WHAT DOES ROOT-CAUSE ANALYSIS MEAN TO YOU? Greensboro NC

The term Root Cause Analysis, or RCA, has become a commodity. Its original intent has been considerably diluted over time.

How does this dilution occur?

Usually well-intentioned initiatives such as RCA are destined to face the abuses of human intervention. The theory sounds great, but it is the reality that counts. When RCA was applied in the aerospace and nuclear industries, it was very rigid in its application in terms of breadth and depth of analysis. As a result, it was very successful in its application. As is the case when such successes occur, people write white papers, articles and books, and present at trade conferences. Via this media pipeline, the ideas catch on within the same industry as well as in other industries.

Now RCA has become popular and is now introduced into the acronym Hall Of Fame along with the likes of TQM, JIT and SPC/SQC. Being the capitalist nation that we are, this invites competition in the field. Consultants emerge, and because they compete against each other, everyone must have their different twist on RCA. This is necessary to make a marketing distinction between competing RCA consultants.

Keep in mind that RCA is now the noun and the competing methods are now the brands of RCA, or the adjectives. The user community is understandably confused at this point because they simply want the RCA that is the rave and every provider in the marketplace says that is what they provide.

Today's market yearns more and more for quicker, faster tools, but not necessarily more efficient and accurate analyses. But the very nature of RCA requires time and careful information gathering. Accuracy and completeness are paramount. Ultimately, Root Cause Analysis represents the most in-depth of all maintenance tasks.

WHAT DISTINGUISHES RCA?

What is the difference between brainstorming, problem solving and RCA? Based on this author's 20 years in the RCA business, here is the way I see it (Figure 1).

Industry uses various methods to solve problems, and each varies in the amount of evidence they use and the amount of time (and, hence, money) they require.

Brainstorming is a process by which subject-matter experts express their opinions about how a certain undesirable event occurred based on a perceived timeline of events and often a predetermined list of "cause categories." These brainstorming sessions produce recommendations to be implemented to solve the problem.

Brainstorming is quick, inexpensive and, hence, often attractive to management. However, of the three approaches listed, it is usually the least accurate, since it fails to establish cause-and-effect relationships and usually does not require evidence to back up opinion (hearsay).

Problem Solving represents an approach that is more accurate than brainstorming but less accurate than RCA. In problem solving, subject-matter experts utilize a tool of some sort to guide their brainstorming efforts to identify the root causes of an undesirable outcome. It is more structured in that it does utilize a disciplined tool to assist with focusing of the brainstorming; however, it does not always require the disciplined collection of evidence to prove and disprove hypotheses.

Popular tools using this method include Ishikawa Fishbone Diagrams and, most notably, the "Five-Whys." The Ishikawa Fishbone Diagram gets its name from its form, which is in the shape of a fish. The spine of the fish represents the sequence of events leading to the undesirable outcome. The fish bones themselves represent those predetermined "cause categories." These can change from user to user, and some of the most popular include the "4 M's": methods, machines, materials, manpower. Team members decide on the categories and continue to ask what factors within the category caused the event to occur. Once they identify these factors, they then ask why the factors occurred. As a brainstorming technique, this tool is less likely to depend on evidence to support hypotheses and more likely to let hearsay fly as fact. This process is also not cause-and-effect based, but categorically based. Team members pick categories to integrate into the diagram, but these categories may not necessarily lead to the real roots of the problem.

With regards to the "Five-Whys", there are varying forms to this method, the most common understanding involves analysts asking the question "Why?" five times—after which they discover the root cause. This approach, however, has several primary flaws. For one, failure does not always occur in a linear pattern. Instead, multiple factors can combine laterally to allow the undesirable outcome to occur. Also, there is never a single root cause—in reality, failures can be traced back to multiple original causes. Also, people tend to use the Five Whys by themselves, not in a team, and rarely back up their assertions with significant evidence.

