBN: 9780429822100