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Root Cause Analysis: Improving Performance for Bottom-Line Results, Fifth Edition 5th edition [Kõva köide]

(APM Product Manager, GE Digital, Roanoke, VA), (President, Reliability Center, Inc., Hopewell, VA), (Principal, Prelical Solutions, LLC.)
  • Formaat: Hardback, 366 pages, kõrgus x laius: 234x156 mm, kaal: 646 g, 33 Tables, black and white; 138 Illustrations, black and white
  • Ilmumisaeg: 12-Jul-2019
  • Kirjastus: CRC Press
  • ISBN-10: 1138332453
  • ISBN-13: 9781138332454
  • Formaat: Hardback, 366 pages, kõrgus x laius: 234x156 mm, kaal: 646 g, 33 Tables, black and white; 138 Illustrations, black and white
  • Ilmumisaeg: 12-Jul-2019
  • Kirjastus: CRC Press
  • ISBN-10: 1138332453
  • ISBN-13: 9781138332454
This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach.

This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results.

Features











Outlines in detail every aspect of an effective RCA system





Displays appreciation for the role of understanding the physics of a failure as well as the human and systems contribution





Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system





Explores the correlation between Reliability Engineering and Safety





Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA

Arvustused

Read full review at https://www.linkedin.com/pulse/root-cause-analysis-improving-performance-bottom-line-sanya-mathura/

