Root Causes Analisys

WHY RCA DOESNT WORK
North America | South America | Europe | Asia | Africa | Australia
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ROOT CAUSE ANALYSIS PRESENTED BY ARMS RELIABILITY

Over the past 16 years ARMS Reliability have been teaching Root Cause Analysis across a wide cross section of industries. In that time we have seen some common traps that prevent companies realising the full benefit of adopting a root cause analysis process. We know the power of an effective problem solving process which: 9 9 9 9 9 9 9 9 Avoids the blame game Embraces all perspectives Is simple and can be used by anyone Gives the confidence to seek creative and effective solutions for any problem Eliminates the usual frustration and arguments Creates a common reality for a problem Ensures buy-in from all stakeholders Includes user-friendly software to create evidencedbased cause & effect charts
Training in Root Cause Analysis

ARMS Reliability has been delivering Apollo Root Cause Analysis courses throughout the world for the past 16 years both at public seminars and at clients sites. Since 1997 we have trained over 20,000 people worldwide. ARMS Reliability has trainers available to meet your training needs in North America, South America, Europe, Asia, Africa and Australia. Book courses online at www.apollorootcause.com
But despite high acceptance and excitement following attendance at a training course, we still see some pitfalls that can be avoided. This ebook lays them bare. Our intent is in line with our training, a problem recognised is a problem half solved. These chapters are written by staff of ARMS Reliability who are experienced in delivering Root Cause Analysis training and conducting investigations for companies from a wide cross section of industries. Foreward By Michael Drew CEO, ARMS Reliability View Public Training Schedule Request Quote for Onsite Training
www.armsreliability.com/rca
Why RCA Doesnt Work

The Impact of Language on RCA Investigations Tips & Hints for Creating More Effective RCA Cause-And-Effect Charts Root Cause Analysis and The Blame Game Listen to your Operators RCA Training for you and your Team...Value for Money? Conclusion and Additional Resources
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WHy RCA DOESNT WORk
CHAPTER 1
THE IMPACT OF LANGUAGE ON RCA INVESTIGATIONS
WHy RCA DOESNT WORk
By challenging the imprecise words consistently, you will create CLARITY where previously there was none.
How many times have you read an incident report and been left wondering what was being investigated, or what the causal relationships were all about? This often occurs when vague or nebulous descriptors are used to explain causal relationships. Below we give some examples of non-descriptive language commonly found in incident reports and suggest strategies you can use as a Root Cause Analysis facilitator to prevent ambiguity or misinterpretation. Three types of vague descriptors commonly used to explain causal relationships, and how to address them:
Poor | Inadequate | Ineffective | Insufficient
Time | Speed | Age | Weight
Wrong | Incorrect
WHy RCA DOESNT WORk
Poor | Inadequate | Ineffective | Insufficient
EXAMPLE
Poor maintenance
EFFECTS
Leads easily into the categorising of causes, such as human error, which can quickly move down the blame path. We will tend to end up with the same generic types of solutions for each category. These terms are often emotive, inflammatory, and can lead to conflict.
SOLUTION
As a means of clarification, ask something to the effect of what is it that makes the maintenance poor? By challenging the imprecise words consistently you will create CLARITy where previously there was none.
WHy RCA DOESNT WORk
Time | Speed | Age | Weight
EXAMPLE
It was the shaft was worn because of wearing over time The Car crashed because the person didnt see the other car and speed The pipe corroded because it was a metal pipe and age We couldnt stop it because it was rolling and its weight Another example of a different context would be maintenance... i.e the machine failed because of maintenance.
EFFECTS
Now whilst all of these causes probably have some specific relevance within the causal pathways in which you find them they all create confusion as there is no clear descriptor to explain the relationship. This will again lead to subjective assessments. People will interpret the reference in their own way. Speed will mean different things to different people, as will weight, age and time.
SOLUTION
Typically what is required is to quantify each of these words. In other words: How much time are you talking about?, What was the speed?, How old is it?, How heavy is it? and What is it about the maintenance that was less than adequate?
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Wrong | Incorrect
EXAMPLE
This sort of description is purely subjective, opinionated and may not be based in fact. If what we are trying to do is to present the facts then these types of words would fail to achieve that.
SOLUTION
your task as a facilitator is to seek clarification of these words. Why is it wrong? What makes it wrong or incorrect? When these questions are asked the responses to them need to be recorded and added to the RealityCharting. The original reference has been replaced by something far more factual and meaningful.
Become an effective Root Cause Analysis Facilitator. ARMS Reliabilitys Apollo RCA Facilitator Course.
WHy RCA DOESNT WORk
CHAPTER 2
CREATING MORE EFFECTIVE RCA CAUSE-ANDEFFECT CHARTS
WHy RCA DOESNT WORk
There is tendency to see the obvious however. We see the things that happen, the things that people do. These are all the action type of causes. What we fail to see as easily are all of the conditions that are there. The benefit of finding the conditions is that conditions are easier to control.
Clues on finding causes
Understanding conditional causes
Too many words
Actions or Conditions
Why does anything happen???...Because it can!

