Root Cause Analysis ─ Improving Performance for Bottom-Line Results

What is RCA? It seems like such an easy question to answer, yet from novices to veterans and practitioners to providers, no one seems to have come to agreement or consensus on an acceptable definition for the industry. Now in its fourth edition, Root Cause Analysis: Improving Performance for Bottom-Line Results discusses why it is so hard to get such consensus and why various providers are reluctant for that to happen.
See what’s new in the Fourth Edition:


Human Error Reduction Techniques (HERT) – new chapter
Failure Scene Investigation (FSI) – Disciplined Evidence Gathering
Categorical versus Cause-and-Effect RCA Tools
Analysis Tools Review
The Germination of a Failure
Constructing a Logic Tree
Introduction of PROACTOnDemandSM
The Advantages of Software-as-a-Service (SaaS)
The Pros and Cons of RCA Templates
Three New Client Case Histories

The authors discuss evidence collection and strategy, failure scene investigation techniques, the human element, and the contribution of human performance and human factors to poor decision making. They clarify definitions that can be considered ambiguous and underscore the distinctions between applying PROACT manually using a paper-based system versus using an automated software tool.

Written by practitioners for practitioners, the book outlines an entire RCA system which involves a cultural paradigm change about how failure is perceived and acted upon in an organization. The authors’ trademark, down-to-earth style provides a step-by-step action plan for how to construct and implement a root cause analysis system that can be applied to any industry.

Read MRI Safety 10 Years Later, co-authored by Robert Latino.

Robert J. Latino is the CEO of Reliability Center, Inc., a Reliability Consulting firm in Hopewell, Virginia that specializes in improving Equipment, Process and Human Reliability. Kenneth C. Latino and Mark A. Latino are Presidents at Reliability Center, Inc.

Introduction to the PROACT Root Cause Analysis (RCA) Work Process Mean Time Between Failure (MTBF) Frequency of Events Maintenance Cost Availability Reliability Balanced Scorecard The RCA Work Process Introduction to the Field of Root Cause Analysis What is Root Cause Analysis (RCA)? Why Do Undesirable Outcomes Occur? The Big Picture Are All RCA Methodologies Created Equal? Attempting to Standardize RCA — Is This Good For the Industry? What is Not Root Cause Analysis? How to Compare Different RCA Methodologies When Researching Them What Are the Primary Differences Between Six Sigma and RCA? Obstacles to Learning from Things That Go Wrong Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP) The Role of Executive Management in RCA The Role of a RCA Champion (Sponsor) The Role of the RCA Driver Setting Financial Expectations: The Reality of the Return Institutionalizing Root Cause Analysis (RCA) in the System Failure Classification RCA as an Approach Opportunity Analysis: “The Manual Approach” Step 1: Perform Preparatory Work Define the System to Analyze Define Undesirable Event Draw Block Diagram (Use the Contact Principle) Describe the Function of Each Block Calculate the “Gap” Develop Preliminary Interview Sheets and Schedule Step 2: Collect the Data Step 3: Summarize and Encode Data Step 4: Calculate Loss Step 5: Determine the “Significant Few” Step 6: Validate Results Step 7: Issue a Report Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process Determining Our Event Data Needs Establish a Workflow to Collect the Data Employ a Comprehensive Data Collection System Analyze the Digital Data The PROACT® RCA Methodology Preserving Event Data The Error-Change Phenomenon The 5-Ps Concept Parts Position People Paper Paradigms Ordering the Analysis Team Novices versus Veterans The RCA Team Analyzing the Data: Introducing the PROACT Logic Tree An Academic Example Confidence Factors The Troubleshooting Flow Diagram Communicating Findings and Recommendations The Recommendation Acceptance Criteria Developing the Recommendations Developing the Report The Final Presentation Tracking for Bottom-Line Results Getting Proactive Work Orders Accomplished in a Reactive Environment Sliding the Proactive Work Scale Developing Tracking Metrics Exploiting Successes Creating a Critical Mass Recognizing the Life Cycle Effects of RCA on the Organization Conclusion Automating Root Cause Analysis: The Utilization of The PROACT Enterprise Version 3.0+ Customizing PROACT For Our Facility Setting Up a New Analysis in the New PROACT FMEA and OA Module Setting Up a New Analysis in the New PROACT RCA Module Automating the Preservation of Event Data Automating the Analysis Team Structure Automating the Root Cause Analysis — Logic Tree Development Automating the RCA Report Writing Automating Tracking Metrics Case Histories Case History #1: ISPAT Inland, Inc. East Chicago, IN Case History #2: Eastman Chemical Company Kingsport, TN Case History #3: LYONDELL-CITGO Refining Houston, TX Case History #4: Eastman Chemical Company World Headquarters Kingsport, TN Case History #5: Southern Companies Alabama Power Company Parrish, AL Case History #6: Weyerhauser Company Valliant, OK Index