on Systems Thinking

If 100 healthcare executives were polled about their definitions of “root cause analysis”, there would be 100 different answers. Here in is the problem, understanding the intent and power of Root Cause Analysis (RCA). For this reason, RCA is viewed as having either limited or phenomenal value to an organization. This article will seek to strip away the labels associated with RCA brands and focus on the processes, their results and how they are communicated (or miscommunicated) to executive management. Effective RCA efforts can fail because of their inability to demonstrate their value to the bottom-line of the organization. [Read more…]

In a recent BMJ article entitled ‘Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?‘, the authors’ state “Although RCA’s have been proposed as a mechanism for change, safety scientists believe the lack of improvement of adverse event rates in healthcare is largely because our methods of approaching change are ineffective”. [Read more…]

I often ask my classes ‘If we follow our procedures to the letter, do nothing more and nothing less; would we optimize our system productivity, safety and reliability?’ The answer is NO. [Read more…]

The graphic of the Swiss Cheese Model (attached is an expression from AHRQ) is a good one and one that many will remember and relate to.

However, I would like to expand on that model and express that more commonly, there is a not a singular or linear path to failure. There are typically multiple paths of failure that converge together at some point in time to cause an undesirable outcome. [Read more…]

I think that 5-year olds had a lock on 5Y’s well before it became a ‘named problem solving tool’. How many times have our kids at that age asked ‘Why’ about everything?

How many ‘Why’s’ do we answer before we say, ‘I don’t know, go ask your mother or father!’

Again (to me), the traditional 5-Y tool is technically incapable of expressing multiple paths of logic that occurred simultaneously. It treats failure like it always happens in a linear pattern (never multiple, simultaneous paths). [Read more…]

We all can relate to hearing our leaders refer to their workforces as ‘their greatest asset’. We can even go to the annual 10K reports and read about it in the CEO blurbs on the front pages. Are these statements genuine, is the human being an ‘asset’?

In that same 10K report we can flip a few pages down to review our income statements and balances sheets to quickly confirm that the human being is listed as a ‘liability’ and that our equipment is our defined ‘assets’. This is consistent with our Generally Accepted Accounting Principles (GAAP). [Read more…]

Author’s Note: I want to reiterate that this Series about reading the basic fracture surfaces, is for novices who often first come into contact with such failed components. This Series is about the basics (101), and is intended to give readers an appreciation for the value of such ‘broken’ parts to an effective investigation/RCA. While this information will be rudimentary to seasoned materials engineers, I know they will all appreciate heightening awareness to the need to retain such failed parts for analysis, versus throwing them away and just replacing the part. Throwing away failed parts is a recipe for a repeat failure, when one does not understand why the part failed in the first place.

In Part I of this series we focused on Erosion and Corrosion as the the first two (2) failure mechanisms of component failure. When Erosion and Corrosion are apparent, there is generally a loss of metal in some form or fashion. [Read more…]

Author’s Note: I want to reiterate that this Series about reading the basic fracture surfaces, is for novices who often come into contact with such failed components. This Series is about the basics (101), and is intended to give readers an appreciation for the value of such ‘broken’ parts to an effective investigation/RCA. While this information will be rudimentary to seasoned materials engineers, I know they will all appreciate heightening awareness to the need to retain such failed parts for analysis, versus throwing them away and just replacing the part. Throwing away failed parts is a recipe for a repeat failure, when one does not understand why the part failed in the first place. [Read more…]

This article is directed at those ‘first responders’ who arrive immediately at the failure scene. These are the people who have to ensure the area is safe, preserve the scene for investigators and contribute to a plan to expedite a quick, safe return to production norms.

Many do not understand how valuable failed parts are to the metallurgical/forensic investigators. Broken parts are to metallurgists’, like the murder weapon is to a forensic crime investigator.

This article is meant to educate those that have access to the failed parts first, as to why they should preserve them in their failed state (not cleaning them up). We want to give them enough knowledge to be dangerous and raise their curiosity as to making a call on the fracture patterns they see. [Read more…]

Guest post by Mark Latino

If managers knew what the overall power of a well supported Root Cause Analysis (RCA) effort meant for their bottom-line, they would be breaking down doors to implement the process.

Unfortunately, this is often not the case, so this paper is an attempt to educate such individuals about the characteristics of an effective RCA methodology. The paper focuses on three aspects of RCA:

1. What is RCA?
2. What it takes to implement an effective RCA process as a way of conducting business rather than a finite ‘program’ that will eventually end
3. How does RCA contribute to a company’s bottom-line? [Read more…]

Guest post by Mark Latino

This case history takes place in a packaging facility in Virginia. The packer on module E5 was checked for vibration integrity during a pre-machine care evaluation. A problem was detected in the folding arm gearbox. The frequency characteristics indicated a bearing was deteriorating.

This seems very straight forward but let’s put the reality of the situation into the problem detected. The gearbox is located in a section of the packer that is not easily accessible. To do the necessary repairs it will require separating the two sections of the machine. When the packer is split it will take an additional two days of work before the unit can be restored to service. [Read more…]

Guest post by Charles J. Latino

At the root of most mechanical and system failures lurks a human cause. Insights into what to look for when solving human-caused failures are essential. Human error is generally described as behavior that goes beyond the norm. A proper definition in the context of this article is, “an action planned but not carried out according to the plan”. To find a means of minimizing human error, one must first understand its characteristics: [Read more…]

In order to know if all RCA is the same, we first have to define ‘What is RCA?’ On the surface this seems quite simple, but unfortunately it is quite complex. When I train or present speeches around the world, I often poll my audiences about how they define ‘RCA’. The fact is I will get as many answers, as I have people that I ask. This is unfortunate because there is no universally accepted definition of what ‘RCA’ actually is. Are there definitions out there, absolutely! There are hundreds of them. Various regulatory agencies have their own such definitions, as do corporations and companies. However, when definitions differ between agencies, corporations and industries, it is hard to measure the effectiveness of ‘RCA’ across the board, because everyone considers whatever they are doing, as ‘RCA’.

[Read more…]

No matter where we work, we will experience failures or ‘undesirable outcomes’ of some kind. As long as we work with other humans, this will indeed be the case. These failures may surface in the form of production delays, injuries, customer complaints, missed deadlines, lost profits, legal claims and the like.

In order to prevent recurrence of any such undesirable outcome, we have to truly understand the causes that led up to that bad outcome. In many of our worlds, the process used to analyze and understand what went wrong is called Root Cause Analysis or RCA. However, for the sake of this article, call this process whatever you want; problem solving, brainstorming, troubleshooting, etc. The common denominator of these terms, is they desire to resolve a failure and ensure it does not happen again.

Let’s get away from labels and specific industries and focus on the anatomy of a ‘failure’. Where does a failure come from? Think about this no matter where you work and see if it applies. [Read more…]