WHy RCA DOESNT WORk
Clues on finding causes
When describing causes, you are searching for words to adequately describe the cause. Clues for finding the causes and for the description of these causes can be taken from the effect that you are questioning.
EXAMPLE: Negative publicity

We are looking for at least two causes here (as in each effect should have at least two causes). Whilst searching for the reason of why we have any publicity at all, which is probably the first cause, we also need to understand what makes that publicity negative, because not all publicity is negative. This would then be the second cause (or perhaps there may be more than one cause for the negativity so then second, third and/or fourth causes may follow). It should be noted that whilst searching for at least two causes it is not restricted to just two causes. This is the basic requirement and yet if diligently challenged more causes may still be found. It is the exhaustive search for causes that will provide the most opportunity for control of your problem, as the more causes you find, then the more opportunities you will have to control change or mitigate aspects of the problem.
EXAMPLE: Hand bleeding

If we take hand bleeding as an example, we are trying to understand what has happened. What were you doing? is a good question to ask and then what happened?. But if I am really perceptive and I examine the word bleeding then I should understand that I must have blood to bleed. So for the hand to bleed something must have happened, ie ...you cut your hand and you bleed because there is blood in your hand.
EXAMPLE: Delayed shipping

If a cause has the word delay in its description, as in delayed shipping, then what does this mean? Delay is a reference to time so in the causes of the shipping delay there must be some reference to time otherwise we havent really understood what we are looking for. So for shipping delay the causes could be something to the tune of a shipment is due (time reference) and we didnt ship it in the time frame required. If you never have a time frame then you can never be late so you need to establish the time frame in the causes of delayed shipping. This basic understanding could then be applied to all causes.
WHy RCA DOESNT WORk
If you follow the Apollo methodology of causal analysis, you need to find at least one action and one condition for each effect, but typically there are more conditions. The context of many conditional causes is that it, something, must exist. Now what does this mean? E.g. To be able to break a rule firstly there must be a rule. The rule must exist. The same can be said of not following a procedure, or not meeting a standard, not following a protocol. In each case the rule, the procedure, the standard or protocol must exist otherwise you can never say that you failed to follow it or achieve it.
EXAMPLE: Radiator Hose

Take a radiator hose for example. your problem would be that you have lost your coolant. Why? Because the radiator hose has burst. So? Why does this mean that you lose all of your coolant? Because the coolant flows through the hose ..otherwise why would you lose any coolant at all? For a hose to rupture there must be a hose. The hose has to exist. Without the hose there would be no ruptured hose. So now you have .. a hose connects motor to radiator(the hose exists), the hose transports coolant (it has a purpose) and that hose has burst(this is what happened). There must be a relationship between the hose and the coolant otherwise the hose rupturing will have no impact on losing coolant. The relationship is the condition in each and every case as is the existence of the item in question. The happening, the event, would be the action.
EXAMPLE: Bolt fell out

