5 Critical Factors RCFA

8/12/2019 5 Critical Factors RCFA

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GET IT RIGHT:

5 CRITICAL

COMPONENTSIN YOUR RCA

PROGRAM


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INCIDENT INVESTIGATION

AN IMPROVEMENTPROCESSContrary to popular belief, Root Cause Analysis (RCA) and RootCause Failure Analysis (RCFA) is not a silver bullet. Neither isfinding the root cause a realistic expectation - if there was onlyone cause, then it would be found easily. But there are stepsyou can take to ensure that an RCA delivers the best possibleoutcomes for your organisation.

Think of root causes in the same way that Olympic athletes workout their weaknesses over a four-year span - making marginalgains and small improvements that lead to a better result at thenext Olympics. Root causes are typically the same. You shouldaddress a number of known faults to reduce an unwanted effectto an acceptable level.

The right RCA tool is immensely powerful, but it should beused in the right context, with the right people, and the rightsupport. The following pages outline how to develop a robustRCA program that will make your current and future RCAinvestigations more successful.
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DefineSET YOUR OBJECTIVES& PROCEDURES


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With this in mind, the first stage of RCA is all about preparation. This shouldhappen in the background, long before any incident occurs. The more preparedyou are now, the better the outcomes if an incident occurs down the track.

Here are the key steps in defining your RCA process.

1. SET YOUR OBJECTIVES

Create trigger points to instigate RCA. These triggers should reflect whatsimportant to your business, and most organisations would typically include:

Safety

Environment

Revenue

Cost Reputation

Frequency

With each of these, ask what an unacceptable measure would be. For example,any reportable safety issue, any reportable release to atmosphere, loss of revenueof more than $30,000, costs of more than $10,000, any event happening more than

four times, and so on. Now, youve got something to measure yourselves against.

DEFINE - SET YOUR OBJECTIVES & PROCEDURES

Every business should have a clearly defined

RCA plan in place. Just in case. After all, the

last thing you need if an incident has occurred

is a scramble to appoint a facilitator, or

gather the tools needed to collect evidence.


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Be honest with your triggers. Its easy to develop a setof triggers that would be right to do, world class,or sending the right message. However, its very rarefor fledgling RCA processes to operate at world class

standards.

Your triggers should match your facilitation resources- the experience of your facilitators, the availability ofstakeholders to participate in the investigations, andthe resources available to deliver the improvements.By getting this balance right, you can accuratelymonitor performance, incorporate it into a continuous

improvement process and - when youre ready for it -youll be world class.

2. IDENTIFY ROLES ANDRESPONSIBILITIES

Who is expected to do what? Make it clear what you

expect of each member of the team.

At the same time, encourage the team to follow thelead of the best players. These people - typicallytechnicians and operators - will arrive at the RCAinvestigation armed with timelines, trends, operatinginstructions and manuals. They are focused and readyfor action.

Document what you expect to be brought to aninvestigation and who is responsible for bringing it.The quality of your RCA investigation depends upon thecauses being supported by evidence - so develop yourprocesses to support the collection of good evidence,which will then be used during the investigation.

As a final point, encourage and support your

facilitators to halt investigations with no evidence.Break up the meeting, and use the time to get thoseresponsible to collect the data required.

Be honest-refine yourtriggers to matchyour capabilities.


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3. SELECT AND TRAININVESTIGATORS

The key to a successful RCA is having a great leader.So what makes a good facilitator?

Appoint someone who:

Recognises the strengths and abilities ofindividual group members and helps them to feelcomfortable about sharing their hopes, concernsand ideas

Supports the group, giving participants confidencein sharing and trying out new ideas

Values diversity and is sensitive to the differentneeds and interests of group members, such asgender, age, profession, education, economic andsocial status

Leads by example through attitudes, approach andactions

Balance the number of facilitators with the capabilitiesof the organisation. It may be tempting to train asmany facilitators as your budget allows, particularlygiven the high turnover rate (unfortunately, manyfacilitators quit after being trained - which oftenboils down to a poor selection of facilitator, quality of

training or insufficient support post-training).