Root Cause Analysis is a process by which a trained, unbiased RCA facilitator uses a team of subject-matter experts to map out the cause-and-effect relationships that are proven to have led to an undesirable outcome. This proof takes the form of physical evidence related to the event and is used to prove or disprove hypotheses developed in the exploration process of determining why things went wrong. RCA will also typically drill down deeper than Problem Solving and identify all of the physical, human and latent root causes.

Popular RCA analysis tools include Logic Trees, Causal Trees, Reality Trees, Is/Is Not Analysis, WHY Trees, WHY Staircases, etc.

To illustrate, consider one tool, the Logic Tree (Figure 2). This is an expression of cause-and-effect relationships that, queued up in a particular sequence, caused an undesirable result. These cause-and-effect relationships are validated with hard evidence. Here, the data lead the analysis—not the loudest expert in the room.

The tree starts with a description of the facts associated with an event. These facts will comprise what is called the Top Box (the Event and the Modes). "Modes" are the manifestations of the failure, and the "event" represents the final consequences that triggered the need for a RCA. While we may know what the Modes are, we do not know how they were permitted to occur. So now, the questioning starts,

Many have been conditioned to ask the question "Why" during such analyses; here, however, analysts ask "How Could". Consider the differences between the two: When simply asking "Why", we are connoting a singular answer and, to a point, an opinion. When asking "How Could", we are seeking all the possibilities (not only the most likely) and evidence to back up what did and did not occur.

The phrase "How Could" brings analysts back through the chain of cause-and-effects, with each link consisting of evidence to back up the assertion. The question changes, however, when it reaches "Human Roots," or a problem caused by a human decision error. Here, analysts do ask "Why" to uncover the reasons why someone made the decision he or she did at the time they made it.

These in turn uncover Latent Root Causes, which represent the rationale for the decision that triggered the consequences to occur. These are called "latent" because they are always there, lying dormant, often part of an organization's systems, practices and/or policies. They require human action to be triggered, after which a sequence of physical root causes occurs. If unbroken, this error chain continues to a point that results in an adverse outcome that requires an immediate response.

MONEY WELL SPENT

RCA is usually unattractive to management on its face value because to do it properly requires time. Most time spent conducting a RCA involves collecting evidence or data. However, this approach will yield the most comprehensive and accurate results, so that when money is spent on recommendations, it is usually money well spent.

For a RCA to be comprehensive requires some essential elements:

1. Identify the real problem to be analyzed.
2. Identify the cause-and-effect relationships that, when combined, led to the undesirable outcome.
3. Perform disciplined data collection and preservation of evidence to support these cause-and-effect relationships.
4. Identify all physical, human and latent root causes associated with the undesirable outcome.
5. Develop corrective actions/counter-measures to prevent the same and similar problems in the future.
6. Effectively communicate to others in the organization about lessons learned from the investigation's conclusions.

Brainstorming, problem solving and RCA all have their pros and cons, and their own variations—and users can abuse them all. No matter what approach a facility uses, if the person facilitating the process does not do so properly, then even the seemingly best approach will fail.

So to avoid this, what should a progressive management ask?

What tool provides the greatest value to our organization?

Why is there such a disparity in pricing?

What are the advantages of one method over another?

Which method will provide the most comprehensive and accurate results?

Which approach will start eliminating reactive work while opening time for more productive proactive work?

BUYING CONCEPTS

When seeking to integrate methodologies into organizations, we should recognize that we are not buying "things." We are buying concepts that will develop the skills of people, who will in turn use them to develop bottom-line results.

If we provide our people approaches based solely on initial investment, then we will get what we pay for. If we put more thought into it and provide them with researched and proven methods and tools, the value received will be phenomenal.

Considering all this, what now does RCA now mean to you?

Editor's Note: Robert J. Latino is senior vice president of strategic development for Reliability Center, Inc., Hopewell, Va. Latino is a practitioner of root cause analysis in the field with his clientele as well as an educator. He is an author of RCI's Root Cause Analysis Methods training and co-author of Problem Solving Methods training. His most recent publication is titled Root Cause Analysis—Improving Performance for Bottom Line Results. He can be contacted at 804-458-0645 x302 or blatino@reliability.com.