book

Root Cause Analysis, 5th Edition

Name: Root Cause Analysis, 5th Edition
ISBN: 9780429822100

by Mark A. Latino, Robert J. Latino, Kenneth C. Latino

June 2019

Intermediate to advanced

366 pages

10h 6m

English

CRC Press

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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
StrategizeExecutionEvaluationMean-Time-Between-FailuresNumber of Failure/Repair EventsMaintenance CostAvailabilityReliabilityBalanced ScorecardThe RCA Work Process
2 Introduction to the Field of Root Cause Analysis
What Is Root Cause Analysis?The Error-Change PhenomenonThe Stigma of “RCA”Why Do Undesirable Outcomes Occur? The Big PictureAre 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 WrongWhat 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®)
The Role of Executive Management in RCAThe Role of an RCA Champion (Sponsor)The Role of the RCA DriverSetting Financial Expectations: The Reality of the ReturnInstitutionalizing RCA in the SystemSample PROACT RCA Procedure (RCI)
4 Failure Classification
RCA as an Approach
5 Opportunity Analysis: “Mindfulness”
Step 1—Perform Preparatory WorkDefine the System to AnalyzeDefine Undesirable EventDrawing a Process Flow Diagram or Block Diagram (Use the Contact Principle)Describe the Function of Each BlockCalculate the “Gap”Develop Preliminary Interview Sheets and ScheduleStep 2—Collect the DataStep 3—Summarize and Encode DataStep 4—Calculate LossStep 5—Determine the “Significant Few”Step 6—Validate ResultsStep 7—Issue a Report
6 Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process
Determining Our Event Data ElementsEstablish a Work Process to Collect the DataEmploy a Comprehensive Data Collection SystemAnalyze the Digital Data
7 Preserving Event Data
The PROACT® RCA MethodologyPreserving Event DataThe 5P’s ConceptPartsPositionPeoplePeople to InterviewInterview PreparationObserve the Body LanguagePaperParadigms
8 Ordering the Analysis Team
Novices versus VeteransThe RCA TeamWhat Is a Team?Team Member Roles and ResponsibilitiesThe Principal AnalystThe Associate AnalystThe ExpertsVendorsCriticsPA CharacteristicsUnbiasedPersistentOrganizedDiplomaticThe Challenges of RCA FacilitationBypassing the RCA Discipline and Going Straight to a SolutionFloundering of Team MembersAcceptance of Opinions as FactsDominating Team MembersReluctant Team MembersGoing Off on TangentsArguing among Team MembersPromote Listening SkillsOne Person Speaks at a TimeDon’t InterruptReact to Ideas, Not PeopleSeparate Facts from Conventional WisdomTeam Codes of ConductTeam Charter/MissionTeam CSFsTeam Meeting SchedulesPROACT RCA Process FlowProcess Flow and Chronic versus Sporadic EventsTeam Approach to Chronic Events
9 Analyzing the Data: Introducing the PROACT® Logic Tree
Categorical versus Cause-and-Effect RCA ToolsAnalytical Tools ReviewThe Germination of a FailureConstructing a Logic TreeThe EventThe Mode(s)The Top BoxThe HypothesesVerifications of HypothesesThe Fact LinePhysical Root Causes/FactorsHuman Root Causes/FactorsLatent Root Causes/FactorsBreadth and All InclusivenessThe Error-Change Phenomenon Applied to the Logic TreeOrderDeterminismDiscoverabilityFinding Pattern in the ChaosVerification TechniquesConfidence FactorsExploratory versus Explanatory Logic TreesUsing the Logic Tree for StorytellingPutting It All Together: A Basic Case
10 Communicating Findings and Recommendations
