Root Cause Analysis
Loma Consulting understands that not everything goes according to plan. As a result, we conduct training courses in root cause analysis, and assist maintenance organizations in conducting analyses and in setting up root cause analysis programs.
RCM and similar disciplines enable the organization to establish strategies to prevent failures and outages. In a perfect world neither failures nor unplanned outages would occur, however this is unrealistic. Root Cause Analysis is a series of tools used to learn from undesired experiences. A wide variety of RCA tools have been developed. The simplest include the “Five Whys”, where the analyst asks the question “Why” about five times (more or fewer questions can be appropriate depending on the complexity of the problem). Five is a rule of thumb. RCA providers have also created long lists of potential root causes – such as failure to follow procedures – that can be used as candidates for root causes of a particular equipment problem. More sophisticated approaches include some variety of “cause mapping” (varieties of this term are used by a large number of companies). Root cause is officially defined as a cause that can:
* Eliminate the failure
* Prevent the failure from recurring
* Be implemented by the organization.
Originally, when equipment failed, maintenance organizations simply took corrective action as quickly as possible, and discarded any traces of the remains of the failed asset. Later, organizations realized the value in conducting a review to identify why the failure occurred and to prevent future occurrences. Every company has established a number of strategies to prevent failures – training programs, preventive maintenance, design standards such as redundant assets, and others. Root Cause Analysis expanded beyond simple equipment failures to look into human related causes – did the technician make a mistake in testing, installing, or maintaining the asset?
The latest insight in RCA involves reviewing management actions to understand how the organization failed to prevent the human error or physical failure. Eventually, root causes came to be divided into three types:
* Physical – the mechanical, electrical, or control failure of the asset.
* Human Error – the mistakes (either knowingly or unknowingly) made by humans
* Latent – organizational problems that enabled the human or physical errors to take place.
The analyst then selects a root cause for action that meets the criteria listed above, and implements the appropriate corrective action, including responsibilities, due dates, allocation of resources, etc.