Root Cause Analysis Solutions: Reliability Center, Inc.

2011-08-16T11:45:00.000-07:00

Register Today for Reliability Center, Inc. September 2011 Public Courses

Can't see this graphic? Click here for information.

Root Cause Analysis: Injury: Discover ALL the Root Causes of this Knife ...

2011-02-10T13:24:00.000-08:00

Knife Cut Injury happens while on the job! See how evidence collected builds this root cause analysis and the final outcome discovery of all the...

Root Cause Analysis: Space Shuttle Challenger: What More Did We Learn?

2011-02-10T13:22:00.000-08:00

Root Cause Analysis on the Space Shuttle Challenger. All evidence, images and reports were public knowledge. See how RCI built this analysis using...

Root Cause Analysis Online Console: Reliability.com

2011-02-10T13:21:00.000-08:00

Root Cause Analysis Made Easy: PROACTOnDemand RCA online web application --- FREE DEMO GUEST ACCOUNT: www.Reliability.com

Root Cause Analysis-Proactive RCA: On Failures That Have Not Happened

2011-02-10T13:19:00.000-08:00

Can we perform RCA on failures that haven't occurred yet? Yes, we can! Learn how to be PROACTive in your RCA investigations.

Root Cause Analysis Templates-Healthcare

2011-02-10T13:17:00.000-08:00

Cut and Paste Root Cause Analysis Templates for PROACT RCA Software. Available Online by Subscription or as a Network Enterprise.

Root Cause Analysis Templates-Industry RCA

2011-02-10T13:15:00.000-08:00

Cut and Paste RCA Templates for PROACT Enterprise or PROACTOnDemand web application. Complete analyses faster using previous suggestions...

Root Cause Analysis: Haul Truck Fire SEE THESE IMAGES! All Evidence Ente...

2011-02-10T13:13:00.000-08:00

Hauler Truck Fire Root Cause Analysis: Follow Ron Hughes as he examines this accident and uses PROACT RCA to facilitate this Root Cause Analysis investigation.

Root Cause Analysis: Solving Chronic Failures

2011-02-10T13:11:00.000-08:00

When is an RCA typically done? What about the Chronic Failures? Learn in this video how PROACT RCA works on Chronic Failures for a PROACTive...

Root Cause Analysis 13min: Germination of a Failure and Intro to PROACTO...

2011-02-10T13:09:00.000-08:00

Reliability Center, Inc. PROACTOnDemand RCA Web Application Demo and THE GERMINATION OF A FAILURE - Why we do a Root Cause Analysis...

Root Cause Analysis:9min- Online Web Application:FREE DEMO ACCOUNT - Lea...

2011-02-10T13:08:00.000-08:00

Reliability Center, Inc. presents PROACTOnDemand - Collaborate globally Online - Permission based, affordable RCA, Developed for all industries...

Healthcare Templates: When and How to Use Them in Root Cause Analysis

2011-02-10T13:01:00.000-08:00

This movie demonstrates the ease of use for healthcare to drill down from root cause analysis templates and use pre-existing logic to complete their investigations.

5 Whys - Fishbone Diagram PLUS Other Methods of Root Cause Analysis

2011-02-10T12:54:00.000-08:00

Reliability Center, Inc. has posted another one of their Root Cause Analysis Movies. We hope it will provide more information for your RCA knowledge base. If you would like to suggest a RCA topic for another movie please let us know! Send your suggestion to info@reliability.com.

Root Cause Analysis Templates: How To Use Them

2011-02-10T12:46:00.000-08:00

Reliability Center Inc. Corporate Overview: Root Cause Analysis

2011-02-10T12:45:00.000-08:00

PROACTOnDemand - RCA Online 24/7

2010-10-14T11:30:00.000-07:00

A Subscription Solution to Delivering your RCA

The PROACT® Root Cause Analysis methodology and software have been integrated into our new RCA SaaS - Software as a Service. Your company can now achieve significant ROI faster, easier and more completely than ever before.

All you need is an IE6+ browser. Nothing or no one can hold you back from conducting a RCA investigation. It's never been easier or more affordable.

Available 24/7 - Globally

Available by Subscription

IT Independent - Secured Data Center

Low Start Up Cost Starting at $300.00

Live Support - PDF Manual - FAQ - Movies

PROACT® Logic Tree Templates Add On

Try it Today with our FREE Functioning Demo

Read our Press Release

Learn More

PROACT Root Cause Aanalysis Methods

2010-10-14T08:00:00.000-07:00

This "hands-on" training is designed to provide the students with the skills and knowledge for eliminating or minimizing the most important undesirable events in their organization. These events typically account for 80% of operationg losses. Geared to engineering, technical, medical and management personnel, its highly detailed and verifiable approach has been proven repeatedly in the field for major organizations worldwide for over 25 years.

PROACT RCA Methods Training
November 16-17, 2010
$1,250.00 US

PROACT Software Training
November 18, 2010
$600.00 US

3 Day Package
$1,850.00 US

Webinar Introducing PROACT® Human Error Reduction Strategies with Advanced RCA for Safety

2010-06-22T08:27:00.000-07:00

FREE 30 Day Trial of PROACT RCA Software included for each participant.