Instead, appoint fewer facilitators but choose themwell. Ensure they get access to quality training fromexperienced trainers, and have enough trainingsessions to build their skills and confidence. Post-training, give them strong support, particularly ininitial investigations.

Its a bonus if

the facilitatorfits by function,technical abilityor discipline, too.


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By training fewer facilitators, you may have budget left over. Run a shorteroverview or participants course for the other people who will take part in RCAinvestigations, such as operators, 1st line managers, technicians, drivers and soon.

4. PREPARE THE GO-BAGYour goal with RCA is to right something when it goes wrong. To do this, you needto collect as much evidence as you can. Have a go-bag at the ready for the RCAteam to go out and collect evidence.

This bag should contain:

Tape measure

Camera

Evidence check sheet

Torch

Clipboard Calipers


Notebook

Magnifying glass

Generic PPE

Pens, pencils, highlighters

Permanent Marker Clear plastic bags (for evidence)


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MeasureCOLLECT DATA & ASSESSITS SIGNIFICANCE


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MEASURE - COLLECT DATA AND ASSESS ITS SIGNIFICANCE

Data collection shouldnt just scrape the

surface. Members of the RCA team should

know their responsibilities and head straight

out to collect the data needed for a thorough

investigation.

Dont be tempted by a quick fix

When an incident occurs in the workplace, your first thoughts are, What are wegoing to do? and What do we need to know?

As a starting point, you need to know how big the incident is - that is, how farfrom normal, how significant? This will tell you how much effort to put into thesolution. To find out how big it is, you go and measure it. Then, you look forimmediate solutions, backed up by a few more measurements.

You implement the solutions, the status quo is restored,

its a job well done. Right?

Not quite.

To future-proof a fix, you need more than start-up data

To ensure that the incident does not reoccur, you need more than just surface

data. Digging a little deeper doesnt take much longer - but it does takecommitment.

Youve set up your roles, responsibilities and procedures; and your go-bag is atthe ready. Use a data collection checklist to guide the collection, and appoint theperson/s to go out and collect it.


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MEASURE - COLLECT DATA AND ASSESS ITS SIGNIFICANCE

A typical checklist looks like this:

Preserve evidence at the scene

Photographs - work with operations to try and get

photographs prior to and during the incident

Retain the failed components, if possible

Interview witnesses

Initiate data mapping

CMMS data

Immediate vibration levels Immediate process conditions

Computer trending

Review documentation

Condition monitoring history

Lubrication history

Management of change history

Process data sheets

Plant line diagrams

Procedures and manuals

Conduct tests or recreations, particularly if there is

minimal or no evidence to collect. In keeping withyour safe practices or under Management of Changeprocedures, plan the start-up or steady state processwith a view to capturing key events or measurements.Your initial data collection will invariably lead you tosome conclusions or at least hypotheses. These can betested if circumstance permits.


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AnalyseEMBED YOUR CHOSENANALYSIS METHOD


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Trust in the

process.The big picturewill take care ofitself.

CONDUCT THE ROOT CAUSE ANALYSIS

ANALYSE - EMBED YOUR CHOSEN ANALYSIS METHOD

With the evidence collected, your RCA team is

ready to start analysing the data, and arriving

at potential solutions. This component relies

on a no-holes-barred attitude, where all ideas

are captured as you journey towards the fix.

Define the problem

Devote about a quarter of the RCA investigation to defining the problem. The moreclear and precise this definition is, the quicker the cause and effect chart will bebuilt.

Use post-it notes in the definition as well as the chart building. Its surprising howoften one of the significant items becomes the problem itself.

At this point, the facilitator should encourage the participants to get thestorytelling out of their system. While they are speaking, the facilitator should becollecting causes on post-it notes and parking them next to the chart or in theholding area for the first pass review.

