Root Cause Analysis - Improving Performance for Bottom-Line Results
By: Robert J. Latino, Kenneth C. Latino
Published by: CRC Press
Publication Date: August 1999
This book outlines the ProAct approach to Root Cause Analysis, developed, taught and implemented by the authors and their organisation, Reliability Center, Inc. There are a number of important principles explained in this book, that will assist those wishing to undertake Root Cause Analysis in their organizations, regardless of which "brand" of Root Cause Analysis they adopt.
The first chapter of the book introduces the key concepts relating to Root Cause Analysis, and outlines the ProAct approach. Before moving on to the detail of the ProAct approach, the second chapter of the book deals with the very important issue of creating an environment within which Root Cause Analysis (or indeed any significant change initiative) can succeed. There is a lot of common sense in this chapter, which revolves around the roles of Senior Management, the RCA "Champion", and the RCA "Driver" in the Root Cause initiative. This chapter of the book is available to be viewed online at www.reliabilityweb.com/articles/rca_xform.htm.
The third to ninth chapters detail the ProAct approach, with the tenth chapter containing some details regarding the ProAct software which is available to support this process. The book concludes with some case studies outlining the findings and benefits that some organizations have obtained from applying the ProAct approach.
The ProAct approach classifies Root Causes into three categories - Physical Roots, Human Roots, and Latent Roots. According to this book, Physical roots are the tangibles that can be seen, and are often the stopping point for those organisations that claim to do Root Cause Analysis. Human roots are those which involve human errors of commission or omission. Concluding root cause analysis at this level results in RCA being branded as a "witch hunt", with the obvious resulting lack of participation in the process by those who may feel hunted. However, says the book, most undesirable outcomes are a result of human errors. In order to avoid repetition of those errors, it is important to delve deeper into the "latent" causes regarding organisational systems, procedures, policies etc. that led to employees making an incorrect decision. The book maintains that the true root causes of any error or failure are these latent causes.
The book also explains James Reason's "Error Chain Concept", which "describes human error accidents as the result of a sequence of events that culminate in mishaps. There is seldom an overpowering cause, but rather a number of contributing factors, hence the term error chain. Breaking any one link in the chain might potentially break the entire error chain and prevent a mishap". The book quotes Flight Safety International as stating that the fewest number of links in aviation accidents was 4, with the everage being 7. The authors state their experience with industrial applications as being that the average number of errors that must queue up to be 10 to 14. This has significant implications for the level of detail required for successful Root Cause Analysis in Industrial applications.
All Root Cause Analysis techniques have, at their heart, some form of logic diagram, and ProAct is no exception. This section of the book, however, contains a number of valuable tips that assist in making sure that the logic diagram is successfully applied.
One other point that is well made in the book, and which, in my experience is one of the most frequent failings of those organisations that apply RCA techniques, is that the RCA analysis is not complete until its recommendations are implemented. Once again, the book makes some valid, practical tips on how to maximise the chances of having recommendations successfully accepted and implemented, and monitoring post-implementation results.
Overall, a highly recommended book on RCA, although it is significantly more expensive than many other, similar books on this topic.
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Revised: Thursday, 08-Oct-2015 12:08:10 AEDT