Foreword xiii
Preface xv
How to Read This Text xvii
Acknowledgments xix
Introduction/Reflections xxi
Authors xxix
1 Introduction to the PROACT® Root Cause Analysis (RCA) Work Process 1(18)
Strategize
3(1)
Execution
4(1)
Evaluation
4(4)
Mean-Time-Between-Failures
7(1)
Number of Failure/Repair Events
8(1)
Maintenance Cost
8(1)
Availability
8(1)
Reliability
9(3)
Balanced Scorecard
12(2)
The RCA Work Process
14(5)
2 Introduction to the Field of Root Cause Analysis 19(20)
What Is Root Cause Analysis?
19(1)
The Error-Change Phenomenon
20(4)
The Stigma of "RCA"
24(1)
Why Do Undesirable Outcomes Occur? The Big Picture
25(1)
Are All RCA Methodologies Created Equally?
26(1)
Attempting to Standardize RCA-Is This Good for the Industry?
26(2)
What Is Not RCA?
28(2)
How to Compare Different RCA Methodologies When Researching Them?
30(3)
What Are the Primary Differences between Six Sigma and RCA?
33(1)
Obstacles to Learning from Things That Go Wrong
34(2)
What Are the Differences between an "RCA," a Legal Investigation and a Safety Investigation?
36(3)
3 Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP®) 39(18)
The Role of Executive Management in RCA
39(3)
The Role of an RCA Champion (Sponsor)
42(3)
The Role of the RCA Driver
45(3)
Setting Financial Expectations: The Reality of the Return
48(2)
Institutionalizing RCA in the System
50(1)
Sample PROACT RCA Procedure (RCI)
51(6)
4 Failure Classification 57(8)
RCA as an Approach
64(1)
5 Opportunity Analysis: "Mindfulness" 65(22)
Step 1-Perform Preparatory Work
70(5)
Define the System to Analyze
70(1)
Define Undesirable Event
70(3)
Drawing a Process Flow Diagram or Block Diagram (Use the Contact Principle)
73(1)
Describe the Function of Each Block
73(1)
Calculate the "Gap"
74(1)
Develop Preliminary Interview Sheets and Schedule
74(1)
Step 2-Collect the Data
75(4)
Step 3-Summarize and Encode Data
79(2)
Step 4-Calculate Loss
81(1)
Step 5-Determine the "Significant Few"
82(1)
Step 6-Validate Results
83(1)
Step 7-Issue a Report
84(3)
6 Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process 87(16)
Determining Our Event Data Elements
87(2)
Establish a Work Process to Collect the Data
89(2)
Employ a Comprehensive Data Collection System
91(2)
Analyze the Digital Data
93(10)
7 Preserving Event Data 103(24)
The PROACT RCA Methodology
103(1)
Preserving Event Data
104(3)
The 5P's Concept
107(1)
Parts
108(1)
Position
109(2)
People
111(8)
People to Interview
115(1)
Interview Preparation
116(1)
Observe the Body Language
117(2)
Paper
119(1)
Paradigms
120(7)
8 Ordering the Analysis Team 127(16)
Novices versus Veterans
128(2)
The RCA Team
130(1)
What Is a Team?
130(1)
Team Member Roles and Responsibilities
131(2)
The Principal Analyst
131(1)
The Associate Analyst
132(1)
The Experts
132(1)
Vendors
132(1)
Critics
133(1)
PA Characteristics
133(1)
Unbiased
133(1)
Persistent
134(1)
Organized
134(1)
Diplomatic
134(1)
The Challenges of RCA Facilitation
134(2)
Bypassing the RCA Discipline and Going Straight to a Solution
134(1)
Floundering of Team Members
135(1)
Acceptance of Opinions as Facts
135(1)
Dominating Team Members
135(1)
Reluctant Team Members
135(1)
Going Off on Tangents
136(1)
Arguing among Team Members
136(1)
Promote Listening Skills
136(1)
One Person Speaks at a Time
136(1)
Don't Interrupt
137(1)
React to Ideas, Not People
137(1)
Separate Facts from Conventional Wisdom
137(1)
Team Codes of Conduct
137(1)
Team Charter/Mission
138(1)
Team CSFs
138(1)
Team Meeting Schedules
139(1)
PROACT RCA Process Flow
139(1)
Process Flow and Chronic versus Sporadic Events
140(1)
Team Approach to Chronic Events
141(2)
9 Analyzing the Data: Introducing the PROACT® Logic Tree 143(40)
Categorical versus Cause-and-Effect RCA Tools
143(1)
Analytical Tools Review
143(4)
The Germination of a Failure
147(1)
Constructing a Logic Tree
148(1)
The Event
149(2)
The Mode(s)
151(1)
The Top Box
152(4)
The Hypotheses
156(1)
Verifications of Hypotheses
157(3)
The Fact Line
160(1)
Physical Root Causes/Factors
161(1)
Human Root Causes/Factors
161(2)
Latent Root Causes/Factors
163(2)
Breadth and All Inclusiveness
165(1)
The Error-Change Phenomenon Applied to the Logic Tree
166(1)
Order
167(1)
Determinism
167(1)
Discoverability
167(1)
Finding Pattern in the Chaos
168(1)
Verification Techniques
168(2)
Confidence Factors
170(1)
Exploratory versus Explanatory Logic Trees
171(1)
Using the Logic Tree for Storytelling
171(1)
Putting It All Together: A Basic Case
172(11)
10 Communicating Findings and Recommendations 183(20)
The Recommendation Acceptance Criteria
183(2)
Developing the Recommendations
185(1)
Developing the Report
186(1)
The Executive Summary
187(1)
The Event Summary
187(1)
The Event Mechanisms
188(1)
The PROACT® Investigation Management System Description
188(1)
The Root Cause Action Matrix Summary
188(1)
The Technical Section (The Explanatory Description)
188(2)
The Identified Root Cause(s)
189(1)
The Type of Root Cause(s)
189(1)
The Responsibility of Executing the Recommendation
189(1)
The Estimated Completion Date
189(1)
The Detailed Plan to Execute Recommendation
190(1)
Appendices
190(2)
Recognition of All Participants
190(1)
The 5P's Data Collection Strategies
190(1)
The RCA Team's Charter
191(1)
The RCA Team's CSFs
191(1)
The Logic Tree
191(1)
The Verification Logs
191(1)
The Recommendation Acceptance Criteria (If Applicable)
191(1)
Glossary of Terms
192(1)
Investigation Schedule
192(1)
Figure and Table Listings
192(1)
Report Use, Distribution, and Access
192(1)
The Final Presentation
193(1)
Have the Professionally Prepared Reports Ready and Accessible
194(1)
Strategize for the Meeting by Knowing Your Audience
194(1)
Have an Agenda for the Meeting
195(1)
Develop a Clear and Concise Professional Presentation
196(1)
Coordinate the Media to Use in the Presentation
196(1)
Conduct "Dry Runs" of the Final Presentation
197(1)
Quantify the Effectiveness of the Meeting
198(1)
Prioritize Recommendations Based on Impact and Effort
199(2)
Determine Next Step Strategy
201(2)
11 Tracking for Bottom-Line Results 203(18)
Getting Proactive Work Orders Accomplished in a Reactive Environment
204(1)
Sliding the Proactive Work Scale
205(2)
Developing Tracking Metrics
207(6)
Process Measures
207(1)
Outcome Measures
207(6)
Exploiting Successes
213(2)
Creating a Critical Mass
215(1)
Recognizing the Lifecycle Effects of RCA on the Organization
216(1)
The Pros and Cons of Using Zero Harm as a Safety Metric
217(2)
Conclusion
219(2)
12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior 221(32)
Ineffective Supervision
224(2)
Improving Your Listening Skills
226(1)
How to Use This Information
227(1)
Lack of an Accountability System
228(1)
Distractive Environment
229(1)
Low Alertness and Complacency
230(4)
Work Stress/Time Pressure
234(1)
Work Stress
234(1)
Time Pressure
235(1)
Overconfidence
236(1)
First-Time Task Management
237(1)
Imprecise Communication
237(6)
Vague or Incorrect Guidance
243(4)
Training Deficiencies
247(2)
New Technology
249(4)
13 Do Human Performance "Learning Teams" Make RCA Obsolete? 253(12)
Is RCA "Old School and Obsolete?"
253(1)
Aligning RCA Dictionaries between HPI and Reliability-The Criticality of Defining Terms
254(1)
Are the HPI Myths about RCA True?
255(6)
The Concept of Learning Teams
261(4)
14 Is There a Direct Correlation between Reliability and Safety? 265(14)
Why Explore This Potential Correlation?
265(1)
An Ironic LinkedIn Post Caught Our Attention
266(1)
The Safety Research Perspective
267(3)
The Reliability Practitioner's Perspective
270(3)
So, Does a Correlation Exist?
273(3)
Conclusion
276(3)
15 Automating Root Cause Analysis: Introducing PROACTOnDemand® 279(22)
Customizing PROACT for Our Facility
279(1)
Setting Up a New Analysis in the New PROACT RCA Module
280(5)
Automating the Preservation of Event Data
285(3)
Automating the Analysis Team Structure
288(1)
Automating the RCA-Logic Tree Development
289(5)
Automating RCA Report Writing
294(3)
Automating Tracking Metrics
297(4)
16 Case Histories 301(24)
Case Study No. 1: North American Paper Mill
301(8)
Case Study No. 2: PEMMAX Consultants, Waterloo, Ontario, Canada
309(2)
Case Study No. 3: PSEG, Jersey City, New Jersey
311(9)
Case Study No. 4: MotorDoc® LLC, Lombard, IL USA
320(5)
Index 325
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 Corporations (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 bachelors 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 bachelors degree in business administration and man­age­ment from Virginia Commonwealth University.

