The PROACT® Root Cause Analysis

Quick Reference Guide

Kenneth C. Latino, Mark A. Latino, Robert J. Latino

• Publisher: CRC Press
• Year: 2020
• Print ISBN:
  9780367517380
• eBook ISBN:
  9781000178302
• Topic: Negocios y empresa
• Subtopic: Toma de decisiones

Root Cause Analysis, or RCA, "What is it?" Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we're applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence.

In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include:

1. Preserving evidence (data)/not allowing hearsay to fly as fact
2. Organizing an appropriate team/minimizing potential bias
3. Analyzing the events/reconstructing the incident based on actual evidence
4. Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented
5. Tracking bottom-line results/ensuring that identified, meaningful metrics were attained

We explore, "Why don't things always go as planned?" When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field.

This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application.

This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few.

1
Introduction to the Field of Root Cause Analysis and PROACT^®

What Is Root Cause Analysis (RCA)?

What a seemingly easy question to answer, yet no standard, generally accepted definition of Root Cause Analysis (RCA) exists in the industry today, of which we are aware. Technical societies, regulatory bodies, and corporations have their own definitions, but it is rare to find two definitions that match. For the sake of having an anchor or benchmark definition, we will use the definitions provided by the Department of Energy (DOE) guideline entitled “Root Cause Analysis Guidance Document (DOE-NE-STD-1004–92).”¹

In the DOE document referenced above, the following is cited:

The basic reason for investigating and reporting the causes of occurrences is to enable the identification of corrective actions adequate to prevent recurrence and thereby protect the health and safety of the public, the workers and the environment.

The document goes to say that every root cause investigation and reporting process should include the following five phases:

1. Data Collection
2. Assessment
3. Corrective Actions
4. Inform
5. Follow-Up

When we look at any investigative occupation, these five steps are critical to the success of the investigation. As we progress through this text, we will align the steps of the PROACT^® methodology with each of these steps in the DOE RCA process.

¹ http://www.hss.energy.gov/nuclearsafety/ns/techstds/standard/nst1004/nst1004.pdf.

For the purposes of this text, while aligning with the DOE guideline, we will use our own definition of RCA, which is

The establishing of logically complete, evidence-based, tightly coupled chains of factors from the least acceptable consequences to the deepest significant underlying causes.

This is a variation of a definition that was proposed on the RCA discussion forum at www.rootcauselive.com.²

While a seemingly complex definition, let’s break down the sentence into its logical components and briefly explain each:

1. Logically Complete—This means all the options (hypotheses) are considered and either proven or disproven using hard evidence.
2. Evidence Based—This means hard evidence is used to support the hypotheses as opposed to using hearsay and treating it as fact.
3. Tightly Coupled Chains of Factors—These fancy words mean we are using cause-and-effect RCA approaches as opposed to categorical (cause categories where we brainstorm disconnected possibilities in each category) RCA approaches.
4. Least Acceptable Consequences—This is the point where the event that has occurred is no longer acceptable (a trigger of some sort has been hit) and an investigation is launched.
5. Deepest Significant Underlying Causes—These seemingly intimidating words mean at what point do we stop drilling down and determine going deeper adds no value to the organization?

This definition certainly encompasses and embodies the intent of the DOE guideline for RCA.

Summary of the PROACT^® Investigation Management System

For the remainder of this text, we will follow the simple steps of the PROACT^® Investigative Management System, consistent with the DOE guidelines. The PROACT^® acronym stands for the following:

² This discussion forum is associated with www.rootcauselive.com and moderated by Mr. C. Robert Nelms.

1. PReserving Evidence/Data
2. Organizing the RCA Team
3. Analyzing the Event
4. Communicate Findings & Recommendations
5. Tracking Bottom-Line Results

As you read this text, think about how each step of the process applies to where you work. When we think about any investigative occupation, they all follow these steps to some degree. This should be our measure to determine if we are doing true RCA or simply Shallow Cause Analysis, where we succumb to taking process shortcuts due to time pressures imposed on us.

Why Do Undesirable Outcomes Occur? The Big Picture

We must put aside the industry that we work in and follow along from the standpoint of the human being. In order to understand why undesirable outcomes exist, we must understand the mechanics of failure.

Virtually all undesirable outcomes are the result of human errors of omission or commission (or decision errors or choices, as they will be used interchangeably from now on). Experience in industry indicates that any undesirable outcome will have, on average, a series of 10–14 cause-and-effect relationships that queue up in a particular pattern for that event to occur.

This dispels the commonly held myth that one error causes the ultimate undesirable outcome. All such undesirable outcomes will have their roots embedded in the physical, human, and latent areas.

Physical Roots: are typically found soon after errors of commission or omission. They are the first physical consequences resulting from choices made. Physical roots, as will be described in detail in coming chapters, are tangible things we can see.

Human Roots: are decisions that are made that did not go as planned. These are the actions (or inactions) that trigger the physical roots to surface.

Latent Roots: are the organizational systems that are flawed in some manner (i.e., inadequate, insufficient, and/or nonexistent). These are the organizational support systems (i.e., procedures, training, incentive systems, purchasing habits) that are typically put in place to help our workforce make better decisions. Latent roots are the expressed intent of the human decision-making process.

What Are the Elements of a True Root Cause Analysis System?

In order to recognize what is RCA and what is NOT RCA (Shallow Cause Analysis), we would have to define the criteria that must be met in order for a process and its tools to be called Root Cause Analysis. In the absence of a universally accepted standard, let’s consider the following essential elements³ of a true RCA process:

1. Identification of the Real Problem to be Analyzed in the First Place: About 80% of the time we are asked to assist on an investigation team, the problem presented to us is not the problem at hand.
2. Identification of the Cause-and-Effect Relationships that Combined to Cause the Undesirable Outcome: Being able to correlate deficient systems directly to undesirable outcomes is critical. Using categorical approaches (as we will explain in Chapter 4, “Analyzing the Data”) will often yield fewer comprehensive results than cause-and-effect approaches.
3. Disciplined Data Collection and Preservation of Evidence to Support Cause-and-Effect Relationships: It is safe to say that if we are not collecting data to validate our hypotheses, we are not properly conducting a comprehensive RCA.
4. Identification of All Physical, Human, and Latent Root Causes Associated with Undesirable Outcome: If we are not identifying system deficiencies that lead to poor decision-making, then, again, we are not properly conducting a comprehensive RCA.
5. Development of Corrective Actions/Countermeasures to Prevent Same and Similar Problems in the Future: If we have merely developed good recommendations but never implement them, then we will not be successful in our RCA efforts. This is where the ball is often dropped as well-intentioned people are pulled away by reactive work, and these proactive opportunities fall by the wayside.
6. Effective Communication to Others in the Organization of Lessons Learned from Analysis Conclusions: One of the greatest benefits of a successful RCA is the dissemination of the lessons learned to avoid recurrence elsewhere in the organization. Oftentimes, successful analyses end up in a paper filing system only to be suppressed from those wh...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Authors
• 1 Introduction to the Field of Root Cause Analysis and PROACT®
• 2 Preserving Event Data
• 3 Organizing the Analysis Team
• 4 Analyzing the Data: Introducing the PROACT® Logic Tree
• 5 Communicating Findings and Recommendations
• 6 Tracking for Bottom-Line Results
• 7 Case History
• Index