Is one of the reasons Root Cause Analysis is so difficult to make part of the everyday corporate culture because most problems can ultimately be traced to a management problem (if you are allowed to take it that far)?

Terry O

I agree --- DC 1600 Penn Av!!!!!!!!1

Terry,
I think the problem is that there is no clear ownership of the problems we face.

I know that you started this thread with RCA in mind but let me tell a related story.

Recently I helped a client identify a $10M opportunity for improving their cash flow through inventory reduction. The comapny sure could use the money, everyone agrees that the opportunity exists, no one is prepared to take action. Why? Because no one owns the problem!

This is all a result of there being a misalignment between the goals, responsibilites and authorities in the organization. This misalignment is the root cause of almost all issues within companies. While this is a management problem it is not necessarily a problem with management (although they have the power to fix it!)

It's possibly the mindset which is to accept all the minor problems as long as things get done, without realizing these minor problems lead to big problems.

In Maintenance dealing with one problem at a time does not pay.

Doing a Pareto Analysis the big problems are identified, then deal with them. If the minor problems keep appearing in those Paretos but below the top of the list, what to do?
* Keep working on the top ones as Pareto Analysis says?
* Assign a resource to deal with the minor while the rest of the crew deal with the bigger ones?

Anyone that knows me knows that I am a big fan of Pareto and if you are looking to solve a range of discrete, individual problems then it is a great approach. However...

..if the issue is a managemnt problem then I am a bigger fan of Systems Thinking. This was developed by Peter Senge in the 1970's and effectively says 'the problems that you face today are a direct result of the policies, processes, measures and reporting that are in place'.

So if the RCA identifies a management problem then look at the policies, processes, measures and reporting. Maybe Pareto can help identify a pattern that will help see which area to address first.

Cheers,

Pls give examples of 'the problems that you face today are a direct result of the policies, processes, measures and reporting that are in place'

Here is a real life example.
The plant in question had poor performance driven by poor reliability. The people responsible for the plant had a list of what their problems were and prioritized their activity. The list included items such as 'high pressure valve failures' and 'drop chute synchronization' (trust me here - it was an item on the list).

They set about targeting these pareto items looking for technical solutions. Much time and money was spent trying to design out problems. this was based on the generally good idea that prevention is better than cure. Still plant performance did not improve.

Were these people stupid or uneducated - definitely not. They were logical thinkers with good technical skills. The problem was that they did not have in place good maintenance practices involving regular care and attention.

When I took over the plant I scrapped the 'technical' problem solving program and put in place new policies and procedures relating to the undertaking of maintenance tasks. I elevated the importance of the achievement of production plan and published teh results daily for all to see. The focus was policy, process, measures and reporting.

The result? We went from 20% downtime to 5% in just a few months. A focus on policy, process, measures and reporting achieved what a list of problems could not.

This doesn't mean that we didn't prioritize, of course we did. What it means is that we got the basics right first and recognized that 'the system' we had in place (or not as the case was) was the root cause.

Hope that helps.

Hello Phil,

quote:

- They were logical thinkers with good technical skills. The problem was that they did not have in place good maintenance practices involving regular care and attention.

When I took over the plant I scrapped the 'technical' problem solving program and put in place new policies and procedures relating to the undertaking of maintenance tasks. I elevated the importance of the achievement of production plan and published teh results daily for all to see. The focus was policy, process, measures and reporting.

The result? We went from 20% downtime to 5% in just a few months. A focus on policy, process, measures and reporting achieved what a list of problems could not.

This is interesting!

But I can't understand how, if these people were logical thinkers and had good technical skills, they missed the "good maintenance practices".

I also find it strange that you had to "elevate the importance of the achievement of production plan" because in my experience it is the otherway round....the achievement of the production plan is the outmost priority, giving a short term 'picture' and hiding the long term one.

I hope I'm explaining myself and I'm sorry if I'm misunderstanding you (and please don't take it that I'm not believing you or playing it down) but could you please give some more details how you achieved this noticeable improvement in such a short time.