Identify evidenced causes and effects

The goal here is to create a common reality onyour cause and effect chart. Starting this process

can seem scary, particularly for those who arenew to the RCA process. These people are staringat a large sheet of brown paper with a primaryeffect on it, and a blank post-it note in their hand.They have no idea where the chart will go.


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To help maintain the flow, drive the caused by caseand go back and repeat the causal chain when it startsto dry up. Keep demanding evidence, and trust that theparticipants will know the difference between actions

and conditions. Write the causes verbatim - cursesand all - to keep things rolling and to really capture themeaning. Language can always be cleaned up for thefinal chart.

Successful RCAs often move beyond the brown paper.Walls and windows get covered in notes to maintainthe flow. Participants will have the mental capacity to

join in the lines that arent there; however, if it lookslike its getting untidy then take a short break and tidyit up.

Identify effective solutions

This is the most creative - and enjoyable - part of theprocess. While the subjects of most investigations arevery serious, the RCA itself shouldnt be too sombre.

Rather, it should be professional - and this relies oncreativity. Within the wacky solutions are clever oneswaiting to be discovered.

Dont constrain yourself to one solution per cause andpay extra attention to those conditions you perceive tobe the norm.

Select the best solutions

Use your organisations solution criteria to the besteffect and avoid turning it into a form-filling exercise.For example, passing the problem on to someoneoutside the team is a sure-fire way of not getting itimplemented. Instead, use a solution assessmentprocess to prioritise similar solutions - which alsohelps with team buy-in.


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To implement the best solutions and actions, manage

a tracking system

Again, the process for this step is specific to individual

organisations. What matters is that you have aprocess. The biggest single reason for RCA failure iswhen the solutions arent implemented - which comesdown to a lack of process.

The most successful RCA programs have in-depthtracking systems in place to ensure solutions, actionitems and whole RCAs are tracked and shared withothers in the organisation. There are many way toaccomplish this using databases and tools which allowmanagers to view a company-wide RCA snapshotshowing outstanding actions and solutions that haveor have not been implemented. A good RCA softwaretool will also have the capacity to share resultseasily across the organisation and track changes andcomments relating to RCA charts, solutions or reports.

Share key findings

Youve put a lot of work into the investigation. Dothe work once, and use it many times. Whether youuse the cause and effect chart itself, the ExecutiveSummary, the photos and trends, or any other datacollected - there are many opportunities to put theinvestigations findings to work in other areas of thebusiness.

IMPROVE - SET STANDARDS FOR REPORTS


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ControlMEASURE THE SUCCESSOF YOUR PROGRAM


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CONTROL - MEASURE THE SUCCESS OF YOUR PROGRAM

To obtain ongoing support for your RCA

program, you need to provide the proof that it

works. You need quantifiable, demonstrable

measures of outcomes. There are a range of

tools and methods that you can use in this step.

Create a business process map

Having read through the report, create a process map to help visualise and controlthe outcomes of the RCA process. This is important - given the investment youvemade in people and resources to get this far. Have copies of the process mapavailable so that if the effectiveness of the program is challenged, you can easilyidentify which parts of the process are failing.

Create leader standard work

The RCA champion should undertake daily, weekly or monthly tasks to helpsupport the process; and the champions manager should have similar goals. Thisleader standard work leads to better performance in key players.


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Some great examples of this work include:

Action tracking system - this is a leading measureof your process. If the actions are gettingimplemented you can be more confident that

improvements are being made.

RCA process critiques - look at things like thenumber of actions versus conditions, with a goodchart exhibiting more conditions than actions (asthere are always a number of conditions in place forany given action to cause an effect).

Adherence to the business process map - this is alagging measure. By selecting areas of the processsupported by documentation, audit from a qualityperspective. Alternatively, talk with key players inthe process to assess their understanding of theirresponsibilities.

