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Root Cause Analysis: Think Again! - by Kevin Stewart

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  • 1. Root Cause Analysis – Think Again! Presented by Kevin Stewart
  • 2. Table of Contents • Introduction • Key elements of a sustainable root cause analysis program • Sustainability • Audit
  • 3. Poll 1 • Does your company truly identify the “root cause” of problems or does it jump to solutions? – We have a process and get to the root cause – We have a process but don’t get to the true root cause – We don’t have a process but continually find the real root of our problems – We don’t have a process and continue to have repetitive problems
  • 4. Introduction • A new way of thinking – Definition of Insanity • “Doing the same thing over and over and expecting different results” • “Doing different things all the time and expecting the same results” – Time to change or stay in our rut
  • 5. Involved or Committed? A new way of thinking
  • 6. SAP BiModal distribution Software installation (involved) New maintenance paradigm (committed) Failed Successful
  • 7. Introduction cont. • It is not – Quick – Easy – if it was you would already have it done – Going to be successful if it is done the same way as other initiatives that failed • It is – Hard – Time consuming (multi year) – Necessary to communicate – Necessary to track and show value – Very, very valuable to your organization
  • 8. Introduction summary • The definition of insanity continues to apply • Think differently about implementing Root Cause Analysis – Not everyone knows what you know so tell them – Decide to be Committed – Long term focus • Program • Cultural shift where everyone gets involved
  • 9. Poll 2 • Does your company have a formal written process for performing and sustaining a Root Cause Analysis process? – Yes – We have a process but it isn’t written or formalized – No it is not documented – No we don’t have an RCA program
  • 10. Elements of a Root Cause Analysis Program 1. An involved Sponsor, or program champion 2. A Resourcing plan complete with a program champion and trained investigators 3. Clear trigger mechanisms to clarify exactly what needs to be investigated. 4. Clear protocols for the collection of and preservation of evidence and information.
  • 11. Elements of a Program 5. A standard reporting process to assist with further analysis and cost savings 6. An ironclad tracking system that forces resolution of the action items through escalated emails or other methods 7. A process to review the investigations for common causes and possible missed or improvement opportunities 8. Tracked value of the RCA program
  • 12. 1) An involved sponsor • Sponsor – Target - Change Agent
  • 13. Recognize this? Sponsor TargetChange Agent Apparently there must be some mistake?
  • 14. Better? Sponsor Target Change Agent Excellent Alignment!
  • 15. An involved sponsor • Sponsor must be involved – Show up at meetings – Ask about progress – Ask to see analyses • Actions speak louder than words • Program difficulties without
  • 16. 2) Resourcing Plan • Who do you need? • What are their duties and responsibilities? – Program champion • Overall program success • Training strategy and implementation • Coaching and counseling facilitators • Tracking and reporting metrics • Assisting with difficult or sensitive Analysis • Depending on size may also be a facilitator
  • 17. Resourcing Plan (cont) • What are their duties and responsibilities(cont.)? – Facilitator • Facilitate incidents based on triggers or as asked • Manage the entire investigation • Continually improve their skills – Participants • Provide pertinent information to further the analysis, as many times they are the ones with the “causes” of problems
  • 18. Resourcing plan cont. • Time commitment? – Program Champion • Half to Full time to start (plan for a year) – Can’t afford it? WRONG! (insanity?) • Tapers off over time as program takes hold – Facilitators • Varies – rule of thumb about ¼ of time or about 1 detailed analysis per month – Participants • Need should be spread but similar to facilitators be careful to not get them involved in multiple analyses from multiple facilitators • Schedule their time
  • 19. Resourcing plan cont. • How do you pick these people? – Lottery? – The way you’ve picked everyone else? • Suggestion – Define skill set first and look for specific skills then train them (the Toyota way) • Tenacity • Work Ethic • Proven long term commitment • People skills (empathy, communication, etc.)
  • 20. Resourcing Plan (cont) • What training do they need? – Champion • Root Cause analysis, advanced topics (master facilitator), facilitator training, team building or management, public speaking, interviewing – Facilitators • Root Cause analysis, advanced topics (master facilitator) – Participants • Training in the process chosen • Who should do the training?