For a bolt to fall out for example, you must first have a bolt. The bolt has to exist but what does the bolt do? It performs a function. It has a purpose. Rather than saying that you have a bolt as one cause of a bracket failing for example, simply recognising the fact that the bolt exists as your causal description, it would be more precise to say what purpose the bolt has, that the bolts secure the bracket (thereby recognising that you have a bolt) and that that bolt has fallen out. What will happen if the bolt falls out? Will it produce the effect you are trying to understand? If it does then you have got it right. So if the bracket is secured by a bolt and those particular bolt falls out wont the bracket fail to perform its function? Unless you can establish the relationship of the bolt to the bracket, then the bolt falling out will cease to have any impact on the failure of the bracket.
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EXAMPLE: Pipe dropped
In another example the pipe dropped because the scaffold collapsed. For this to make any sense we first need to understand the relationship between the two. So unless you put the pipe on the scaffold then the scaffold collapsing would have absolutely no bearing on the pipe dropping. So to clarify, the pipe dropped and this was caused by the pipe being on the scaffold when the scaffold collapsed. A way of testing the logic of this connection is to work the connection from right to left. i.e.. if the pipe is on the scaffold and the scaffold collapses will the pipe drop? Now this statement is, to all intents and purposes, quite logical but there is a catch here. It will only fall if it is unsupported by anything else. you have just identified another cause. So in reality what you are really saying (working from right to left) is that if the pipe is on the scaffold and is unsupported by anything else, then when the scaffold collapses the pipe will drop. Does this make sense? yes it does. So you now know that the logic of that connection is sound. you have tested the logic of the connection.
HINTIn other words it should make sense if you were to read it from left to right
which is how the caused by logic works, but that it should also make sense when you read it from right to left. Actively look for any exceptions that make a lie out of this statement. If you find an exception then you have effectively found another cause to add to your list.
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Too many words
Another area that could be improved upon is in regards to the number of words that are used to describe causes. A common pitfall is to use too many words to describe causes. What is then far more likely to happen is to combine a couple of causes into one cause box. The impact of this will be displayed in the logic of the next connection. Because the cause is now far more complex it is a lot harder to clearly identify specific causes. Often causes will be related to a part of the effect but not the other part. So the logic starts to break down and the chart becomes harder to understand.
EXAMPLE: Non-return valve failed

Why because it was old and not maintained. you could write this description in one box but then when you ask the next caused by question you will get some answers that relate to Old valve and you will have others that pertain to not maintained. If this were to be included in one connection then it would fail to make sense. The age of the valve and the maintenance of the valve are separate concepts and the causes for each of these need to be separated for it to make any sense in the chart. By being concise in the description, limiting the description to just 2 or 3 words, then this combining of causes becomes less possible and the chart will be easier to understand.
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There is often confusion with labelling causes correctly. Some people will label a cause as an action whilst others will label the same cause as a condition. Does this matter? The answer is yes it does. This is based on the understanding that it is easier to control a conditional cause. It is controllable. It tends to deal with tangibles. The actions, the things that happen instantaneously, are far harder to control. They are unpredictable otherwise we would have done something about it already, and they are also largely centred around the people elements and therefore it is difficult to get reliable, consistent outcomes from controls centred on these types of causes. So then yes it is important to try and label causes correctly.
EXAMPLE: Shaft is worn

If I were to say that the shaft is worn would this be an action or a condition? It is a condition isnt it? It is the state the shaft is in prior to anything happening. If I were to say that the shaft is wearing, what would you say? Is this an action or a condition? It is the action cause that leads to, or causes, a worn shaft. If however it is wearing and wearing and wearing, doesnt this become a condition over time? It is the same thing happening over and over again. It is all related to how you see things. How causes are described by individuals will have a direct impact on how causes are subsequently labelled.as either actions or conditions. In other words there will be some variations. Perhaps it is important to understand what is behind the labelling process. i.e. the labelling of causes as either actions or conditions. It is really about understanding what you have found but also what needs to be found - to discover what is missing and then to search for it. It is about ensuring that we ask the next question - that we dont miss anything. It is about that exhaustive search for all causes. This is the real reason behind the labelling process.
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If you have two conditional causes for an effect essentially you should automatically be searching for an action that made use of those conditions. The labelling process prompts you to ask the next question. By being diligent in this pursuit you will find more causes. More causes are better because you now have more opportunities for control.
What is the difference between actions and conditions?

