Root Cause Analysis, or RCA, "What is it?" Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we’re applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence.
In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include:
- Preserving evidence (data)/not allowing hearsay to fly as fact
- Organizing an appropriate team/minimizing potential bias
- Analyzing the events/reconstructing the incident based on actual evidence
- Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented
- Tracking bottom-line results/ensuring that identified, meaningful metrics were attained
We explore, "Why don’t things always go as planned?" When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field.
This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application.
This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few.
Table of Contents
1. The PROACT RCA Methodology Overview. 2. Preserving Event Data. 3. Organizing the RCA Team. 4. Analyzing the Data: Introducing the PROACT® Logic Tree. 5. Communicate Findings & Recommendations. 6. Tracking for Bottom-Line Performance. 7. Case Study (A3 Report Format).
Kenneth C. Latino is Reliability Champion of MeadWestvaco in Covington, Virginia. He has a bachelor of science degree in computerized information systems from Virginia Commonwealth University. He began his career developing and maintaining maintenance software applications in the continuous process industries. After working with clients to help them become more proactive in their maintenance activities, he began consulting and teaching industrial plants how to implement reliability methodologies and techniques to help improve the overall performance of plant assets.
Over the past few years, a majority of Kenneth’s focus has centered around developing reliability approaches with a heavy emphasis on Root Cause Analysis (RCA). He has trained thousands of engineers and technical representatives on how to implement a successful RCA strategy at their respective facilities. He has co-authored two RCA training seminars: one for engineers and another for hourly personnel.
Kenneth is also co-software designer of the RCA program entitled the PROACT Suite. PROACT was a National Gold Medal Award winner in Plant Engineering’s 1998 and 2000 Product of the Year competition for it first two versions on the market. He is currently president of the Practical Reliability Group, a Reliability consulting firm dedicated to delivering approaches and solutions that can be practically applied in any asset-intensive industry.
Mark A. Latino is president of Reliability Center, Inc. (RCI). Mark came to RCI after 19 years in corporate America. During those years, a wealth of reliability, maintenance, and manufacturing experience was acquired. He worked for Weyerhaeuser Corporation in a production role during the early stages of his career. He had an active part in Allied Chemical Corporation’s (now Honeywell) Reliability Strive for Excellence initiative that was started in the 1970s to define, understand, document, and live the Reliability culture until he left in 1986. Mark spent 10 years with Philip Morris primarily in a production capacity that later ended in a Reliability Engineering role. Mark is a graduate of Old Dominion University and has a bachelor’s degree in business that focused on production and operations management.
Robert J. Latino is CEO of Reliability Center, Inc. (RCI). RCI is a reliability consulting firm specializing in improving equipment, process, and human reliability. He received his bachelor’s degree in business administration and management from Virginia Commonwealth University.
Robert has been facilitating RCA and FMEA analyses with his clientele around the world for over 20 years and has taught over 10,000 students in the PROACT® methodology. He is co-author of numerous seminars and workshops on FMEA and RCA as well as co-designer of the award winning PROACT Suite Software Package.
Robert is a contributing author of Error Reduction in Healthcare: A Systems Approach to Improving Patient Safety and The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations.
Robert has also published a paper entitled, "Optimizing FMEA and RCA Efforts in Healthcare" in the ASHRM Journal and presented a paper entitled, "Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?" at the ASHRM 2005 National Conference in San Antonio, Texas. He has been published in numerous trade magazines on the topic of reliability, FMEA, and RCA and is also a frequent speaker on the topic at domestic and international trade conferences.
Robert has also applied the PROACT methodology to the field of Terrorism and Counter Terrorism via a published paper entitled, "The Application of PROACT RCA to Terrorism/Counter Terrorism Related Events."