The Recommendation Acceptance CriteriaDeveloping the RecommendationsDeveloping the ReportThe Executive SummaryThe Event SummaryThe Event MechanismsThe PROACT® Investigation Management System DescriptionThe Root Cause Action Matrix SummaryThe Technical Section (The Explanatory Description)The Identified Root Cause(s)The Type of Root Cause(s)The Responsibility of Executing the RecommendationThe Estimated Completion DateThe Detailed Plan to Execute RecommendationAppendicesRecognition of All ParticipantsThe 5P’s Data Collection StrategiesThe RCA Team’s CharterThe RCA Team’s CSFsThe Logic TreeThe Verification LogsThe Recommendation Acceptance Criteria (If Applicable)Glossary of TermsInvestigation ScheduleFigure and Table ListingsReport Use, Distribution, and AccessThe Final PresentationHave the Professionally Prepared Reports Ready and AccessibleStrategize for the Meeting by Knowing Your AudienceHave an Agenda for the MeetingDevelop a Clear and Concise Professional PresentationCoordinate the Media to Use in the PresentationConduct “Dry Runs” of the Final PresentationQuantify the Effectiveness of the MeetingPrioritize Recommendations Based on Impact and EffortDetermine Next Step Strategy
11 Tracking for Bottom-Line Results
Getting Proactive Work Orders Accomplished in a Reactive EnvironmentSliding the Proactive Work ScaleDeveloping Tracking MetricsProcess MeasuresOutcome MeasuresExploiting SuccessesCreating a Critical MassRecognizing the Lifecycle Effects of RCA on the OrganizationThe Pros and Cons of Using Zero Harm as a Safety MetricConclusion
12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior
Ineffective SupervisionImproving Your Listening SkillsHow to Use This InformationLack of an Accountability SystemDistractive EnvironmentLow Alertness and ComplacencyWork Stress/Time PressureWork StressTime PressureOverconfidenceFirst-Time Task ManagementImprecise CommunicationVague or Incorrect GuidanceTraining DeficienciesNew Technology
13 Do Human Performance “Learning Teams” Make RCA Obsolete?
Is RCA “Old School and Obsolete?”Aligning RCA Dictionaries between HPI and Reliability—The Criticality of Defining TermsAre the HPI Myths about RCA True?The Concept of Learning Teams
14 Is There a Direct Correlation between Reliability and Safety?
Why Explore This Potential Correlation?An Ironic LinkedIn Post Caught Our AttentionThe Safety Research PerspectiveThe Reliability Practitioner’s PerspectiveSo, Does a Correlation Exist?Conclusion
15 Automating Root Cause Analysis: Introducing PROACTOnDemand®
Customizing PROACT for Our FacilitySetting Up a New Analysis in the New PROACT RCA ModuleAutomating the Preservation of Event DataAutomating the Analysis Team StructureAutomating the RCA—Logic Tree DevelopmentAutomating RCA Report WritingAutomating Tracking Metrics
16 Case Histories
Case Study No. 1: North American Paper MillCase Study No. 2: PEMMAX Consultants, Waterloo, Ontario, CanadaCase Study No. 3: PSEG, Jersey City, New JerseyCase Study No. 4: MotorDoc® LLC, Lombard, IL USA
Index

Content preview from Root Cause Analysis, 5th Edition

12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior

While we have discussed human error sporadically thus far, we will expand on it in this chapter as its own entity. This is a book that describes our view of what effective Root Cause Analysis (RCA) is all about. This is not a book that focuses only on human error, but rather its contribution to how and why things don’t always go as planned. It is important for analysts to have a good understanding of human behavior when investigating an undesirable outcome. Understanding human behavior will help the analyst formulate interview questions. These questions will allow discussion by the employees about subjects that will give insight into the cultural norms present ...

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Root Cause Analysis, 5th Edition

by Mark A. Latino, Robert J. Latino, Kenneth C. Latino

12

The Role of Human Error in Root Cause Analysis: Understanding Human Behavior

Become an O’Reilly member and get unlimited access to this title plus top books and audiobooks from O’Reilly and nearly 200 top publishers, thousands of courses curated by job role, 150+ live events each month,
and much more.