Book description
This book explores the anatomy of a failure, as well as a potential failure. 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. The new edition is completely revised with many updates and new chapters.
Table of contents
- Cover
- Half Title
- Title Page
- Copyright Page
- Dedication Page
- Table of Contents
- Foreword
- Preface
- How to Read This Text
- Acknowledgments
- Introduction/Reflections
- Authors
- 1 Introduction to the PROACT® Root Cause Analysis (RCA) Work Process
-
2 Introduction to the Field of Root Cause Analysis
- What Is Root Cause Analysis?
- The Error-Change Phenomenon
- The Stigma of “RCA”
- Why Do Undesirable Outcomes Occur? The Big Picture
- Are All RCA Methodologies Created Equally?
- Attempting to Standardize RCA—Is This Good for the Industry?
- What Is Not RCA?
- How to Compare Different RCA Methodologies When Researching Them?
- What Are the Primary Differences between Six Sigma and RCA?
- Obstacles to Learning from Things That Go Wrong
- What Are the Differences between an “RCA,” a Legal Investigation and a Safety Investigation?
- 3 Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP®)
- 4 Failure Classification
- 5 Opportunity Analysis: “Mindfulness”
- 6 Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process
- 7 Preserving Event Data
-
8 Ordering the Analysis Team
- Novices versus Veterans
- The RCA Team
- What Is a Team?
- Team Member Roles and Responsibilities
- PA Characteristics
- The Challenges of RCA Facilitation
- Promote Listening Skills
- Team Codes of Conduct
- Team Charter/Mission
- Team CSFs
- Team Meeting Schedules
- PROACT RCA Process Flow
- Process Flow and Chronic versus Sporadic Events
- Team Approach to Chronic Events
-
9 Analyzing the Data: Introducing the PROACT® Logic Tree
- Categorical versus Cause-and-Effect RCA Tools
- Analytical Tools Review
- The Germination of a Failure
- Constructing a Logic Tree
- The Event
- The Mode(s)
- The Top Box
- The Hypotheses
- Verifications of Hypotheses
- The Fact Line
- Physical Root Causes/Factors
- Human Root Causes/Factors
- Latent Root Causes/Factors
- Breadth and All Inclusiveness
- The Error-Change Phenomenon Applied to the Logic Tree
- Order
- Determinism
- Discoverability
- Finding Pattern in the Chaos
- Verification Techniques
- Confidence Factors
- Exploratory versus Explanatory Logic Trees
- Using the Logic Tree for Storytelling
- Putting It All Together: A Basic Case
-
10 Communicating Findings and Recommendations
- The Recommendation Acceptance Criteria
- Developing the Recommendations
- Developing the Report
- The Executive Summary
- The Technical Section (The Explanatory Description)
- Appendices
- Report Use, Distribution, and Access
- The Final Presentation
- Have the Professionally Prepared Reports Ready and Accessible
- Strategize for the Meeting by Knowing Your Audience
- Have an Agenda for the Meeting
- Develop a Clear and Concise Professional Presentation
- Coordinate the Media to Use in the Presentation
- Conduct “Dry Runs” of the Final Presentation
- Quantify the Effectiveness of the Meeting
- Prioritize Recommendations Based on Impact and Effort
- Determine Next Step Strategy
-
11 Tracking for Bottom-Line Results
- Getting Proactive Work Orders Accomplished in a Reactive Environment
- Sliding the Proactive Work Scale
- Developing Tracking Metrics
- Exploiting Successes
- Creating a Critical Mass
- Recognizing the Lifecycle Effects of RCA on the Organization
- The Pros and Cons of Using Zero Harm as a Safety Metric
- Conclusion
-
12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior
- Ineffective Supervision
- Improving Your Listening Skills
- How to Use This Information
- Lack of an Accountability System
- Distractive Environment
- Low Alertness and Complacency
- Work Stress/Time Pressure
- Work Stress
- Time Pressure
- Overconfidence
- First-Time Task Management
- Imprecise Communication
- Vague or Incorrect Guidance
- Training Deficiencies
- New Technology
- 13 Do Human Performance “Learning Teams” Make RCA Obsolete?
- 14 Is There a Direct Correlation between Reliability and Safety?
- 15 Automating Root Cause Analysis: Introducing PROACTOnDemand®
- 16 Case Histories
- Index
Product information
- Title: Root Cause Analysis, 5th Edition
- Author(s):
- Release date: June 2019
- Publisher(s): CRC Press
- ISBN: 9780429822100
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