Date:July 14, 2010
Time: 2:00pm - 2:30pm EST

Register Today

Go beyond in-house tools and standard reporting requirements. Drive down into the latent system or organizational roots that create an environment ripe for Human Error. Fix the Systems, not the Symptoms.

RCI's PROACT Human Error Reduction and Safety Performance Training will teach employees to uncover and manage potential human error traps in their workplace. When these concepts are fully utilized safety incidents are decreased greatly and reliability is improved through longer runs without incident.

By actively raising the workforce awareness and incorporating techniques to avoid error your overall availability will continuously improve while you enjoy a safer more productive work environment.

**Webinar lasts approximately 30 minutes and Q&A session to follow. Software download instructions provided per participant.**

For more information contact us:

804-458-0645
info@reliability.com

Announcing RCI's Redesigned New Generation Web Sites

2010-06-22T07:37:00.000-07:00

www.Reliability.com

www.PROACTforIndustry.com

www.PROACTforHealthcare.com

Enhancements to our RCI web sites include:

Improved Navigation: Web pages work intuitively and logically helping visitors access the information they need quickly and accurately. Cross Browser tested, Load time performance excellerated bringing Precise information you need to make informed decisions about your Reliability initiatives.

Improved Look and Feel: More vibrant and seamless view of RCI’s products, services, and resources. The RCI sites use Best Web Practices for display, color and design. Divided into business sections of Corporate, Healthcare and Industry, all channels are complete with resource information pertaining to each channel.

New Features and Tools: The RCI sites include content rich pages that include pertentent articles and movies, case histories and detailed topical information. Our Help Desk is a click away for instant help including live chat and remote web sessions. Enjoy the resource area that includes PROACT® movies and demos PLUS an article database with tons of RCI articles allowing comment posting, discussion and sharing.

Join our culture of Reliability and gain direct access to all RCI Products, Services, Tools and Resources to fulfill any Reliability initiative in Best Practices for successful Reliability implementation. Our informative web sites exist exclusively for our highly valued clients and web visitors who have a growing need to understand, develop and implement their own Reliability Culture to compete in the global marketplace.

Share your comments, suggestions and questions with us.

804-458-0645

info@reliability.com

Reliability Center, Inc. Celebrates 25 Years in the Reliability Business

2010-02-23T06:45:00.001-08:00

For Release: Upon Receipt

Contact: Bob Latino 804-458-0645 x304, blatino@reliability.com
or Mark Latino 804-458-0645 x303, mlatino@reliability.com

Reliability Center, Inc. (RCI), one of the most respected and established Reliability companies in the world, today announced that it is celebrating its twenty-fifth year of service. RCI has been providing the perfect combination of Reliability vision and execution to its clients with PROACT®, their signature branded service for Root Cause Analysis.

Over the past twenty-five years RCI has grown into one of the major global providers of RCA and Human Error Reduction solutions. Its innovative analysis solutions have increased the precision, productivity and profitability of numerous business, industry, government and healthcare organizations worldwide. As our customers expand their facilities and require more exact analytical procedures to ensure safety, mechanical and human reliability, RCI will continue to provide a wide range of services to meet their needs. Designed to be a learning and growth facilitator, RCI can help organizations produce the paradigm shifts necessary to challenge the limits of mediocrity and thrive in an increasingly competitive global marketplace.

RCI is a family owned and operated company in Hopewell, Virginia. Through its PROACT® brand, RCI has become a premier domestic and international resource for Reliability consulting services, training programs, and software products. "We are grateful to our customers for their support, friendship and trust extended to RCI over these many years," says Robert J. Latino, CEO, Reliability Center, Inc. “We will continue to provide innovative Reliability technologies to the Industrial and Healthcare sectors for years to come. Our founder and my father, Charles J. Latino, dedicated his whole career to saving lives and generating billions of dollars in savings to companies worldwide due to improved Reliability.”

Among the companies and organizations that successfully use PROACT® to eliminate undesirable events are Georgia Pacific, AES, BHP Billiton, Husky Energy, Amtrak, University of Michigan, PEMEX, SABIC & Memorial Sloan Kettering Hospital.

For more information visit http://www.reliability.com/.

PROACT RCA Training, Tools & Resources

2010-01-29T07:38:00.000-08:00

"Reliability" has become a mainstream term these days as companies try and add precision to their operations. Reliability Tools such as preventive maintenance, predictive maintenance, and Root Cause Analysis along with a Precision attitude is the key to obtaining high availability. It is important to maintain a high level of Equipment, Process, and Human reliability when the economic recovery is occurring. The more effective the use and understanding of these tools the stronger the company comes out of the recovery gate.

Technical Support Humor

2009-10-14T11:58:00.001-07:00

Sometimes trying to figure out a problem on your computer can be frustrating. This cartoon describes such an experience in a funny way. Thought we'd share it with you!

