Root Cause

Hidden but powerful forces within our organizations are causing people to make serious mistakes. Until someone deals with these forces, they will continuously but unpredictably snare people into doing things they should not do. These forces are like a “trap,” waiting to catch the next person. The most proactive of all industrial action might be to identify and remove these latent traps. But all our attempts to identify and remove these latent causes of failure start at the human. Humans do things “inappropriately,” for “latent” reasons.

Root Cause Analysis (RCA) is a useful tool for trouble shooting breakdowns and efficiently coming to a solution. I propose the following seven points for successful implementation of RCA that will naturally result in increased profits.

Many different factors contribute towards the failure of a pump. Some factors that did not seem to have contributed to earlier failures were not examined or considered and may become the cause of failure under other situations. Failures do not occur suddenly. Usually there are many symptoms, which signal a failure situation and are generally termed as potential failure modes. The ignorance of such symptoms almost always leads to failure. Below are two case studies pertaining to mechanical seal systems, a vital component of pumps operating in running process plant.

As a teacher and a practitioner of root cause analysis, I see not only the physical motions of going through such an effort, but also the psychology behind what makes or breaks it. When you consider the effort that goes into determining root causes and developing recommendations, why should it be such a hard sell to get something done?

Loaded with cliché and ambiguity, true root cause analysis is neither being practiced nor even desired in most areas of life. Plenty of organizations are addressing the “physical” causes of failure. Even more seem to enjoy finding out “who did it” so that disciplinary action can occur. But only a few seem willing to dig deeper in an attempt to understand the “root” causes of things that go wrong. Are you one of the few, or are you contributing to the ambiguity?

DOE Order 5000.3A, “Occurrence Reporting and Processing of Operations Information,” investigation and reporting of occurrences (including the performance of root cause analysis) requires the and the selection, implementation, and follow-up of corrective actions. The level of effort expended should be based on the significance attached to the occurrence. Most off-normal occurrences need only a scaled down effort while most emergency occurrences should be investigated using one or more of the formal analytical models. A discussion of methodologies, instructions, and worksheets in this document guides the analysis of occurrences as specified by DOE Order 5000.3A.

If I have an unwanted situation which consumes resources and tends to happen in a repeated fashion then there is a possibility that it might be beneficial to figure out what is really causing this situation to occur and remove it so the situation does not occur again. This is generally referred to as Root Cause Analysis, finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms.

RCM may have been thought of as a strategy best left to large organizations. That may have been a perfectly logical assumption. Small-to medium-sized enterprises (SMEs) and lean operations simply seem to have less money to invest in and fewer resources to cope with the many activities required for RCM success. Now, however, out of joint academic/industry collaboration in Spain, comes information that may help begin to put these types of popular misconceptions to rest. The RCM methodology described in this overview of the Spanish research has been adapted to meet the specific needs of today’s smaller, leaner organizations. And it is not just a theory, either. The practicality of this approach is being confirmed through actual testing in SME and/or lean companies.