A Different Root Cause Analysis Experience
Read in 9 min. We often hear the word Root Cause Analysis, and Root Cause Failure Analysis yet, I really wonder if we really know what it truly means. In fact almost every industry has their own unique Root Cause Analysis technique to follow.
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Some of the basic questions being raised in the first place that needs an answer is, How far should we go on with our analysis? Although, there is a wide range of analytical tools on the market that had been provided such as Ishikawa or Fishbone Diagram, FMEA, Pareto Analysis, Kepner Trego, 8 disciplines, TOPS, P-M Analysis, FMECA, 5 Whys, Fault Tree, etc.,but the real question raised is that, are these tools really meant to address the root cause of the problem ? Each of these tools will claim yes, but I really doubt if they do.
First let us define what Root Cause Analysis is all about. From Wikipedia, free encyclopedia, Root Cause Analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is hope that the likelihood of the problem recurrence can be minimized. However, it is recognized that complete prevention of recurrence by a single intervention is not always possible.
Let me explain the last sentence as this was discussed in my recent Newsletter, If Failures Can Really Be Eliminated? Complete elimination of failure in our equipment is not possible, the best that maintenance can do is to delay and anticipate its recurrence, and in its technical sense failures are inevitable and are meant to happen.
Root Cause is not a silver bullet or rocket science thing that will eliminate all known problems. This tool can only be useful if we truly understand what its intent and purpose is all about, yet most people from industries abuse the word Root Cause thinking that it is meant to put an end to all their problems. All I can say is that in every way, they are wrong. We need to understand that Root Cause is being performed so that we can learn from the things that go wrong.
The problem lies in how we understand the problem and how we analyze it. Pareto will say that 80% of the effects come from 20% of the causes. My question is the 20% really the root cause or just some probable causes. Why-why states that by performing why-why 5 times, and the team finds it hard to answer, the bottom line, the root cause had been define. But worst than that when we find the person who is guilty, then the root cause had been finally been identified.
In view of these, let me shed some light on what a true and meaningful Root Cause Analysis is all about:
LESSONS ON ROOT CAUSE ANALYSIS
1st: Root Cause is not about Failure Modes or probable causes, it is always based from facts and the facts are always based from evidence that had been gathered. Root Cause will always have to be based upon pure evidence. Every failure had some sort of clues to leave as to why it occurred. Do we talk to people who were involved in the problem? Did we examine the part that failed? Did we find anything unusual about the event that took place? Is our RCA efforts based purely from evidence or not?
2nd: Root Cause is about learning from the things that go wrong. This statement had change the way I think about failures. Let me put it this way. Have you ever heard the word “Benchmarking other industries success” or is it most worthwhile to benchmark other industries failures. Can we learn from success of other people or can we learn from our own failure and adversities. Let me get a little soft and philosophical about this matter so we can understand it better. Let me share to you some quotes about people who learned from failures.
There is a tendency to walk away from failure and leave it buried. An enormous amount of institutional learning gets buried because failures don’t get analyzed. So the real learning is what’s learned from failure, by Andrew Grove, Chairman and Co-founder of Intel Corporation
You don’t learn about yourself through your success. You only learn through your failures and your mistakes, by Wynonna (The Judds)
Most people make a common mistake . . . by thinking of failure as the enemy of success . . . You’ve got to put failure to work for you . . . go ahead and make mistakes. Make all you can. Because, remember that’s where you’ll find success . . . On the far side of failure by Thomas Watson of IBM
What people see of my success is only one percent but what they don’t see is the 99 percent which are my failures by Soichiro Honda, President of Honda Corporation
Rethinking, failure is not bad after all; this is our greatest teacher if we can learn from them the same principle applies in Root Cause Analysis.
3rd: People commit mistakes and errors, almost every failure or problem will lead to an error or mistake done by a human being. Even with the best system in place, people err and the analyst must realize that not all mistakes people make are within their control. In this regard, I would strongly emphasize that Root Cause is not a tool to put a blame and punishment on someone. This will only make people more defensive. Some industries which truly understand what Root Cause is provide some sort of amnesty program and emphasized it clearly in the beginning of any RCA investigation process that we only would perform a thorough Root Cause Analysis because we want to learn from the things that go wrong and not to blame or punish someone. We all contribute to problems yet most of the time we are like Pontius Pilate washing hands thinking that we ain’t part of the problem.
4th: A true and meaningful Root Cause Analysis is done in 3 Levels, first by determining the Physical Cause, then analyzing the Human Cause and lastly determining the Latent Cause of the problem. All Physical Failures are triggered by Humans, but humans are negatively influence by Latent Causes. Therefore Root Cause analysis ends when the Latent Causes of the problems are exposed. Latent Causes are not only about flawed systems, flawed procedures, trainings, policies, decisions but rather it simply humbles us to ask the following:
What is it about the way we are that contributes to our problems? What is it about the way I am that contributes to our problems? Are we really sure that if we are on the shoes of the person who committed the mistake, will we do otherwise or also commit the mistake? What was in the person’s mind that eventually leads him to commit that mistake? I think a Classic example here would be the Lessons of the Challenger Explosion where 73 seconds after the flight on January 28, 1986, ended the life of the 6 astronauts and one civilian. What amount of pressure had management been into that led them into this tragedy? Are we sure if we are on their shoes we had done differently or otherwise the same? Think about it. People make the systems, management make decisions and we are all humans. Latency is understanding why people did what they did that eventually leads to this problem. We can only learn from the things that go wrong if we can accept the fact that we are part of the problem itself. This RCA philosophy tells us that RCA have no room for pinpointing mistakes and blaming others. It simply has no room for it.
5th : But the greatest lesson so far one can benefit on truly understanding Root Cause is that it is always better to analyze failures than to fix them every time. It is said that if we become good at fixing failures, then something is definitely wrong, why because we are doing it much too often. Troubleshooting is no longer an effective strategy, in the real world mostly in manufacturing what we need are people who can analyze problems and not troubleshoot them. This meaning eventually makes us understand the difference between a reliability person from a mere mechanic, since a mechanic mostly uses his hand as his tools to fix problems while a reliability person mostly uses his brain and mind to understand and analyze the problem instead of using his hand much too often. Sometimes I find it funny on how most industry thinks, most industry often yells that they have no time to perform an RCA Analysis yet they have all the time to fix the problem again and again and again which makes their people really good at fixing failures.
DETERMINING YOUR RCA REQUIREMENTS
Here are simple guidelines that can help us to determine our RCA requirements.
Does everyone in the organization understand the objective of performing a Root Cause Analysis? Are they united in their purpose or they have their own agenda?
Is management willing to be trained in Root Cause Analysis? Does management truly understands what RCA can and cannot do?
Will the teams be allowed to complete the RCA analysis and will their recommendation be implemented?
Is 3rd party consultation being required in the initial process or not?
Are we willing to learn from the things that go wrong and be part of the learning process?
To conclude, what makes Failsafe’s Latent Cause Analysis different from the other analytical approaches, well LCA takes your analysis a step further from the rest.
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