This cartoon plus more can be found at "XKCD - A Webcomic of Romance, Sarcasm, Math, and Language" (http://xkcd.com/627/)

CSB: To Investigate Or Not To Investigate

2009-09-16T10:48:00.001-07:00

CSB: To Investigate Or Not To Investigate

Posted using ShareThis

PROACT Root Cause Analysis Training at BHP Houston, TX

2009-09-14T11:14:00.000-07:00

Reliability Center, Inc. recently completed another PROACT® Root Cause Analysis workshop at the BHP Billiton Petroleum Group offices near the Galleria in Houston, Texas. This 3 day training session combined RCI's 3 day PROACT® Root Cause Analysis Methods© workshop with the intensive PROACT® Suite Software workshop which included the NEW PROACT® Logic Tree Knowledge Management Templates. The participants built a Logic Tree for a chronic problem that BHP Billiton team really wanted to solve. The training session was held in a new training and communications facility that had plenty of bells and whistles. Just check out the wall board!

The Houston office is the home for BHP Billiton Petroleum Group’s global network installation of the PROACT® Suite Software. BHP Billiton sites as far away as Australia can instantly access completed root cause analysis (RCA) investigations from around the world. By leveraging completed investigations on similar issues, BHP Billiton will be able to multiply the effect of successful RCA investigations to achieve significant improvements in productivity and costs.

During the recent downturn it has become even more important to improve operational performance through reliability improvement and greater asset availability. Please call (804-458-0645) or email (info@reliability.com) us to learn more about how we can help you achieve your company goals and help build a more successful future.

PROACT Root Cause Analysis Training at BHP Trinidad

2009-09-14T08:13:00.000-07:00

Reliability Center, Inc. recently completed another PROACT® Root Cause Analysis workshop at the BHP Billiton Petroleum Group offices in beautiful Trinidad. The 4 day training session combined RCI's PROACT® Root Cause Analysis Methods© workshop along with the intensive PROACT® Suite Software workshop which included our NEW PROACT® Logic Tree Knowledge Management Templates. Several new RCA's with high impact were started during the training and we look forward to hearing about the real root causes they discovered and their recommendations to eliminate them from happening again.

BHP Billiton Petroleum Group has a global network installation of RCI's PROACT® Suite Software and is already starting to leverage the learnings from completed root cause analyses (RCA) investigations they've completed at other BHP facilities around the world.

During the recent downturn it has become even more important to reduce operating and maintenance costs, improve quality and productivity, and increase asset output and reliability, all while pursuing safety perfection and environmental excellence.

RCI offers many tools and resources to help companies achieve Reliability Excellence. Visit http://www.reliability.com/ to learn more about our Root Cause Analysis Methods training, Human Error Reduction Strategies Training, PROACT® Software Solutions and Logic Tree Knowledge Management Templates.

Call 804-458-0645 or email info@reliability.com for more information.

The root cause just isn’t that important

2009-08-28T08:03:00.000-07:00

The root cause just isn’t that important

Hi Tor. As a fellow provider I will agree that the use of the term "root cause" is so diluted in today's environment it is meaningless. If we take the word to its literal sense then we would take all of our analyses back to Adam and Eve which we both agree is very non-value added. Given that, the question becomes where should our analyses stop?

To excerpt a quote from your post "An example: A mill has problems with failing bearings in most of its rotating equipment. After a quick look, we find out that equipment isn’t aligned, there are no lubrication routes set up, no clean oil storage, no sealed storage for spare bearings...Let’s work on solutions that we know will improve the problems." In the short-term again, I would agree.

However, if we do not drill down deep enough to uncover the system deficiencies that contributed to the failure, then just fixing the physical side may not make the problem go away. If we go ahead and align the equipment properly, then if the person who misaligned it in the first place is not trained in how to do it right, they will do it wrong again. If the procedue in place was obsolete, someone else will follow it next time. If the alignment tools they are using are worn or not calibrated, it will be done wrong again. Where were the oversight systems (QA/QC [certifications], vibration monitoring results, etc.) that should have caught the failure before it occurred and we suffered component losss? Was the person aligning trained in how to do so properly or was it just on-the-job training? If it was a training issue, that is an underlying system that affects more than just alignment training.

On the other issues the same applies. Why were there no lubrication routes? Yes we can recognize they are not there and then put them in place, but the underlying system is still flawed. If the underlying system allowed that condition to exist without rectifying it, it will happen again (and likely is happening currently) somewhere else in the facility. This is like finding out that P&ID's are not current when investigating a single failure. If we dug that deep to find the P&ID issue, you should check other P&IDs also as they may possess the same flaw. The system of not updating P&IDs is the problem, not just the set of drawings in the case of the one failure.

Unless we at least drill deep enough to uncover the system's contributions to a failure, then the failure will likely recur somewhere else in the facility. I could care less what we label wherever we stop the analysis. Our goal as analysts should be to prevent recurrence by implementing effective and timely interventions as well as distributing lessons learned to others who could be faced with similar conditions and prevent the failure next time.