Well the conditions were already there. It was like that. The conditions pertain to the ability of something to happen. The action makes use of the conditions to create an effect. It tends to be instantaneous in terms of time. It is that thing which is different, that has changed.
EXAMPLE: Fire
If I were to ask What are the causes of a fire what would you say? Well there needs to be some fuel. There needs to be oxygen. There needs to be an ignition source. Well you can have paper, oxygen and matches but that doesnt mean you have to have a fire. Something needs to happen. Something needs to make use of the conditions that are present, the ability of fire to happen, to actually cause a fire. This is what has changed, happened. This is the action. It is that single moment in time when the action makes use of the available conditions to create an effect. If even one of the conditions were eliminated the fire would have no opportunity to occur. There is tendency to see the obvious however. We see the things that happen, the things that people do. These are all the action type of causes. What we fail to see as easily are all of the conditions that are there. The benefit of finding the conditions is that conditions are easier to control.
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Why does anything happen???... Because it can!
This simple statement should bring to mind what all of the conditions are that need to exist for an event to occur. When you examine the last part of the statement you are essentially trying to understand the ability of something to occur.trying to understand what conditions are present. Why does an object fall? For example why does an object (anything for that matter) fall?...It falls because it can fall. Why can it? Because it is at height (elevated above a surface).because it is heavier than air, because it is in the presence of gravity. Surely all of these conditions must be true for something to fall, to be able to fall? Then something happens that makes use of these conditions.the action.
EXAMPLE:
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CHAPTER 3
THE BLAME GAME
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Will knowing who did it, stop it from happening again?
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How often have you looked at corrective actions and thought that they would have little, if any, impact in preventing the problem from reoccurring? It wasnt just once. and it continues to happen.
The question is why?

Yet the answer is not a simple or straightforward one. Do we believe that the person(s) creating these corrective actions are not trying to do their best? No I dont think so. I firmly believe that almost all people are trying to do their best. So where does that leave us? We are caught up in a system where the reactive, quick fixes are the goal, the way of dealing with incidents on a day to day basis. If you were to have a downtime incident and you were to bring the power back on quickly after an outage, or the machine is back in operation after a short space of time then the reaction from the management group and from all of your peers is typically.Well done! Great job! A pat on the back for those who have performed the job well. In other words we give respect and accolades to those who can fix it quickly. Conversely there is often little reward or acknowledgement for hours of diligent work in the pursuit of actions that will resolve the issue once and for all. We reinforce the quick fixes.
Now dont get us wrong here because the ability to do the quick fix is and always will be a valuable skill, but the real challenge is to understand whether we have prevented the problem from re-occurring?
What happens after the initial fix is put into place? Where do you go to from there? In the completely reactive model, the fire-fighting model, where breakdown maintenance often takes precedence over planned maintenance (which then sets you up for the next round of failures), there is always a fire that needs tending, so we will typically tend to jump to that fire, to the next problem on the list. I have dealt with that one, whats next?
The Blame Game

