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