Robert J. (Bob) Latino
CEO
Reliability Center, Inc.
www.Reliability.com
www.Proactforhealthcare.com
804.458.0645 Tel
804.452.2119 Fax

The Role of Leadership in Patient Safety

2009-08-28T05:40:00.000-07:00

This was an excerpt from a Joint Commission Alert today, "Leaders must consistently make safety a top priority in their decision-making. Safety must be supported at all levels of the organization and by both administrative and clinical leaders. Unfortunately, patients and health care staff may perceive a considerable difference between what leaders say and what is actually occurring—for example, when leaders do not support the reporting or managing of errors for fear of litigation. It is common for staff to believe that financial considerations consistently trump quality and safety concerns."

Two points strike me about this Alert, 1) why is their a need to issue such an alert to remind healthcare leadership that patient safety should be a priority of theirs? and 2) are fears of litigation trumping patient safety efforts?

From a patient's standpoint, if I am ill then I should see the hospital as a safe haven. What we learn from this is that the hospital is a place we should extend caution when in, as no one is looking out for us as much as we are (and our families). Why should this be the case in the most advanced country on earth?

Human Beings: Assets or Liabilities?

2009-08-27T11:52:00.000-07:00

Do you feel that our government considers the human being an asset or liability when it comes to the healthcare system debate?

Are your Root Cause Analysis recommendations working like they should?

2009-08-24T08:36:00.000-07:00

Do the recommendations from your incident investigations prevent recurrence of the undesirable events or just meet the required Title 29 OSHA regulations?

Root Cause Failure Analysis Costs Too Much Money??

2009-08-17T12:06:00.000-07:00

If RCFA is costing you too much money, then you are doing it wrong!!! This is a common paradigm that must be overcome. Many believe that implementing the recommendations from RCFA will be an expensive venture. I am not saying that this is never the case, but I am saying that in my experience it is rare. It is rare because the majority of causes of these chronic failures are deficient organizational systems.

Organizational systems are the “rules” that govern how a facility operates. For example, organizational systems include maintenance procedures, operating procedures, policies, guidelines, training systems, purchasing systems, etc. People make decisions based on these systems. If these systems are flawed, then poor decisions are going to be made resulting in operational failures.

Correcting deficient systems is not expensive but it does take courage. Providing training or correcting procedures is not capital money but it does involve the “soft” issue of dealing with the human behaviors and attitudes. Sometimes we tend to think we can throw money at any problem and it will go away. Sometimes it might! Most of the time we end up wasting money because many times we spend the money on equipment and not people. Money spent on helping our people to make better decisions in the field is money that will provide far greater returns than many equipment investments.

Read this article written by Reliability Pioneer & RCI Founder, Charles J. Latino:

Workers Are Industry’s Most Important Resource:
Harness Their Power by Mastering the Art of Serving

Robert J. Latino
CEO, Reliability Center, Inc.
blatino@reliability.com
804-458-0645

Root Cause Analysis for Manufacturing and Healthcare

2009-08-13T10:45:00.000-07:00

I am an expert in investigating undesirable outcomes no matter the industry. I base my observations on 25 years of experience in both the manufacturing industries and healthcare. I am a practitioner, educator, author and developer of software tools to aid in more extensive and accurate investigations.

To this end, I would like to relay some highlights of my findings from hundreds of root cause analyses that I have been involved with to various degrees (in both industry and healthcare).

1. No matter the industry, failure occurs most often because people make inappropriate decisions to do or not do something (errors of omission or commission). People usually make these decisions with good intent; however the basis of the decision is made with poor information. These decision errors are what we refer to as Human Root Causes.

2. This poor information comes from deficient or non-existent organizational systems (policies, procedures, procurement practices, training systems, etc.) that are supposed to provide us proper information to make educated decisions. These systems issues are what we refer to as Latent Root Causes.

3. Poor decisions result in unintended physical consequences (i.e. – wrong meds dispensed, paperwork filled out wrong, delays in handling blood, etc.) which if not caught will eventually result in patient harm or a close call (high risk). These observable consequences are what we refer to as Physical Root Causes.

So to summarize:

Undesirable Outcome <>

* Work Stress (leaner staffing, more patients, more failures, increased stress at home from economy, divorce, etc.)

*Time Pressure (encourages short-cuts to be taken)

*Overconfidence (“I’ve done this a 1000 times before”)

*First Time Task Management (agency people, new hires)

*Imprecise Communications (top to bottom, lateral, between departments, language barriers, etc.)

*Vague/Incorrect Guidance/Procedures (obsolete policies & procedures, vague compliance requirements, conflicting requirements from management., etc).

*Lack of Training (in service, on new technology, on new procedures, on new regulations, etc.)

*New Technology (no training provided, no new procedures put in place, preventive maintenance not kept up, etc.)

Looking at these we understand that no matter where we work, we all work in systems where we have our specific roles within those systems. The common denominator of undesirable outcomes is that at some point there was human involvement.

Our role in RCA is not to find out “who” did it, but to understand why they thought the decision they made was the right one. An RCA should not end with Human Error; it should begin with it and strive to understand the rationale for the decision itself and not the person! It cannot get back to being more basic than addressing our decision making and what affects it! Thanks for your time.

