Root Cause Analysis (RCA) vs. Shallow Cause Analysis …€¦ · Root Cause Analysis (RCA) ......

Root Cause Analysis (RCA) vs.

Shallow Cause Analysis (SCA):

What’s the Difference?

Bob Latino, CEOReliability Center, Inc.www.Reliability.com

First Time Attendee

Objectives

1. Viewing RCA as a system and not simply a task2. Pro’s and con’s of common tools to express logic3. Constructing a logic tree to tell a story4. Practical Case Studies: The nature of the failure is

irrelevant.

Viewing RCA as a system

and not simply a task

Latent Roots

Org. System Deficiencies

Workplace Cultural Influencers

Sociotechnical Factors

Undesired Consequence

Failures

Physical Roots

Errors (Human Roots)

RCA System Process Flow Diagram

Preserve

Analyze

Communicate

Retain Incident

Information

Determine RCA Is Required

Gather Additional Data

Select Team

Members

Establish Functional Guidelines

Review Available

Develop and Verify Hypothesi

Determine Verification Data

Report Team

Findings

Present Team Recommendations

Implement Recommendations

Measure Effectiveness

“First-Pass” Data Collection

Build Logic Tree

Triggered RCAs - ReactiveChronic Failures - ProactiveHigh Risks - Proactive

Inputs

Develop and Verify Hypothesis

Build Logic Tree

Pro’s and con’s of common tools to express logic

Mode Mode

Hypothesis

Physical

Latent Latent

Hypothesis

5-WHY FISHBONE LOGIC TREE

Common Analysis Tools

Comparison

Problem

How Can?

Materials

Man Mgmt

Machines

Constructing a logic tree to tell a story -

Concept

Policies & Procedures

Human Performance/

Human Factors

Communication Systems

Technology Systems

Training Systems

Management Oversight/

Enforcement

Cultural Norms & System’s Failures (Defenses)

Undesirable Outcome

(least acceptable consequence)

Undesirable Outcome

(least acceptable consequence)

Physical Roots

Human Roots(Active)Latent Roots

How one labels causes/contributing

factors, doesn’t matter!

Germination of an Undesirable OutcomeThe Basics

Triggering Decision

Near Miss

Observable Consequences

Anatomy of a Logic Tree

Going beyond the Blame Game

Latent Roots

Org. System DeficienciesWorkplace Cultural Influencers/

Just CultureSociotechnical Factors

Undesired Consequence (Event)

Failures Modes

Physical Roots

Errors (Decisions/”Choices”)

Root Cause Failure Analysis (RCFA)

Decision Error Analysis (DEA)

Layers of Human Performance

The Hourglass ViewTransition from Deductive to Inductive Thinking

Undesirable Outcome(Physical Manifestations)

Human Root Causes(Behavior Related)

Latent Root Causes(Systems Related)

Deductive(General to Specific)

Physics (H

Inductive(Specific to General)

an (Soft)

(How Can?)

(Why?)

Constructing a logic tree to tell

a story -Application

Root Cause Analysis: The establishing of logically complete, evidence-based, tightly coupled chains of factors from the least acceptable consequences to the deepest significant underlying causes (www.rootcauselive.com)

Logic Trees are a Component of RCARCA Definition I Use…

(Bear with me, that’s a mouthful…)

How Can?

logically complete

evidence-based

tightly coupledVerification Log (5P’s)

Verification Method –

Verification Outcome –

Responsibility –

Due Date -

HOW COULD? vs WHY?Categorical vs Cause-

and-Effect

In More Simplistic TermsLogic Tree Expression Used for ‘Reconstruction’

EventMode(s)

M M M M

Role Playing Give me a hand with the logic…

Top Box - Facts

Do We Do RCA on Incidents?

What Would be the ‘Event’ if We Had a Critical Pump Failure?

Unexpected Production Shutdown

Motor Failure

Critical Pump Bearing Failure

Seal Failure

Role Playing Give me a hand with the logic…

Top Box - Facts

How Can?

The Process Basics

From the Driver to the Driven

Pump (Driven)Motor (Driver)

Roller Bearing

“How can a bearing fail?”

Unexpected Shutdown

Motor Failure

Critical Pump Bearing Failure

Erosion Corrosion Fatigue Overload

Seal Failure

Role Playing

Give me a hand with the logic…

Top Box - Facts

Then, Once Again…’How Can?’

Quick Lesson in Component FailureMetallurgy 101

Source: http://www.reliability.com/failure-scene-investigation.html

Erosion

Uniform Loss of Metal

Corrosion

Pitting (Electrical

Phenomena)

Fatigue

Cyclic Failure

Overload

Instantaneous Fracture

Delta MD88 Oil Cap Issue

Delta Reputational

Plane ‘Call Back’ Due to Smoke

MD88 APU Oil Cap Loose

LTA Cap Design –Appears Locked

Cap Seal Failure

LTA Tightening

Failure to Detect

Other Hypotheses

How Can?

Exploratory vs. Explanatory Logic TreesStorytelling Tool

Such an expression demonstrates

relationships between systems, decisions and

outcomes…a Story!

= Exploratory

= Explanatory

M M MM

LR LR LR

Correlating Swiss Cheese to a Logic TreeReasons, James. Human Error. 1990.

Swiss Cheese Goals1. Minimize # of Holes2. Minimize Diameter of Remaining Holes3. Don’t Let Remaining Holes Line Up

Mode 1

LR 1 LR 2 LR 3

Mode 2

Latent

Physical

Prove that such practical tools can be

applied anywhere, by anyone…even a 5th grader!

Practical Case #1: Industrial Case Study

Let’s Put These Concepts into Practical Reality!

Unexpected Shutdown of Production

Source: Screenshots used with permission from www..reliability.com

How Can?

So What is the Difference Between RCA and SCA?...It Depends!

Latent Roots

Org. System Deficiencies

Workplace Cultural Influencers

Sociotechnical Factors

Undesired Consequence (Event)

Failures Modes

Physical Roots

Errors (Decisions)

Breadth

Evidence Strength

Effectiveness (ROI)

Knowledge MgmtStructure- AI, IIoT, ML, DL

Thanks for Your Time!www.Reliability.com

blatino@reliability.com

Root Cause Analysis (RCA) vs. Shallow Cause Analysis …€¦ · Root Cause Analysis (RCA) ......

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