Quick SummaryUncovering the evidence is the most important factor in any Root Cause Analysis investigation, in fact without evidence, it is entirely impossible to carry on.
Evidence - The Lifeblood Of Root Cause Failure Analysis
Those who rely on data too much miss out the most important aspect of any Root Cause Analysis. Hence, if data is not the most important factor in performing a Root Cause Analysis, then what is it? The answer is “EVIDENCE”, and uncovering the evidence is the most important factor in any Root Cause Analysis investigation, in fact, it can be said that evidence is the “Lifeblood of any Root Cause Analysis, without evidence, it is entirely impossible to carry on such a probe.
First, let us define what evidence is all about. Evidence is a piece of information that supports a conclusion. Wikipedia define evidence in its broadest sense to include anything that is used to determine or demonstrate the truth of an assertion. Philosophically, evidence can include propositions which are presumed to be true used in support of other propositions that are presumed to be falsifiable.
The term has specialized meanings when used with respect to specific fields, such as policy, scientific research, criminal investigations and legal discourse. Without evidence present in our RCA efforts, all we have will be inconclusive and biased opinions, hypothesis, hearsay and arguments.
Failures do not just happen without leaving a trace or clue; it will always leave some sort of clue for the investigator or analyst to uncover. Root Cause Analysis separates the facts from fiction. RCA is not about trial and error and seeing which one works and not.
Although there are many techniques in analyzing a problem which provides a quick answer, it does not mean the answer is correct every time. A true and meaningful Root Cause Analysis will definitely take the time to prove that what we will uncover will be based on facts and that every single fact we find will be based on evidence. When the facts are backed up by evidence, then we now have a crystal clear understanding and appreciation of what Root Cause is all about.
EVIDENCE OF THE MISSING MONEY
A Car wash manufacturer sold one of his turn key car wash system to a client in Maryland. This includes a change machine for people who wish to wash their cars. After quite some time, the owner realized that he was losing a significant amount of money from this machine each week and insinuates that the manufacturers employees have a spare key and are stealing the money. The problem started when the new franchise owner complain to Bill which is the owner of the car wash that he was losing a significant amount of money from this coin machine every time he open it.
Bill cannot believe that his employees are the once stealing the money since they have worked with him for a long time. So the owner decided to install a hidden camera and found out who the real culprit was and definitely it was not the employees who was stealing the money. The owner followed where the bird went and found around $ 4,000.00 USD in the roof of the car wash and more under a nearby tree. The new owner apologized to the people he used to blame for stealing the money.
TYPES OF EVIDENCE
A friend of mine, Charles Robert Nelms, founder of Failsafe Network which is one of the leading providers of Root Cause Analysis in the US classify evidences into three categories. He named it the 3P’s which are People, Physical and Paper. These evidences are arranged according to its importance.
The most important evidence to consider is people. People who witness the failure should be interviewed at once. People have senses, they see things, hear them, feel them. They all have opinions as to what went wrong in the first place. People also tend to forget things easily, that’s why, interviewing people should be prioritize after a failure had occurred. Remember that people evidence are the easiest to evaporate. What is important is to interview and ask them the right questions such as :
- What did you hear or how did it sound like?
- What happen first? And then what?
- What were you doing at the time when the failure occurred?
- Where there others with you that witness the failure?
- Was there any signs before the failure occurred?
- What do you think went wrong with it?
- How do you feel about your job?
- What do you think people working here feels about their jobs?
Interview as many people as you can, minimum of 10 people and spent an hour for each person. Have a set of questions on hand and write down their response. Tape recorders can only be used with the consent and approval of the person you are going to interview. Interview should be done as close as possible to the event where the interviewee was during the time of failure. After you have interviewed a number of people, you will be quite surprise with the information that you have gathered since a sequence of events will emerge from the interview.
Be compassionate and friendly when interviewing people, the more relax the person is during the interview, then the more information can be gathered. Tell them that no one will be punished as a result of the interview and the reason for conducting this interview is to know the truth as to why the failure occurred in the first place. Another thing is to remain focused and unbiased during the interview. Remember that there are always two sides of a coin.