Robert J. Latino
CEO, Reliability Center, Inc.
blatino@reliability.com
804-458-0645

Comment by:
Roberta Mikles, RN
Patient Advocate

I wanted to take time to personally thank you for this information. I found it to be valuable and, in fact, it supports what I have been saying for some 30 years of working in health care, at various levels. I hope that those, who are on this listserve, will take to heart that which you have stated, from your vast experience, and bring back to their facilities this information. Having been involved in patient advocacy, I have found it most difficult to get providers to 'listen' to the simple solutions to correct problems.

Most of my advocacy, in the beginning, was focused on dialysis facilities of which have many, many problems. One article, http://www.renalbusiness.com/articles/dialysis_patient_safety.html that I wrote on 'patient safety' in the dialysis unit, was received with great welcome, however, nothing changes, even in light of the newly revised dialysis facility Conditions of Participation/Coverage. Presently, I am a (charter) member of a Patient & Family Advisory Council at a large hospital. We are made up of 51% patients and/or family members and 40% hospital staff. I have found this to be an effective avenue of change.

I am also on the World Patient Safety Day committee that was founded in 2001 by Patti O'Regan a Nurse Practitioner in Florida who has been quite involved in patient safety. You might be familiar with her due to her vast work at various levels.

Again, thank you for sharing such valuable information.

Roberta Mikles, RN
Patient Advocate
858-675-1026
World Patient Safety Day
annually - July 25th
www.patientsafetyday.com
member- WPSD Legislative Action Committee

PROACT® Root Cause Analysis Goes to PEMEX in Mexico City

2009-08-05T10:18:00.000-07:00

Reliability Center Inc. (RCI) taught their 3-day PROACT® Root Cause Analysis Methodology workshop in the Sheraton-Maria-Isabel Hotel in Mexico City. Participants from most divisions of PEMEX worked extensively with two problems that had been previously analyzed: 1) a weld failure on a pipeline and 2) repetitive failures on a turbo compressor. In both problems, the advantages of implementing the PROACT® RCA methodology successfully assisted the teams to arrive at the best solutions in the shortest time. As the students learned the PROACT® RCA Methodology, they were also presented with RCI's exclusive PROACT® Software System and Templates, which helped facilitate the RCA process.

To learn more about RCI's PROACT® Root Cause Anaylsis Methods Training call 804-458-0645 or email info@reliability.com. Or visit http://www.reliability.com/industry/training/rcamethods.html.

U.S. Labor Department’s OSHA issues letters to oil refineries stressing compliance with process safety management standard

2009-07-31T07:11:00.000-07:00

With this downturn in the economy it is recognized in heavy industry that short-sighted costs reduction efforts may expense safety and cause more undesirable outcomes to occur. The Chemical Safety Board (who investigates major manufacturing failures) recently issued this statement to that effect:

http://www.reliability.com/industry/index.html

Shortly thereafter, OSHA released this statement:

http://www.dol.gov/opa/media/press/osha/osha20090648.htm

Why are they making such proactive statements now?

In refining specifically we remember the tragedy at BP’s Texas City Refinery where similar safety oversights were referred in the final investigative report as contributing to the deaths of the 15 contractors. We all can remember the Challenger and Columbia Shuttle disasters where safety culture issues were also cited in the government reports as contributing to the accidents.

The Challenger accident investigation report cited “normalization of deviance” as a contributing factor. This is the continual degradation of safety standards over time to the point of acceptance. We take short cuts in our safety processes oftentimes because of time and resource pressures. We take these shortcuts and then nothing negative happens. We view this as being acceptable and now we have a new, lower standard. That sequence repeats itself until we have a catastrophe and then the standards are set back to “0” and heavily enforced…until normalization of deviance sets in again. This explains the 17 year cycle between the Challenger and Columbia disasters.

Is what happened at TVA any different? The difference today may be in semantics. Today, with the economy being so poor, we are faced with where the cost cuts will come from. Oftentimes these decisions are made at the top and the effects of these decisions impact the sharp end (those closest to the work).

Oftentimes we mistakenly believe that letting people go will affect our bottom-line in a positive manner. This may be true if we are looking at the short term financial statements being prepared to demonstrate appealing quarterly returns for the shareholders. However, what is often not seen is the impact on operations, maintenance and reliability when these cuts occur.

Just because people leave does not mean the problems go with them. The reality is the problems remain, only with fewer people now to address them. The remaining workforce now is doing the work of 2 and sometimes 3 people and they are heaped with an increased number of failures to resolve. This scenario is real and most of us can relate. What this means is our failure rate will likely increase because of our inability to keep pace with resolving them while keeping the processes running.

Given this economy, when cost cutting decisions affect safety (which cutting maintenance, operations and reliability costs will do), we can expect to hear of an increase in the number of major industry accidents in the news.

Robert J. (Bob) Latino
CEO
Reliability Center, Inc.
www.Reliability.com
www.Proactforhealthcare.com
804.458.0645 Tel
804.452.2119 Fax

Brainstorming vs Failure Analysis

2009-07-21T07:25:00.000-07:00

BY: Ronald L. Hughes, Senior Consultant, Reliability Center, Inc.