From conversations with people who attend the courses that are presented in Root Cause Analysis, something else becomes blatantly clear. We still seem, on many different levels, to be playing the blame game. The question of who still seems to be of paramount importance to some, perhaps many people. The question to ask these people is Will knowing who did it, stop it from happening again? Now the way of thinking by far the most common answer to this question will be No(although there are exceptions). So why do we feel that we need to focus on the who? If the goal of doing Root Cause Analysis is to prevent recurrence of the problem the challenge lies not so much in who was involved but rather emphasising, or focusing, on what you can do to stop it from happening again. This focus will lead to gathering more factual information which is the essence of understanding the problem first and foremost.
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The who side of the question is pretty easy to determine, but if that is what we focus on then it is likely to limit thorough questioning, and leads quickly and easily down a blame path. Sanctions are given or jobs lost, all based on the knowledge of who was at fault. But where does this lead? Wouldnt this lead to a lack of reporting mistakes or faults as there will be unwanted consequences because of the report? Doesnt it elevate risk as there would now be a culture of hiding or covering up mistakes? When you ask questions, what are likely to get? The truth? Something else to consider is whether people intend to cause damage, create failures, injure themselves or hurt others? Again the overwhelming answer is still NO. That people are often involved in many incidents, and make mistakes, is seemingly the constant part of the equation. But that is the nature of the beast. People are fallible, they do make mistakes and no matter how hard we try to control this aspect, the human error side of causes, it is forever doomed to failure. If we rely on trying to control people then our solutions will have no certainty in their outcome. Going down this path is simply not reliable.
Hierarchy of Control
This is echoed in the concept of the Hierarchy of control where corrective actions are placed within the Hierarchy, as being either a form of Elimination, Substitution, Engineering, Administrative or P.P.E. controls. The first three of these are perceived to be very strong controls, or hard controls, with almost guaranteed, reliable, consistent results. They are however more time consuming and typically involve spending money to achieve your desired outcome. Administrative controls or the use of PPE as a form of control are perceived to be soft controls. They are relatively quick to implement and dont cost too much and yet if you were to ask the question will they prevent recurrence, almost universally the response will be NO! They may however satisfy the need to report. I have ticked the box and created a perception of having done something about the incident. To take this a step further, these soft options now get signed off by management who are fully cognisant of the Hierarchy of control. If we keep taking the soft options however is it any wonder that we are still fire-fighting. If we dont fundamentally change or control causes that create the problem then the problem still has an ability to happen again, regardless of the who, the person involved. This could be anyone.
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Creating another Procedure

How often have you heard or seen, as a response to a problem .create another procedure? Would you be certain that this will prevent recurrence of the problem? It could be said that you have tried to control the problem. you can certainly show that you have done something. Would it however be defensible in a court of law if someone were to subsequently get hurt? If you expect someone to remember every single procedure, of every single task, of the many tasks that they need to perform in every single day, is this feasible? And we all know it is a soft control!! An administrative one. So do the courts.
The Argument about Sanctions

Who learns the most from the mistakes that are made? Isnt it the person or the people involved? This was put into perspective for me by another instructor at a conference in Indianapolis in 2010. He said to me if someone makes a mistake for instance and the cost of that mistake might be, say, $500,000, and you are so angered by this that you then sack the person who made the mistake (quite possible, even probable)it is like sending someone on a $500,000 training course and then sacking them the next day. Does this make any sense?
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CHAPTER 4
LISTEN TO YOUR OPERATORS
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The downtime lost on this insignificant problem was quantified to be worth over $1million in losses to the business. The solution identified during the Root Cause Analysis equalled $34,000!
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When it comes to looking for failures during a Reliability Study or for causes during a Root Cause Analysis investigation, Listen to your operators. They are the eyes and ears of your production facility. it doesnt matter if you are running a chocolate factory, bottling beer, or drilling for oil, they all have one thing in common operators on the front line. These valuable members of your team are often the first to notice problems occurring; these problems may only stop the machine once a shift for a few minutes while they go and hit the reset button. These high frequency short duration issues often get reported but are not seen or considered as critical because we have not yet witnessed a major stoppage. After all, we hit the reset button and the machine starts again. A few things start to naturally happen at this stage.
Operators stop reporting faults because nobody does anything about them operators start to change the operating practice of the machine to allow for these
issues during their shift. This then becomes normal operating practice, without any form of risk assessment having been performed. These changes are usually only identified following a major incident investigation. When it is often too late. Reliability is like Safety - Ignore the little things and before long it could be something major. Typical comments used by operators during Reliability Studies and RCA investigations are:
Weve been doing it that way for years We kept reporting it to management I used to do that task but we removed it from our check list because we never found
anything
Great examples exist like the operator who used to carry out torque checks on a rotating piece of equipment at the end of shift, only to be told it was no longer required. Two years later the Reliability investigation into downtime on the machine revealed sheared bolts as the number one failure mode on the machine. We re-introduce the torque checks and the problem disappears. Or the Root Cause Analysis performed on a light curtain trip that stopped the machine once a shift for five minutes. The downtime lost on this insignificant problem was quantified to be worth over $1million in losses to the business. The solution identified during the Root Cause Analysis equalled $34,000! The problem solved. So during Reliability Studies and Root Cause Analysis, listen to your plant engineers, equipment specialists and OEMs, but, whatever you do, dont forget to Listen to your operators.
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CHAPTER 5
ROOT CAUSE ANALYSIS TRAINING - VALUE FOR MONEY!
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Change will only occur when the pain from changing becomes less than the pain of staying the same.
Important questions to ask as you embark on a training course:

