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Root Cause Analysis (RCA) Tip Many do not think about the timeline between an incident (i.e. – tube rupture, leak in hazardous piping, etc.) and its ultimate consequences (i.e. – environmental release). There is a span of time between the failure that initiated the consequence and the point in time in which the consequence was isolated. Why is this important? Because the manner in which we respond to the initiating failure may influence the magnitude of its consequences. If that is the situation, a case can be made to add a MODE labelled something like “Improper Response”. By addressing this MODE we will be forced to explore the appropriateness of our responses to the incident and see if we could have done things better and minimized the magnitude of the consequences. By not addressing this, we miss the opportunity to review our response systems and only focus on what lead up to the physical incident itself. Tip provided by Bob Latino Root Cause Analysis (RCA) Tip When conducting a Root Cause Analysis (RCA) we often start off with the Event being some physical type of failure (i.e. – pump failure, turbine trip, etc.). However, when we reflect on this, what is the real reason that an RCA is being commissioned, because of the physical failure or because of its consequences? When we sit back and think about it, the RCA is often being requested because of some type of business issue. The RCA is not requested because the pump failed, but it is because the failure of the pump resulted in an 8-hour outage? When trying to decide whether you are starting at an appropriate level in your RCA, ask yourself, “What was the consequence of the incident that you were starting at? Asking this question will usually raise you one more level above the failure itself and into the business impact that it had on the organization. In the long run, this will help get the attention of the upper level management for providing support for your recommendations to ensure that the negative business impact does not happen again. Tip provided by Robert Latino Avoiding a disconnected RCAWhen conducting Root Cause Analysis (RCA) investigators can get caught up in the apparent causes of the failure. This can come in the form of interviews that contain repeating comments about the reason something failed that make logical sense. When you hear these kinds of comments realize it may be conventional wisdom you are hearing. You must treat the interview as information that may provide some insight to possible hypotheses for your analysis. Hypotheses have to be verified as to whether or not they occurred. If you base your entire analysis on conventional wisdom you are in the box before you even begin your analysis. This can lead to a incomplete analysis because other possibilities are not considered. Tip provided by Mark Latino When do you stop drilling down in your Root Cause Analysis (RCA)?A rule of thumb could be that you drill down until the solution is obvious. As we know, the deeper we drill the more detail is provided. There will come a point where the solution is obvious and there is no real value in drilling any deeper. For instance, we might find that an operator did not follow a correct procedure that was in place because:
The solutions become obvious at this point that we should correct the training system by filling in the “loophole” and provide the operator the appropriate training. There will always be a question as to the value of going deeper and this ultimately becomes a subjective decision on behalf of the analyst and the team. Tip provided by Bob Latino |
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