Many analyses or incident investigations are done by putting together an “ad hoc” committee of subject matter experts to solve the undesired event by using their individual expertise to map out the failure mechanism. It is also common practice to assign a single person the role of Principal Analyst were he or she alone is expected to perform the analysis by interviewing the pertinent employees individually to uncover the cause(s) of the failure being investigated. Both of these methodologies are nothing more than “brainstorming” activities and do not constitute a valid failure analysis or incident investigation. Failure analysis or problem solving involves much more than just a brainstorming solution to an identified problem. Brainstorming indeed does have a viable role (generating hypotheses of what could have occurred and uncovering observations) in the analysis effort but by itself seldom uncovers all the causes of the incident being investigated. If all the causes are not uncovered then the analysis is not complete.

RCA meetings of a good cross-functional team (both subject matter experts and non-experts) are very important if you want to explore all the possibilities of the incident. Without these meetings the investigation tends to follow a single path based on perspective in lieu of evidence. This is true “shallow cause analysis” as the synergistic effect of the team environment has been eliminated and thus not all the possibilities explored.

RCA investigations must look at all forms of evidence not just the human perceptions that come out of brainstorming sessions. Although interviewing personnel is important to uncover the observations noted at the time of the failure or incident, positional evidence, parts examination and paper data should also be used to verify what people perceive as the failure mechanism. If these other types of data do not correlate with the information obtained during the interviews then something else must have happened to cause the failure.

The success or failure of your problem solving efforts often depends on the strategies used to conduct the analysis. A sound management strategy must be devised and put into place for every step in the Root Cause Analysis process in order for the analysis to be both effective and efficient.

Obviously collecting and maintaining the paperwork (data collection, hypothesis verifications, recommended solutions to identified root causes, etc.) associated with the failure investigation can be a daunting task. For this reason the use of software that is designed specifically for this purpose is extremely beneficial and is highly recommended. Although there are several packages on the market RCI’s PROACT® System is by far the best and most complete of the software packages designed for this purpose.

As a failure analyst I find that PROACT® is an invaluable tool for doing my job. My analysis efforts are not only easily managed, but are much quicker than ever before.

PROACT RCA Workshop at PEMEX in Mexico City

2009-07-15T12:11:00.000-07:00

PROACT® Methodology Training
Mexico City, Mexico
July 8-10, 2009

Below is a photo of the students that attended RCI's 3-day PROACT® Methodology workshop in Mexico City. Participants from various divisions of PEMEX participated interactively with the instructor to apply RCI’s methodology to on-going real issues within their respective facilities. As they learned the PROACT® Root Cause Analysis Methodology, they were also introduced to the PROACT® Software and Templates, which can facilitate the Root Cause Analysis process.

PROACT® is a powerful tool set which can help your organization become more productive and efficient. PROACT® can help you identify and eliminate inefficiencies in your processes and enable you to improve your margin and productivity. This in turn will position your company for increased growth as the economy improves.

If you would like more information about training in the PROACT® Methodology we invite you to contact RCI at 804-458-0645 or info@reliability.com. We're happy to assist you.

Learn more>>>

OSHA News Release: OSHA Issues Letters to Oil Refineries

2009-07-14T05:45:00.000-07:00

OSHA News Release: 06/10/2009

U.S. Labor Department’s OSHA issues letters to oil refineries stressing compliance with process safety management standard

http://www.dol.gov/opa/media/press/osha/osha20090648.htm

2009-07-13T12:25:00.000-07:00

In a year that promises to be a financial challenge for most corporations, we must make decisions as to where to invest our scarce dollars and where to cut from our current operations. When faced with these decisions, we must be realistic and pragmatic about how short-term decisions impact our long-term goals. Yes, times are hard now, but how well positioned will we be when the economy picks up (and keep the faith, it will pick up)?

View Mr. John Bresland's, Chairman of the Chemical Safety Board, movie about safety in oil refineries and also read Mr. Robert J. Latino's artcle titled:
RCA an Investment or Expense: PDF

Increase In VIT Plant Accidents Worries DOE

2009-05-29T12:44:00.000-07:00

By Annette Cary, Herald Staff Writer
509-582-1533
Blog:Root Cause Analysis Solutions
Google Groups: Reliability RCA

HANFORD -- The Department of Energy is concerned about an increase in accidents requiring medical attention and other safety-related incidents at the Hanford vitrification plant this year. "The (vitrification plant) project has recently experienced several reportable and nonreportable events that indicate the construction site safety performance may be in jeopardy," wrote John Eschenberg, DOE manager of the vitrification plant project, in a letter to Bechtel National. The problems "may have resulted from a fundamental breakdown in work planning, hazards identification and control, and/or a generally poor level of diligence and awareness," Eschenberg wrote.

Bechtel is redoubling its safety efforts to reverse the trend, said Ted Feigenbaum, the new Bechtel project director for the Waste Treatment Plant, or vitrification plant. The construction project had a series of safety problems in 2004 and again in 2005, but launched efforts then that improved its safety performance. Seeing the plant's rate of safety-related incidents start to rise again has been disappointing, Feigenbaum said. Most of the recent incidents have been caused by complacency or losing focus on safety, rather than a lack of good safety procedures or correct safety equipment for the plant's 800 construction workers, he said.

