6 Critical Steps for a

Successful Root Cause

Analysis

Success

• Do we want it ?

• How do we achieve it?

6 Elements

• Information

• Preparation

• Conduct the RCA

• Challenge what you know

• Reporting

• Success

Step 1……Information

• 3 forms

• Collected information

• Stored information

• Information that employees accumulate

over time

Collected Information

• Once an incident, an accident, an

unwanted event has occurred how do we

respond?

• Information is critical!

• How do we collect it?

• This must be timely!

• Misinformation

• Someone must own it

Triggers

• A clear understanding of what your risk

matrix declares as investigation trigger

points is vital.

Stored Information

• Access your CMMS systems

• How good is your information??

• Abbreviated or Generic descriptions

• Electronic Data

Information that employees accumulate

• People have experience and knowledge to

share.

• Ensure that you have the right people in

the room

Step 2….Preparation

• Room and amenities

• People

• Data, Reports

• Visual stimuli

• Who owns this task?

• 7xP’s

Step 3 ….Conduct the RCA

• Get the right facilitator

• Trained/untrained

• Experienced/inexperienced

• Good at it/ ?

• Who doesn’t have a vested interest in the

outcome

• Should it be the subject matter expert?

Facilitation

• What are the attributes of a good

facilitator?

• Knows the process

• Good listener

• Keeps control of the group

• Good communicator

• Can remain neutral

• Respects all contributions

Step 4….Challenge your charts

• How do you know you have “got it”?

• Review your cause and effect chart

• Critical challenge is the key

• Be consistent

• Be logical

• Follow the rules

• Have evidence to support the information

Step 4….Challenge your Charts

• Demand excellence in the cause and

effect charts

• The chart reflects what you know

• It is an iterative process

• A quality chart can be an effective

learning tool

• Be specific

Excellence in Charting

• A lot can be gained from making the effort

in trying to achieve the best possible chart.

• Will it ever be perfect?.......Rarely

• Opportunities for improvements can

however be identified.

• At the end of the day the chart becomes

the validation for the choices made

regarding corrective actions.

Step 5….Reporting

• Effective communication is the key

• Who should be able to read the report?

• Time is valuable

• Kiss principle

Reporting ….Key elements

• Clear defining statement

• The cause and effect chart and also the

cause and effect summary

• Corrective actions assigned to critical

causes…..ownership needs to be given

and due dates set

• Attendees, cost information, appendices

Step 6…..Success

• Easy to say….. hard to prove

• Measure the impact of any changes that

are implemented

• Success breeds success

• Advertise

Attitude to Root Cause Analysis

Positive or Negative???

Blame?

Time?

Previous experience?

Lack of support?

• LEARNING FROM THE INCIDENTS AND

EVENTS THAT HAPPEN IS VITAL TO AN

INDUSTRY TRYING TO MAKE

IMPROVEMENTS.

• THE NEED TO BE EFFECTIVE IN THE ART

OF ROOT CAUSE ANALYSIS THEREFORE

BECOMES IMPERATIVE.

• TO BE SUCCESSFUL IN THIS PURSUIT REQUIRES …

• THAT EFFECTIVE STRUCTURES EXIST THAT GATHER INFORMATION CONTINUALLY AND ALSO IMMEDIATELY AFTER AN EVENT

• STRUCTURES THAT SUPPORT AND ALLOW SOUND PREPARATION TO OCCUR ARE IN PLACE

• THAT COMPANIES TRAIN EMPLOYEES TO THE LEVEL THEY NEED TO BE EFFECTIVE FACILITATORS

• THAT THE IMPLEMENTATION OF CORRECTIVE ACTIONS IS ASSURED AND THAT WE MEASURE THE IMPACT OF THOSE CHANGES.

Acceptance

• If you are willing to accept investigation

reports that are less than what they should

be ….then that is what you are most likely

to get!

• If it is worth doing then it is worth doing

well!

Codicil

• Success in the performance of Root

Cause Analysis will happen more

consistently when clear process structures

are in place and when positive

management support is given to the

process!

Contact Details

Jack Jager ARMS Reliability jjager@armsreliability.com