Root Cause Analysis - Improving Performance for Bottom-Line Results - 5TH Edi...

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Root Cause Analysis - Improving Performance for Bottom-Line Results - 5TH Edition CRC Press 2020

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


CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2020 by Mark A. Latino, Robert J. Latino, and Kenneth C. Latino
CRC Press is an imprint of Taylor & Francis Group, an Informa business


Contents
Foreword............................................................................................................... xiii
Preface......................................................................................................................xv
How to Read This Text....................................................................................... xvii
Acknowledgments............................................................................................... xix
Introduction/Reflections.................................................................................... xxi
Authors................................................................................................................ xxix
1 Introduction to the PROACT® Root Cause Analysis (RCA)
Work Process....................................................................................................1
Strategize............................................................................................................3
Execution............................................................................................................4
Evaluation..........................................................................................................4
Mean-Time-Between-Failures....................................................................7
Number of Failure/Repair Events..................................................................8
Maintenance Cost.............................................................................................8
Availability........................................................................................................8
Reliability...........................................................................................................9
Balanced Scorecard......................................................................................... 12
The RCA Work Process.................................................................................. 14
2 Introduction to the Field of Root Cause Analysis.................................. 19
What Is Root Cause Analysis?...................................................................... 19
The Error-Change Phenomenon...................................................................20
The Stigma of “RCA”...................................................................................... 24
Why Do Undesirable Outcomes Occur? The Big Picture..........................25
Are All RCA Methodologies Created Equally?..........................................26
Attempting to Standardize RCA—Is This Good for the Industry?.........26
What Is Not RCA?...........................................................................................28
How to Compare Different RCA Methodologies When
Researching Them?........................................................................................30
What Are the Primary Differences between Six Sigma and RCA?.........33
Obstacles to Learning from Things That Go Wrong.................................34
What Are the Differences between an “RCA,”
a Legal Investigation and a Safety Investigation?......................................36
3 Creating the Environment for RCA to Succeed: The Reliability
Performance Process (TRPP®)..................................................................... 39
The Role of Executive Management in RCA............................................... 39
The Role of an RCA Champion (Sponsor)...................................................42
The Role of the RCA Driver...........................................................................45


4 Failure Classification.................................................................................... 57
RCA as an Approach......................................................................................64
5 Opportunity Analysis: “Mindfulness”....................................................65
Step 1—Perform Preparatory Work.............................................................. 70
Define the System to Analyze.................................................................. 70
Define Undesirable Event.......................................................................... 70
Drawing a Process Flow Diagram or Block Diagram (Use the
Contact Principle).......................................................................................73
Describe the Function of Each Block.......................................................73
Calculate the “Gap”................................................................................... 74
Develop Preliminary Interview Sheets and Schedule.......................... 74
Step 2—Collect the Data................................................................................75
Step 3—Summarize and Encode Data.........................................................79
Step 4—Calculate Loss................................................................................... 81
Step 5—Determine the “Significant Few”..................................................82
Step 6—Validate Results................................................................................83
Step 7—Issue a Report....................................................................................84
6 Asset Performance Management Systems (APMS): Automating
the Opportunity Analysis Process.............................................................87
Determining Our Event Data Elements......................................................87
Establish a Work Process to Collect the Data.............................................89
Employ a Comprehensive Data Collection System.................................... 91
Analyze the Digital Data...............................................................................93
7 Preserving Event Data................................................................................ 103
The PROACT® RCA Methodology.............................................................. 103
Preserving Event Data.................................................................................. 104
The 5P’s Concept........................................................................................... 107
Parts................................................................................................................ 108
Position........................................................................................................... 109
People.............................................................................................................. 111
People to Interview.................................................................................. 115
Interview Preparation............................................................................. 116
Observe the Body Language.................................................................. 117
Paper............................................................................................................... 119
Paradigms...................................................................................................... 120
8 Ordering the Analysis Team..................................................................... 127
Novices versus Veterans.............................................................................. 128


9 Analyzing the Data: Introducing the PROACT® Logic Tree.............. 143
Categorical versus Cause-and-Effect RCA Tools..................................... 143
Analytical Tools Review.............................................................................. 143
The Germination of a Failure...................................................................... 147
Constructing a Logic Tree........................................................................... 148
The Event........................................................................................................ 149
The Mode(s)................................................................................................... 151
The Top Box................................................................................................... 152
The Hypotheses............................................................................................ 156
Verifications of Hypotheses......................................................................... 157
The Fact Line................................................................................................. 160


10 Communicating Findings and Recommendations............................... 183
The Recommendation Acceptance Criteria.............................................. 183
Developing the Recommendations............................................................ 185
Developing the Report................................................................................. 186
The Executive Summary.............................................................................. 187


11 Tracking for Bottom-Line Results............................................................203
Getting Proactive Work Orders Accomplished in a Reactive
Environment..................................................................................................204
Sliding the Proactive Work Scale................................................................205
Developing Tracking Metrics...................................................................... 207
Process Measures..................................................................................... 207
Outcome Measures.................................................................................. 207
Exploiting Successes..................................................................................... 213
Creating a Critical Mass............................................................................... 215
Recognizing the Lifecycle Effects of RCA on the Organization............ 216
The Pros and Cons of Using Zero Harm as a Safety Metric.................. 217
Conclusion..................................................................................................... 219
12 The Role of Human Error in Root Cause Analysis:
Understanding Human Behavior............................................................. 221
Ineffective Supervision................................................................................ 224
Improving Your Listening Skills................................................................226
How to Use This Information.....................................................................227
Lack of an Accountability System..............................................................228
Distractive Environment..............................................................................229
Low Alertness and Complacency...............................................................230
Work Stress/Time Pressure.........................................................................234
Work Stress....................................................................................................234
Time Pressure................................................................................................235
Overconfidence.............................................................................................236
First-Time Task Management...................................................................... 237
Imprecise Communication.......................................................................... 237
Vague or Incorrect Guidance...................................................................... 243
Training Deficiencies.................................................................................... 247
New Technology........................................................................................... 249
13 Do Human Performance “Learning Teams” Make RCA Obsolete?..... 253
Is RCA “Old School and Obsolete?”...........................................................253
Aligning RCA Dictionaries between HPI and
Reliability—The Criticality of Defining Terms.........................................254
Are the HPI Myths about RCA True?........................................................255
The Concept of Learning Teams................................................................. 261


14 Is There a Direct Correlation between Reliability and Safety?........265
Why Explore This Potential Correlation?..................................................265
An Ironic LinkedIn Post Caught Our Attention...................................... 266
The Safety Research Perspective................................................................ 267
The Reliability Practitioner’s Perspective.................................................. 270
So, Does a Correlation Exist?....................................................................... 273
Conclusion..................................................................................................... 276
15 Automating Root Cause Analysis: Introducing
PROACTOnDemand®................................................................................. 279
Customizing PROACT for Our Facility..................................................... 279
Setting Up a New Analysis in the New PROACT RCA Module...........280
Automating the Preservation of Event Data.............................................285
Automating the Analysis Team Structure................................................288
Automating the RCA—Logic Tree Development..................................... 289
Automating RCA Report Writing............................................................... 294
Automating Tracking Metrics..................................................................... 297
16 Case Histories............................................................................................... 301
Case Study No. 1: North American Paper Mill........................................ 301
Case Study No. 2: PEMMAX Consultants, Waterloo, Ontario,
Canada .......................................................... 309
Case Study No. 3: PSEG, Jersey City, New Jersey.................................... 311
Case Study No. 4: MotorDoc® LLC, Lombard, IL USA............................ 320
Index......................................................................................................................325

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