Physical evidence is the second most important evidence of all. It can conceivably include all or part of any object. This includes pictures and photographs taken, actual part or component that failed, sample or debris that scattered, video or surveillance camera during the time of failure, laboratory results of the parts being analyzed. Example, the actual bearing that failed will be part of a physical evidence. One of the important things to consider in physical evidence will be to preserve them. When equipment fails, maintenance try to restore them at once, in order for operations to continue and downtime to be on a minimum.
On the other hand, it is also important to the team performing the analysis and investigation to freeze up the evidence as quickly as possible in order for them to uncover the evidence while it is still fresh. The restoration team must understand that parts that failed should not be thrown away and should be preserve every time equipment fails otherwise parts evidence will totally be impossible for the investigative team. There will always be traces of evidence left on the part that failed.
Positional evidence likewise is included in the Physical Evidence. This includes mapping out the position during the time of failure. What are the readings on the gauges during the time of failure, temperature, what valves are open or close, where does the leak seem to be coming out, what buttons are pushed etc.
Map everything if possible. As the restoration team tries to bring back the equipment up, most of the positional evidences are lost, and again, it is important for the investigative team to “INITIALLY LOOK” at the equipment that failed before restoring them back to normal again. As much as possible try to draw and record every piece of information you can when uncovering positional evidence.
Detective Varnike was playing golf in a garden of hotel, when a shot was suddenly heard in one of the rooms. In a few steps the detective appeared near the loggia of a first floor and slightly pushed an opened the door and squeeze himself into the room. Help someone wanted to kill me! Cried addressing to Varnike a well-known movie star which was in the hotel's room. Just there was a man in a mask here. I was attacked by him. I protected myself as I could, then he shot. Probably, during the struggle I had snatched the pistol out from his hands. After that he rushed to the door and disappeared in a corridor.
Please, call the police! After Detective Varnike observes the room, he said Maybe, I will invite the correspondents, which are sitting in the hallway right now? Asked Varnike. Probably, they are only what you wish. And the police hardly should be disturbed because of such worthless performance!
Question: Why did Detective Varnike refuse to pursue the criminal? What piece of evidence in the above that convince the detective that there was no one that attacked the actress and that the mess was all her doing? (Answer will be provided to those who will email me and in the next edition of my newsletter.)
When we speak about paper evidence, these refers to all recorded documents that we can gather such as history records, PM records, strip charts, manuals, operators logbook, training records, specs and procedures used, Condition-monitoring records, equipment drawings and schematics. Paper evidence should be summarize by the team or person doing the probe or investigation. The investigator should collect all paper evidence as much as possible for a thorough review of the process.
In summary paper evidence we should look for will include those of operations, maintenance and personnel related data. What is important for the investigator is to determine which data are relevant and important at the time of failure.
80% of the time spend on Root Cause Analysis must be based on evidence gathering which includes the 3P’s. Root Cause is not about solutions and countermeasures but rather understanding why the problem did occur in the first place so that we can all learn from them and to understand how and why it occurred we need to dig up evidence. I really find it very difficult or impossible to conduct a Root Cause Analysis in just 24 hrs or a couple of days and arrived with the Root Cause of the problem.
Having worked on various industries such as shipping, assembly lines, manufacturing and mining industries and with all the trainings I’ve been through in all these years on problem solving tools allows me to think that Root Cause is all about solution and countermeasures. I am definitely dead wrong. We all have a human intuition that when we encounter a failure we want a solution fast in order to get rid of the failure, and most of as have the temptation to modify without understanding the Root Cause of the problem.
I know that we have a lot of failures which are chronic in nature and up to now continue to exist in our plant. We must understand that the most important factor in performing a Root Cause Analysis is to gather evidence so that we can understand truly once and for all why the failure occurs in the first place. We need to become one with failure and understand them. Most people think that failure is bad for business; I think failure is telling us something in the first place. Failure is the best teacher we can ever have as we can all learn from them.
People see of my success is only one percent but what they don’t see is the 99 percent which are my failures . . . From Sochiro Honda, President of Honda
What You Can Learn From The Things The Go Wrong by C. Robert Nelms:
Your thoughts matter to others - more than you can imagine.
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