In one incident since DOE sent the letter earlier this month, parts of a tower crane and a tall mobile crane touched when one of the crane operators failed to wait for instructions from the ground to proceed, according to Bechtel. In a case cited in the letter, a worker was using a remote control to move a scissor lift this month when he accidentally moved the lift the wrong way and it ran over his foot, breaking a bone. In another incident last month, a worker was cutting an I-beam and got pinned by one of the cut pieces but was not seriously injured.

Bechtel has stopped work by some groups of workers for short periods after some of the incidents to examine safety problems and refocus on safety. Long term its strategy is to "get as many eyes" as possible on safety issues, Feigenbaum said. Managers will be spending more time on the construction site with a safety check-list to observe procedures and talk with workers, he said. The managers will be working with safety professionals. Representatives of building trades unions are
expected to walk the site with supervisors and make recommendations. Bechtel also will be relying on its construction workers as it reinvigorates a program that asks the experienced workers who are most respected by other workers to observe other workers and recommend ways they can work more safely.

Bechtel also plans to bring safety experts from its other construction sites around the world to take a fresh look at safety issues at the vitrification plant. A program Feigenbaum has used at other job sites will award gift certificates or other prizes to workers observed using safety precautions to provide positive reinforcement for the safety push. Workers are being encouraged to maintain a mental focus on safety, follow procedures and not to rush, Feigenbaum said.

Article Orginated at: http://www.tri-cityherald.com/kennewick_pasco_richland/story/593114.html

Comment by:
Mark Latino, President, Reliability Center, Inc.

It is evident that cultural issues are at play. When you see words or statements like complacency, failed to wait for instructions, and losing focus there is a supervision problem. When workers become complacent it is because the rules have not been reinforced routinely. Good supervision constantly reinforces safe working practices and provides employees with instant feedback. When a supervisor observes an unsafe act and says nothing because they have to be at a meeting they have in an instant given approval for the act, even though it may not have been the intent.

There are Human Error Reduction practices that supervisors can learn which will allow them to manage human error. Human error traps can be identified when you know what to look for and avoided if you know what to do when you realize you are in a trap. This coupled with an effective Root Cause Analysis process will reduce on the job safety incidents.

Learn more about PROACT® Human Error Reduction for Safety Performance

Cut Costs Without Cutting Manpower from www.mfrtech.com

2009-05-29T07:26:00.000-07:00

Cut Costs Without Cutting Manpower
Article published at :
Manufacturing & Technology eJournal http://www.mfrtech.com
Blog: Root Cause Analysis Solutions
Google Groups: Reliability RCA

The economy is tough. Manufacturers, especially, have been slashing jobs to cut costs. But there are better ways to slim down a production operation without cutting all the manpower.

Seth Hummel, vice president of business process improvement firm IQC (http://www.4iqc.com/) is telling companies that haven't implemented a business-wide lean manufacturing initiative they can still cut costs by tackling concepts that best fit their identified opportunities for improvement. "You don't have to take on the expense of a full-blown lean program to save money," Hummel says. "Instead, take a look at select lean tools such as Root Cause Analysis and Value Stream Mapping. Eliminating the cost of poor quality is a sure fire way to add money to the bottom line and save jobs."

Hummel also suggests companies focus on: *Quality system detail: Those companies that don't have "responsibility" and "authority" adequately documented in their QMS are scrambling to make sure their "new" company organizational chart fits all of the to-do's that still need to be done. *Cultural Analysis and Alignment: What part of the company's culture is not aligned with its focus and how do the best cultural opportunities for improvement match up to the best process/product opportunities for improvement?

Have you tried any of these ideas at your business or found other creative, successful solutions to cutting costs without cutting workers?

Robert J. Latino, CEO, Reliability Center, Inc. offers his comments on this excellent article:

Unfortunately there is a prevalent mentality in industry that believes that laying people off improves the bottom-line. This is true if we are appeasing those who review strictly our income statement in the short-term and want to see a decrease in one of our largest expenses for each quarter.

However, the resonating effects of this decrease in staff is not as obvious on the books, nor are these effects often searched for with any depth especially in the long-term view. Do we honestly believe that by letting people go that our problems in our processes go out the door with them? Do we calculate on our books the cost of the intellectual capital that we just sent packing down the road, the people that knew how to fix the problems? When we send these people packing, unfortunately the same number of failures will still occur but we will have less people address them.

In other words we will have more failures now to deal with, in addition to the added work responsibilities as a result of the layoff. What normally happens under these conditions? I have more work to do and more failures to solve, so the chances are the number of human errors will increase thus increasing the overall failure rate. Where do we find these numbers on our balance sheets and income statements? Who looks for them?

I have always found it amusing that when I read many 10k reports the CEO's inevitably call their workforce their greatest assets on page 1, That is of course until you turn the page to the financials where our workforce is a liability (expense) and our equipment is an asset! How often do we layoff our equipment?

Learn about how to reduce or eliminate Human Error at your facility:
PROACT® Human Error Reduction for Safety Performance

Learn about ways to retain your corporate knowledge:
Workers Are Industry's Most Important Resource; Harness Their Power!

