Root Cause Analysis

Improving Performance for Bottom-Line Results, Fifth Edition

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

• Publisher: CRC Press
• Year: 2019
• eBook ISBN: 9780429822100
• Edition: 5
• Topic: Business
• Subtopic: Business Development
• Index: Business

This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach.

This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results.

Features

• Outlines in detail every aspect of an effective RCA 'system'
• Displays appreciation for the role of understanding the physics of a failure as well as the human and system's contribution
• Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system
• Explores the correlation between Reliability Engineering and Safety
• Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA

1

Introduction to the PROACT^® Root Cause Analysis (RCA) Work Process

Having worked as practitioners/consultants in the field of industrial reliability for nearly 100 cumulative years, we have learned that tools like Root Cause Analysis (RCA) can only be successful if they are incorporated into a sustainable work process. Have you ever thought about all of the many elements of maintenance/reliability? It is the alphabet soup of acronyms: RCA, RCM, FMEA, ODR, CMMS, KPI, MRO, PdM, PM, etc. The list goes on and on. The problem is that while all of these elements are critical to implementing a successful reliability initiative, it is overwhelming for those tasked with doing it at the plant level. There is a tendency to want to apply all of these tools and technologies to all areas of the plant all at once.

Anyone who works in a large industrial facility knows that reaction always seems to take precedence over proaction. We are not saying that is right, but it is a reality. The “failure of the day” always takes priority over longer-term improvement efforts. Therefore, we need to be practical in our approaches and expectations.

We often hear the old adage, how does one eat an elephant? One bite at a time! We need to do the same when trying to improve reliability in a large facility. We suggest a very simple model that encompasses all of these critical elements in a practical work process: Strategize, Execute, and Evaluate (Figure 1.1).

In this chapter, we will describe a simplified Asset Performance Management (APM) work process (Figure 1.2) and demonstrate where RCA fits into the big picture. APM is a set of work processes and tools that work together to continually improve the performance of our industrial assets.

FIGURE 1.1
Critical elements in a practical work process.

FIGURE 1.2
Simplified APM work process.

In a large industrial facility such as an oil refinery, chemical plant, or paper mill, there are tens of thousands of assets that must be managed to meet business goals. This is a monumental effort for those tasked with managing the performance of these assets. To do this effectively, you must have a comprehensive asset strategy, precision execution of the strategy, and a continuous evaluation process to ensure the strategy is working.

Let’s examine each aspect of this work process to better understand how RCA can help drive continuous asset performance improvement.

Strategize

When this author was a practitioner in the paper industry, the mill where he worked had over 50,000 assets to manage. Managing large numbers of assets is certainly not uncommon. It is more the rule than the exception. With these many assets to manage, we must ensure that we are doing the right work at the right time to mitigate risks to the operation. So step one is to determine the importance or “criticality” of the assets. This is typically done with an assessment that takes into account the relative importance of the asset based on safety, environmental, production, and financial factors. We will not get into a detailed discussion of criticality analysis in this book as there are many great resources on this topic. However, it is important to understand that each asset can have very different impacts on the operation. For this reason, we cannot base our asset strategy solely on manufacturer recommendations as they cannot possibly know how the asset will be used in our specific operation. The same exact asset can be used in two different applications within a facility: one could be highly critical, and the other is not.

Once we have a good sense of the relative importance of each asset, select critical, yet manageable systems, and perform asset strategies on the assets in that system. Again, there are numerous techniques and methodologies for developing an asset strategy. Therefore, we will not delve into the pros and cons of each method. In general, the output will be to define the failure modes (risks to the operation) and determine the proper mitigating tasks (Preventive Maintenance [PM], Predictive Maintenance [PdM], Lubrication, Operator-Driven Reliability [ODR], etc.). A good asset strategy will ensure that all spare parts are defined and on the Enterprise Asset Management’s (EAM) bill of materials (BOM) and that critical parts are in the storeroom and well maintained. Lastly, determine if capital is required to get the system to a level where it can reliably perform its intended function. With older plants, there is often a need to invest in capital improvements to ensure assets can perform reliably.

Execution

Having a great asset strategy is worthless if we do not execute the work in the field. Execution is key to seeing the improvements come to life. The actions from our strategy must be executed in our plant’s execution systems and work processes. This is typically done within operations, maintenance, and engineering. Tools like APM, EAM, Process Historians, and others are key enablers to making the process work. This is also where work processes for planning, scheduling, precision maintenance, lubrication, rebuild specifications, and many others come into play. The execution plan must be fully integrated into our work processes, so this is not seen as additional work or the “Program of the Day.”

Evaluation

Finally, we need to evaluate to ensure the deployed strategy is working. This can be done in a variety of ways. Asset health and condition monitoring solutions can be used on a more micro basis to visualize and understand the status of assets and their current health/condition. Scorecards, Metrics, and Key Performance Indicators (KPIs) are a great way to measure the performance of strategies on a more macro basis. These tools are typically populated from various data collection/analysis systems to show whether the strategy tasks are being performed and at the proper frequency. We can also use our RCA process to uncover the root causes of poor asset performance and determine the mitigating actions to update on our strategy when we find that the strategy missed a failure mode or a mitigating action was incorrect or at the wrong frequency.

Many APM systems will employ an asset health solution to consolidate and summarize current asset health data into a single view. Reliability and asset-related data is notoriously difficult to see in one view. Vibration data is in one system, work order history in another, and don’t forget about all the data tucked away in spreadsheets and other “homegrown” solutions. An asset health solution is designed to pull all of this information together to make it easy for Reliability Engineers, Maintenance Planners, etc. to make strategy adjustments as asset condition dictates.

To better understand the performance of our assets on a more macro basis, many facilities utilize tools like balanced scorecards, metrics, and KPIs to get a better view of how their overall facility is performing. An effective methodology for determining our company’s asset performance objectives is to create a strategy map. A strategy map takes all of the objectives of the company and puts them into various perspectives. The perspectives can vary from company to company, but for the area of APM, there are four main perspectives:

1. Corporate
2. Assets
3. Work practices
4. Knowledge and experience

Within each of the four perspectives, a number of individual objectives are defined. For instance, within the corporate perspective, we look at objectives that directly relate to goals defined within the company. These are typically related to the fiscal performance of the business but can also be related to critical operational issues like environmental and safety performance. Other objectives related to the corporate perspective might be customer satisfaction issues like on-time deliveries, quality of the product, and many others. However, in the area of APM, we typically focus on those areas that relate to financial, safety, and environmental performance as it relates to the utilization of assets.

Following is a list of typical perspectives and objectives related to asset management:

1. Co...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Foreword
• Preface
• How to Read This Text
• Acknowledgments
• Introduction/Reflections
• Authors
• 1 Introduction to the PROACT® Root Cause Analysis (RCA) Work Process
• 2 Introduction to the Field of Root Cause Analysis
• 3 Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP®)
• 4 Failure Classification
• 5 Opportunity Analysis: “Mindfulness”
• 6 Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process
• 7 Preserving Event Data
• 8 Ordering the Analysis Team
• 9 Analyzing the Data: Introducing the PROACT® Logic Tree
• 10 Communicating Findings and Recommendations
• 11 Tracking for Bottom-Line Results
• 12 The Role of Human Error in Root Cause Analysis: Understanding Human Behavior
• 13 Do Human Performance “Learning Teams” Make RCA Obsolete?
• 14 Is There a Direct Correlation between Reliability and Safety?
• 15 Automating Root Cause Analysis: Introducing PROACTOnDemand®
• 16 Case Histories
• Index