Robert has been facilitating RCA, FMEA and Opportunity Analyses with his clientele around the world for over 34 years, and has taught over 10,000 students in the PROACT® methodology. He is co-author of numerous seminars and workshops on these topics as well as co-designer of the award winning PROACT® Investigation Management System.

Robert is an author of Patient Safety: The PROACT Root Cause Analysis Approach and contributing author of Error Reduction in Healthcare: A Systems Approach to Improving Patient Safety, The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations and Nurse Communication: Safe Care, Positive Workplaces, & Rewarding Careers.

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: Whats the Difference?" at the NAHQ National Conference. 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."

Kenneth C. Latino is an Asset Performance Management (APM) Product Manager with GE Digital. 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. Prior to his current role at GE, Kenneth was the Reliability Engineering Manager at the WestRock paper mill in Covington Mill.

Over the past few years, a majority of Kenneths focus has centered around developing reliability approaches with a heavy emphasis on Asset Performance Management (APM) with specific focus around failure elimination and Root Cause Analysis (RCA). In the course of his career, 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 courses: one for engineers and another for hourly personnel.

Kenneth is also co-software designer of the RCA software solution entitled the PROACT Investigation Management System. The PROACT solution is used by hundreds of companies around the world every day to understand the causes of failures to help eliminate/mitigate their reoccurrence.