Failure Scene Investigation Workshop

2009-05-20T11:48:00.000-07:00

iPresentation by Victor May
Blog: Root Cause Analysis
Google Groups: ReliabilityRCA

Just as in any crime scene, the dissemination of the clues uncovered provides the answers that solve the mystery. This comprehensive 3 day hands-on workshop in analysis verification techniques provides the participants with the skills and knowledge to strategically obtain and interpret the data necessary to solve failure by demonstrating how different analytical tools are used to prove or disprove hypotheses. View Now and then share your comments.

Turbine Driven Boiler Feed Pump Catastrophically Fails Without Warning

2009-05-20T11:15:00.000-07:00

iPresentation by Ronald L. Hughes
Blog: Root Cause Analysis Solutions
Google Group: Reliability RCA

The boiler feed pump caused the plant to trip due to low boiler feed. The failure took place in three tenths of one second therefore leaving minimal to no reaction time for operators. Many of the pump housing bolts were missing, the turbine to pump coupling had sustained heavy damage, and the site management wanted answers. View Now and then share your comments.

Root Cause Analysis and Short Cuts

2009-04-15T15:53:00.000-07:00

I am curious to hear the opinions of others on the effects of time pressure when imposed on those charged to do Root Cause Analysis. Some industries have imposed definitive time frames in which RCA's should be completed (i.e. 45 days). When such industries impose these time frames, what is expensed (if anything) in terms of the quality of the outcome of the analysis (the deliverables)?

My personal opinion is that data collection takes the biggest hit because that is typically what takes the greatest amount of time in the course of the analysis. If this is true, then the overall quality of the analysis has to lack some credibility as either it is not as comprehensive as it should be, or what is provided is not backed up by solid evidence to support the hypotheses.

Given that thinking, any approach that someone calls "RCA" which does not require data collection to serve as evidence, cannot be absolutely credible. Is this logic incorrect?

This has been the problem I have had with quality techniques like the 5-Whys and the Fishbone Diagram in that oftentimes hearsay is permitted to fly as fact and solid evidence is not required. These are the primary reasons in which I personally do not consider these two tools as "RCA" approaches but rather performance improvement tools or problem solving tools. I consider such tools as less rigorous than "RCA" and applicable to situations with less severe consequences.

There are other reasons I feel the 5-Whys are not appropriate for applications with more severe consequences. One is that this tool advocates that failure happens in a linear fashion and gives the impression that there is a single cause. It discounts the possibility of simulataneous and multiple paths coupling together at the same time to result in an undesirable outcome. Also, asking "Why" is a very limiting question as it connotes the need for an opinion and singular answer. When dealing with the physical side of failure, asking "How Could" provides the possibility of exploring all options not just the most likely. There is a completely different response to ask "Why a crime occurs?" as opposed to "How a crime occurs?".

Likewise, the Fishbone Diagram is a categorically based tool which first requires the selection cause category sets (the fishbones) and then relies mainly on brainstorming to see what the team thinks could have happened under these categories. This tool, to me, does not drill deep enough using cause-and-effect logic to uncover the human and systemic issues associated with reasoning and decision-making. Many I have seen stop the analysis when there is no more room on the piece of paper to drill deeper or expand wider. This is really what I call "shallow cause analysis" when applied in this fashion.

I understand that all of these tools have variations of use and that the skill of the analyst is really the key to unlocking the potential of any tool. I am speaking in generalities based on what I see in reality during my travels. I am also curious to see how others feel about calling the 5-Whys and the Fishbone diagram, RCA tools.

On future posts we can discuss form-based RCA as that is a different animal all together.

Bob Latino

What results have you achieved?

2009-04-14T12:46:00.000-07:00

When asked what, when and where to use the RCA tool I have had to answer “anywhere on any problem” . By looking at the history of any RCA methodology a lot can be learned. Knowing the conditions of the RCA methodology conception can answer what types of problems it will solve best.

If the RCA method was developed to solve safety related issues it will most likely work best for safety but not as well on equipment reliability issues. If the method was developed to solve equipment reliability issues it will most likely work best on equipment issues. Many times solving equipment issues will also solve safety, quality, and environmental issues as a by product of the analysis.

The PROACT RCA process was born within a Reliability group charged with increasing the overall reliability of each of it’s sites. The mission was to uncover failure mechanisms, solve them, implement corrective actions, and share lessons learned within the corporation. The RCA tool was dubbed “The Learning Tool” and that is what makes it apply anywhere.

The RCA process is critical in today’s climate because the lessons learned can guide companies to the best places to cut costs that affect the bottom line.

My main intent is to reach out to hear from you about your success and the challenges you face with your RCA process. In talking with some of you over the years, hearing what has worked for you and impacted your organization. I would like to hear about your RCA efforts and how they are working. What results have you achieved?

Let’s hear about your RCA and Reliability success stories. If you are having challenges with your RCA efforts let’s get started helping you achieve your goals with one of the most powerful tools out there.

Mary Dyer

Welcome

2009-03-26T12:16:00.000-07:00

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