Who reinforces this learning or monitors the standard of facilitation and the reports that are generated? Who provides any feedback or confirms and endorses the process or endorses the outcomes that are generated from it? Is there a mentor or expert to provide the appropriate feedback? Is there a compulsion to use or demonstrate competency in the use of the training material they have learned?
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Q. Do companies get the most out of the training dollar that they increase for their employees? Answer. No!
Whilst training per se is perceived to be important, as evidenced by the volume of training that occurs throughout industry, I feel that companies are still not getting the biggest bang for their buck from the training that they provide their employees. Training is provided regularly for employees to attend for the benefit of the company and also of the employees and in completing the course the employee(s) will leave with some new knowledge and skills or perhaps with prior knowledge being challenged, changed, reinforced or enhanced. What then happens though when these people get back into the workforce? Do they apply this new learning or do they go back into their comfort zones continuing to do what they did before? If there is no compulsion to utilise their training, then it is quite possible that those people who have received the training may not use it, as trying anything new or different often requires more initial effort and it is possible, even probable, that they may get it wrong to start with and become disillusioned by the experience. Practice takes time and we are typically, across industries, time poor. Unless people are given the time and opportunity to practise, using and perfecting these new skills, then there is the chance that they wont use it of their own volition. Is this the outcome that we desire? Change will only occur when the pain from changing becomes less than the pain of staying the same. Change will occur when there is enough motivation for that change. People who have attended training are often perceived to be experts following their return to the workplace. Sometimes this results in being thrown into the deep end of the of the next big incident that occurs. youve had the training! Often there is a perception that there is little time available to investigate the root cause A few hours or days of training and practice however makes no-one an expert in anything. It is the constant application or use of this training that will create competence.
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All of this boils down to the question about what structures exist within the company to support the training (any type of training) that is being provided? The training itself starts people along a learning curve and progresses them to a point along that curve with as many variations as there are people attending the training as to where they sit along that curve, at the completion of the training program. Important questions to ask as you embark on a training course:
Who reinforces this learning or monitors the standard of facilitation and the reports that are Who provides any feedback or confirms and endorses the process or endorses the outcomes Is there a mentor or expert to provide the appropriate feedback? Is there a compulsion to use or demonstrate competency in the use of the training material they
have learned? If there is no strategy in place to address the questions above then do we move training attendees from where they sit along that learning curve to application of excellence in the subject matter that they were trained in? Surely this is the end goal. Unless organisational structures exist to support the training then much of it is predestined to fail and not live up to the expected outcomes that generated the initial interest for the training in the first place. If 6, 12 or even 18 months down the track the training received is not being used then what will the perception be? The perception at that time may be that the training was poor, of little value, too hard or didnt work and so on. The training is then perceived as being inadequate and consequently that particular training package is not sourced again or may be sourced from an alternative supplier supplying a similar product to attempt to provide what was initially sought. If this cycle were to continue, (which it inevitably does) without making changes to how training is presented and managed, in a few years the client company will be back to square one and lining up for another go at a training package that was presented at some time previously. Does this ring any bells with anybody?? It is my opinion that it is not necessarily the training that is at fault here, but perhaps the lack of effective support for the training. Support should move people systematically from their early learnings into the application of excellence in its practice and use. If the training is seen to be important enough to conduct, then surely this support is where the client company ensures the biggest bang for the training buck! What is the purpose of the training? Is it to bring about some change in the people being trained? Is it to cover/correct perceived weaknesses in learning? Upskilling? For whatever reason the training is being conducted, the training must be have been considered to have value. Then why is it that there is limited or non-existent support for much of the training after the course?? that are generated from it? generated?
Click to learn more about creating an effective problem solving culture in your organisation
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CONCLUSION & ADDITIONAL RESOURCES
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In this eBook we discussed some of the common challenges our clients face when facilitating or participating in an RCA investigation.
By reading this book we hope you have acquired a new perspective on the language used in investigation reports, cause-and-effect relationships, escaping a corrective action mindset, avoiding the blame game, and where to look for valuable facts about failures. Its important to have the correct performance measures to ensure the process is adding value to your organisation. ARMS Reliability is able to assist in improving your RCA program on a number of levels. Click to learn more about Continuous Improvement. If you are interested in learning more about the Apollo Root Cause Analysis method, visit our website for more information www.apollorootcause.com.
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Acknowledgements
Apollo RCA: Apollonian Publications, LLC is the owner of
Apollo Root Cause Analysis and RealityCharting software. Apollo RCA is a powerful methodology to help you become one of the best problem-solver on the face of the planet.
RealityCharting: Version 6.0 has been released. If you

