book

Root Cause Analysis, 5th Edition

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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StrategizeExecutionEvaluationMean-Time-Between-FailuresNumber of Failure/Repair EventsMaintenance CostAvailabilityReliabilityBalanced ScorecardThe RCA Work Process
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?
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)
RCA as an Approach
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
Determining Our Event Data ElementsEstablish a Work Process to Collect the DataEmploy a Comprehensive Data Collection SystemAnalyze the Digital Data
The PROACT® RCA MethodologyPreserving Event DataThe 5P’s ConceptPartsPositionPeoplePeople to InterviewInterview PreparationObserve the Body LanguagePaperParadigms
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
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
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
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
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
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
Why Explore This Potential Correlation?An Ironic LinkedIn Post Caught Our AttentionThe Safety Research PerspectiveThe Reliability Practitioner’s PerspectiveSo, Does a Correlation Exist?Conclusion
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
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

Content preview from Root Cause Analysis, 5th Edition

Index

A

Acceptable risk, 64, 68
Accountability system, 228–229
Adverse Drug Event (ADE), 150
AEDC, see Arnold Engineering Development Complex (AEDC)
Agreed-upon strategy, 229
AI, see Artificial intelligence (AI)
Aircraft subsystem diagram, 67
Amine Scrubbing Unit, 153, 154
Analysis flexibility, 30–31
Analytical processes, to RCA, 29
Analytical tools review, 143–147
“Annual Shutdowns,” 71
APM, see Asset Performance Management (APM)
Arnold Engineering Development Complex (AEDC), 275
Artificial intelligence (AI), 171, 260
Asset health summary, 4, 99
Asset performance management (APM)
- automating data analysis
  - collecting event data, 89–91
  - comprehensive data collection system, 91–93
  - digital data, 93–101
  - event data elements, 87–89
- availability ...