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Root Cause Analysis


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Table of Contents

Introduction to the PROACT Root Cause Analysis (RCA) Work Process
Mean Time Between Failure (MTBF)
Frequency of Events
Maintenance Cost
Balanced Scorecard
The RCA Work Process
Introduction to the Field of Root Cause Analysis
What is Root Cause Analysis (RCA)?
Why Do Undesirable Outcomes Occur? The Big Picture
Are All RCA Methodologies Created Equal?
Attempting to Standardize RCA - Is This Good For the Industry?
What is Not Root Cause Analysis?
How to Compare Different RCA Methodologies When Researching Them
What Are the Primary Differences Between Six Sigma and RCA?
Obstacles to Learning from Things That Go Wrong
Creating the Environment for RCA to Succeed: The Reliability Performance Process (TRPP)
The Role of Executive Management in RCA
The Role of a RCA Champion (Sponsor)
The Role of the RCA Driver
Setting Financial Expectations: The Reality of the Return
Institutionalizing Root Cause Analysis (RCA) in the System
Failure Classification
RCA as an Approach
Opportunity Analysis: "The Manual Approach"
Step 1: Perform Preparatory Work
Define the System to Analyze
Define Undesirable Event
Draw Block Diagram (Use the Contact Principle)
Describe the Function of Each Block
Calculate the "Gap"
Develop Preliminary Interview Sheets and Schedule
Step 2: Collect the Data
Step 3: Summarize and Encode Data
Step 4: Calculate Loss
Step 5: Determine the "Significant Few"
Step 6: Validate Results
Step 7: Issue a Report
Asset Performance Management Systems (APMS): Automating the Opportunity Analysis Process
Determining Our Event Data Needs
Establish a Workflow to Collect the Data
Employ a Comprehensive Data Collection System
Analyze the Digital Data
The PROACT (R) RCA Methodology
Preserving Event Data
The Error-Change Phenomenon
The 5-Ps Concept
Ordering the Analysis Team
Novices versus Veterans
The RCA Team
Analyzing the Data: Introducing the PROACT Logic Tree
An Academic Example
Confidence Factors
The Troubleshooting Flow Diagram
Communicating Findings and Recommendations
The Recommendation Acceptance Criteria
Developing the Recommendations
Developing the Report
The Final Presentation
Tracking for Bottom-Line Results
Getting Proactive Work Orders Accomplished in a Reactive Environment
Sliding the Proactive Work Scale
Developing Tracking Metrics
Exploiting Successes
Creating a Critical Mass
Recognizing the Life Cycle Effects of RCA on the Organization
Automating Root Cause Analysis: The Utilization of The PROACT Enterprise Version 3.0+
Customizing PROACT For Our Facility
Setting Up a New Analysis in the New PROACT FMEA and OA Module
Setting Up a New Analysis in the New PROACT RCA Module
Automating the Preservation of Event Data
Automating the Analysis Team Structure
Automating the Root Cause Analysis - Logic Tree Development
Automating the RCA Report Writing
Automating Tracking Metrics
Case Histories
Case History #1: ISPAT Inland, Inc. East Chicago, IN
Case History #2: Eastman Chemical Company Kingsport, TN
Case History #3: LYONDELL-CITGO Refining Houston, TX
Case History #4: Eastman Chemical Company World Headquarters Kingsport, TN
Case History #5: Southern Companies Alabama Power Company Parrish, AL
Case History #6: Weyerhauser Company Valliant, OK

About the Author

Robert J. Latino is the CEO of Reliability Center, Inc., a Reliability Consulting firm in Hopewell, Virginia that specializes in improving Equipment, Process and Human Reliability. Kenneth C. Latino and Mark A. Latino are Presidents at Reliability Center, Inc.


The Latino brothers have been trail blazers in Root Cause Analysis for as long as I have known them. They have been particularly visionary in pioneering the inclusion of Human Factors into this field, via the PROACT methodology, over the past decade and a half. As always, their vision has been right on target!a As assets become more sophisticated, and we become more reliant on machinery, human error (and the reasons for it) are a far greater part of the reliability picture. This book will provide even greater support to companies that want to get the most out of their physical assets, and the PROACT methodology will continue to deliver unique value as they continue to evolve the method. --Daryl Mather, Owner and Principal Consultant, Reliability Success Pty Ltd "Having been involved since 1988 in the use of RCI's root cause methodology, I know it provides repeatable success regardless of the magnitude of failure or type of industry. I can solidly contribute $10 million in savings from using the process. The knowledge in this book will stop the cycle of repeated failures. --Tim Stovall, CMRP, Reliability Leader, NOVA Chemicals, Inc. ! a technique that allowed us to fix a chronic processing problem that plagued one of our gas plants for more than ten years.a If not for this technique, we would still be 'fire fighting' this problem today. --Alan Laundry, Tech. Services Manager, Westcoast Energy, Inc., Ft. St. John, BC. Very complete course on how to perform RCA from start to finish. Real life examples of problems are excellent in making connections. --Doug Plucknette - Eastman Kodak ... an excellent thought process stimulator. The ideas generated are excellent and much good variety of industries represented, lots of interaction and information exchanged. --Thomas Bublitz - Herman Miller, Inc. A must for reliability engineers. --Tom Hutchinson - Mead Paper ! am finally convinced that this is the tool of choice (when compared to RCM) --Doug Walwyn, Maintenance & Reliability Engineer, General Mills, Inc. Very Informative. Exceeded my every expectation. --Carl Bright, Maintenance Supervisor, Cryovac Sealed Air Corp. Praise for Previous Editions: Unfortunately, hero-based maintenance, noble as it is, is not the most effective business strategy and points to a reactive corporate culture. ! The problem solving methods discussed in this book cover much more than how to determine the obvious cause of the problem. This book discusses how to set up a blame free methodology that encourages deeper problem discovery that results in permanent solutions. It stresses that Root Cause Analysis requires a dedicated team coupled with management support and explains ways to communicate the impact so a business case can be made. Best of all it teaches how to create an entire company of proactive problem solvers that will move your operation to the next level of profitability and effectiveness. ! I am confident that this book will have a profound effect on your problem solving ability. --From the Foreword by Terrence O'Hanlon, CMRP, Publisher, The reviewer would like to recommend this book to all reliability and maintenance engineers for a serious look at the material presented in the book and to reliability schools for graduating engineering students. It is a good book that explains the root cause analysis approach to engineering systems. -- Krishna B. Misra, in International Journal of Performability Engineering, April 2008, Vol. 4, No. 2

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