have been trained in the past on Apollo RCA methodology and have received or currently own an older version of RealityCharting, you are entitled to a free upgrade to Version 6.0. Contact us to ensure you get your free copy.

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WHY RCA DOESNT WORK

North America | South America | Europe | Asia | Africa | Australia

ROOT CAUSE ANALYSIS PRESENTED BY ARMS RELIABILITY

Training in Root Cause Analysis

Why RCA Doesnt Work

www.armsreliability.com/rca North America | South America | Europe | Asia | Africa | Australia

WHy RCA DOESNT WORk

THE IMPACT OF LANGUAGE ON RCA INVESTIGATIONS

www.armsreliability.com/rca North America | South America | Europe | Asia | Africa | Australia

WHy RCA DOESNT WORk

Poor | Inadequate | Ineffective | Insufficient

Time | Speed | Age | Weight

WHy RCA DOESNT WORk

Poor | Inadequate | Ineffective | Insufficient

www.armsreliability.com/rca North America | South America | Europe | Asia | Africa | Australia

WHy RCA DOESNT WORk

Time | Speed | Age | Weight

WHy RCA DOESNT WORk

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WHy RCA DOESNT WORk

CREATING MORE EFFECTIVE RCA CAUSE-ANDEFFECT CHARTS

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WHy RCA DOESNT WORk

Clues on finding causes

Understanding conditional causes

Too many words

Why does anything happen???...Because it can!

WHy RCA DOESNT WORk

Clues on finding causes

EXAMPLE: Negative publicity

EXAMPLE: Hand bleeding

EXAMPLE: Delayed shipping

WHy RCA DOESNT WORk

Understanding conditional causes

EXAMPLE: Radiator Hose

EXAMPLE: Bolt fell out

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WHy RCA DOESNT WORk

Understanding conditional causes

EXAMPLE: Pipe dropped

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Too many words

EXAMPLE: Non-return valve failed

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WHy RCA DOESNT WORk

EXAMPLE: Shaft is worn

WHy RCA DOESNT WORk

What is the difference between actions and conditions?

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WHy RCA DOESNT WORk

Why does anything happen???... Because it can!

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WHy RCA DOESNT WORk

THE BLAME GAME

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WHy RCA DOESNT WORk

Will knowing who did it, stop it from happening again?

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WHy RCA DOESNT WORk

The question is why?

The Blame Game

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