The Germination Of A Failure: The Role Of Human Factors In Effective Root Cause Analysis

Because of the lack of a universally accepted definition or standard for RCA, we are left to our own conventions in the marketplace as to what is most ?effective? or a ?Best Practice? for our own facilities or organization. This lack of uniformity in the application of RCA produces an equal lack of uniformity in the measureable outcomes of RCA on the bottom-line from site to site and industry to industry. What is the definition of success for an RCA? Is it regulatory compliance? Is it some quantifiable measure of bottom-line performance? Is compliance and bottom-line performance the same thing? Can we measure the ROI we receive by doing compliant RCA? These questions must be adequately addressed if any definition of RCA is to be effective on the bottom-line. Like our various Corporate Vision and Mission Statements, what would be our Vision and Mission for RCA? When pondering the answer to this question, we should consider: ? What Key Performance Indicators will the Success of RCA be Linked to? This provides a direct correlation to the corporate dashboard and therefore garners support for the RCA effort when implemented at the sharp end. Not until we know what KPI?s will effectively measure our maintenance and reliability objectives can we begin to establish which opportunities will afford the greatest returns1. ? What Bottom-Line Metrics will be Tracked to Measure the Effectiveness of Our RCA Effort? Will it be increased production, profitability, regulatory compliance, etc.? Will it be decreased injuries/fatalities, claims, customer complaints, risks, etc.? We should be specific about these metrics and their correlation to the metrics on our corporate dashboard. ? What Will Trigger an RCA Investigation? Normally companies will establish quantifiable thresholds to be surpassed before an RCA will be conducted. Examples may be an OSHA recordable injury, a failure event in which production losses exceed $250,000, an equipment failure in excess of $50,000 or a regulatory violation. This is the norm. However, we should realize this is using our RCA skills totally on a reactive basis. High Reliability Organizations (HRO) strive for proaction and they also use RCA proactively. Why can?t we use RCA to analyze why unacceptable risks from an FMEA are so high? It is perfectly applicable yet rarely implemented in this fashion.