Performance against the triggers - another laggingmeasure. Use your CMMS system to determine

costs and frequency rates; or your safety andenvironmental systems for rates and severities.Cross reference with the number of RCAs heldand keep track of the performance of theseRCAs to highlight savings from a reduction inrecurring failures, near misses, safety incidents,and so on. You may even be able to tout theseaccomplishments at your annual performance

review or if you are interviewing for a new position.


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CONCLUSIONIn this ebook, we looked at 5 critical components in building asuccessful RCA program in your organisation: Define, Measure,Analyse, Improve, Control.

These components form the foundation of ongoing, iterativeimprovements that lead to the main game that is, reducing oreliminating unwanted incidents from your workplace.

Define, Measure, Analyse, Improve, Control (DMAIC) is arecognised, data-driven improvement cycle that will help youimprove business processes, and is a proven framework for

application in many different settings.


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PUBLIC TRAINING COURSESWe hold public training courses in cities throughout the world. Learn

more about our 2 Day Facilitators Course

ONSITE TRAININGAll our training courses are available for delivery onsite at your

facility or a training venue of your choice. If you choose to book onsite

training, we highly recommend doing the3 day Facilitator coursewhich

offers students the opportunity to work on a real life problem from their

workplace under the guidance of one of our experienced trainers.

ONSITE TRAINING BENEFITS Cost effective for a larger group size

Avoid travel expenses for attendees

Reduced time away from work for students

Schedule convenience - working around your availability and

schedule

Personalisation and customisation for certain courses to make it

relevant for students

Get all team members speaking a common RCA language

FACILITATION SERVICESSometimes there will be an issue of sensitivity that requires greater

objectivity and facilitation skills in finding out the root cause and

developing solutions. Click to learn how we can help.

Learn more about the Apollo Root Cause AnalysisTM

method at www.apollorootcause.com
http://www.apollorootcause.com/training/course-outlines/#2day)http://www.apollorootcause.com/training/course-outlines/#3dayhttp://www.apollorootcause.com/training/course-outlines/#3dayhttp://www.apollorootcause.com/services/http://www.apollorootcause.com/https://plus.google.com/share?url=http://hub.apollorootcause.com/reliabilityweb-1https://twitter.com/intent/tweet?url=http://hub.apollorootcause.com/reliabilityweb-1http://www.linkedin.com/shareArticle?mini=true&url=http://hub.apollorootcause.com/reliabilityweb-1http://www.apollorootcause.com/training/public-training-courses/http://www.apollorootcause.com/contact/onsite-contact/http://www.apollorootcause.com/contact/onsite-contact/http://www.apollorootcause.com/training/public-training-courses/http://www.apollorootcause.com/http://www.apollorootcause.com/services/http://www.apollorootcause.com/training/course-outlines/#3dayhttp://www.apollorootcause.com/training/course-outlines/#2day)


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About ARMS ReliabilityARMS Reliability is a service, software, and training organisation

providing a one stop shop for Root Cause Analysis, as well as Reliability

Engineering, RAMS, and Maintenance Optimisation for both new and

existing projects.

Since 1997, ARMS Reliability has been an authorised training provider of

the Apollo Root Cause AnalysisTMmethodology. In 2012, our agreement

went global and ARMS Reliability now provides RCA training, software, and

services throughout the world.

Apollo Root Cause AnalysisTM

MethodThe Apollo Root Cause AnalysisTMMethod is an intuitive principle-basedroot cause analysis process that:

Easily embraces all perspectives

Eliminates the usual frustration and arguments

Creates a common reality of your problem

Ensures buy-in from all stakeholders Integrates a user friendly software application to create evidence -

based cause & effect charts

For more information on how ARMS Reliability can help, please contact us

at the office location nearest you (details below).

You can also make an enquiry onwww.apollorootcause.com

www.apollorootcause.com [email protected]

NORTH / CENTRAL / SOUTH AMERICAP 1 512 795 5291

AUSTRALIA / ASIA / NEW ZEALANDP 61 3 5255 5357

EUROPEP 44 122 445 9362

SOUTH AFRICAP 27 10 500 8232
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5 Critical Factors RCFA

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