Hello To All,

Root Cause Failure Analysis, is done in 3 levels and the last level is the Latent Cause of The Problem, this is where management decisions fail, systems are flawed, procedures are inadequete, trainings are limited and so on.

Now people act because of this so called governing laws, and if the law is flawed then the person will likewise contribute to the problem.

I still have a hard time dealing with the latent cause, but before we need to start a meaningful and truthful Root Cause Failure Analysis, we must let our people know that it will be purely be based on evidence, it is not about problem solving techniques, but it is determining what really cause the problem to occur.

Likewise, RCFA must be understood on the level that we ask How can the problem occur and why did the problem occur instead of who cause the problem. RCFA must steer away from blaming people and punishing them, there is no room for this in the RCFA methodology, its aim is to understand why do good people make decision in a time like this and how can we prevent it from happening again.

Hence, when performing RCFA, refrain from pinpointing and blaming anyone. All people do commit errors as studied by James Reasons, yet we can learn from our mistakes and improve.

My Warm Regards,


Rolly Angeles
Teacher

I go to the source and analyze the failure and work backward from there. I do only machines and not people. If the fault was lack of training, so beit! No one is at fault: a problem exists - fix it and move on. Finding underlying causes and removing them so the problem does re-occur is a mark of success IMHO.

Rennie, I do not take any offence from your comments, let me try to explain what I was saying.

In your note you said:
But I can't understand how, if these people were logical thinkers and had good technical skills, they missed the "good maintenance practices".

What they did was focus on finding a 'silver bullet', the technical breakthrough that would 'solve all their problems'. This focus blinded them to the management approach that they should have applied. Worse than this, if asked, they would have said, 'yes, we do our maintenance' and I know, because I was there, that their response to improving maintenace was that they needed a CMMS. (Which they did not and I will explain that in a moment.)

What these guys did (and what in my experience many companies do) is 'place an undue emphasis on the factors that are most easily observed'. In the case above this was the downtime associated with a few specific failures. So rather than work on the management system they searched for a technical solution. Technical solutions are OK just as long as you already have the fundamentals in place.

The thing about management solutions rather than technical solutions is that acccpeting the need for a different management process means accepting that the old process is no longer appropriate. If you are in charge of that process then you are accepting that you were the cause of the failure. This is why, in my opinion, technical solutions are more popularly followed. One can then blame the technology rather than tehmselves. It also explains why a change in management is often needed to get real improvements in place.

You are right that often the issue is production taking precendence over maintenance. Usually the emphasis is on production OUTPUT (oten driven by time)rather than PERFORMANCE.

I am sure that every maintenace person would argue that you need to trade production time for maintenance time in order to achieve improved performance. The point that I was trying to make is that they paid too little attention to the the performance aspects of the plan. If process rates fell short they could often make this up with overtime or they could hold excess stock to make up for their own inefficiency. What we had to do was elevate the importance of achieving the plan (a function of both performance and time). This meant maintaning process rates not just end of line volumes.

How did we achieve a turn around in so little time? I could write a whole entry about this (in fact I wrote a whole book!)but here is the short version.

Step 1: Get Organized - work on house keeping, visual management and minimizing self imposed chaos.

Step 2: Apply the Fundamentals with Rigor. By fundamentals I don't mean fancy hi tech tools and techniques, I mean lubricate and grease, make sure that air lubricators are working, clean electrical cabinets, organize your maintenance with a plan (what, when, who, how). The tough thing here is not the plan, it is the rigor.

We didn't need a CMMS at that stage, we need to get our systems right.

I will not pretend that achieving the improvement we did was easy but it was simple.

If you want to know more I am happy to share more - let me know. There is also a short article on Step 2 on my web site. Follow this link http://www.initiateaction.com/articles.htm#artilces

Thanks Phil, that's a lot clearer now for me.

....i like the website & articles.

cheers

Rennie