  • 21. Poll 3 • Does your company have a written plan documenting the resource requirement for a Root Cause Analysis program? • Yes • We have a plan but it isn’t documented • No it is not documented • No we don’t have an RCA program
  • 22. 3) Trigger When will you do an Analysis? Informal Trigger
  • 23. Formal Trigger
  • 24. Trigger Metric 0 1 2 3 4 5 6 7 8 9 Qrt 1-2 Qrt 2-2 Qrt 3-2 Qrt 4-2 Qrt 1-3 Qrt 2-3 Qrt 3-3 Qrt 4-3 Qrt 1-4 Qrt 2-4 Qrt 3-4 Hours Quarter RCA Downtime Trigge or number of Non-compliances
  • 25. Poll 4 • Do you have any kind of formal or informal process to define when to do an official Root Cause Analysis? – Yes – No
  • 26. 4) Preservation of Evidence • Why is evidence thrown away? • Failed bearings (physical evidence) • Opportunities – Establish parts graveyard – Communicate – Basic rules – Train to comply • Establish written policy
  • 27. 5) Standard Report • Standardization is key – Report ID – Report date – Simple format – Investigation details – Significance – Cost and Manpower – Standard placement
  • 28. 6) Tracking System • Based on email • Features – Simple transference – Alert proper people – Due date – Escalation features – Others complete – No deletion
  • 29. Poll 5 • Does your company have any system to formally track action items that may come from a Root Cause Analysis to insure they are completed? – Yes we have a system and it is used with success – Yes we have a system and it somewhat utilized – Yes we have a system but it isn’t utilized – No we don’t track action items – No we don’t have an RCA program
  • 30. 7) Common Causes • Equipment solution • Systemic solution
  • 31. 8) Tracking Value • ROI – Track manpower for analysis – Track cost of solutions – Track savings for each 𝑅𝑂𝐼% = 𝐶𝑜𝑠𝑡 𝑠𝑎𝑣𝑖𝑛𝑔𝑠 (𝑅𝑒𝑡𝑢𝑟𝑛) 𝐼𝑛𝑣𝑒𝑠𝑡𝑚𝑒𝑛𝑡 (𝐶𝑜𝑠𝑡 𝑡𝑜 𝑎𝑐ℎ𝑖𝑒𝑣𝑒 𝑟𝑒𝑠𝑢𝑙𝑡𝑠) x100
  • 32. Tracking Value 𝑅𝑂𝐼% = 𝐶𝑜𝑠𝑡 𝑠𝑎𝑣𝑖𝑛𝑔𝑠 (𝑅𝑒𝑡𝑢𝑟𝑛) 𝐼𝑛𝑣𝑒𝑠𝑡𝑚𝑒𝑛𝑡 (𝐶𝑜𝑠𝑡 𝑡𝑜 𝑎𝑐ℎ𝑖𝑒𝑣𝑒 𝑟𝑒𝑠𝑢𝑙𝑡𝑠) X 100 Cost of investigation = team of 4 for 2 meetings of 4 hour and 2 hours respectively $100 / hr cost of employee Cost of solution = (purchase, install, implement, troubleshoot, etc.) $2,000 Cost Savings = elimination of repetitive problem that was costing $40,000 / year Answer = 40000 / (2400 +2000) = 40000 / 4400 = 9.09 = 909% ROI
  • 33. Total Savings 0 1000000 2000000 3000000 4000000 5000000 6000000 7000000 8000000 9000000 2008 2009 2010 2011 2012 Jan Feb Mar Apr May Jun Ju; Aug Sep Oct Nov Dec Yearly Savings Monthly Cumulative
  • 34. Poll 6 • Does your company track the value of your RCA program? – Yes and it is widely known and reported company wide – Yes but it is not widely know company wide – Yes but it is only know by certain individuals – No we don’t know what value our RCA Program provides – No we don’t have an RCA program
  • 35. Sustainability • 2nd Order change defined • Time required Deciding - or being forced – to do something significantly or fundamentally different from what we have done before. The process is irreversible; once you begin it is impossible to return to the way you were doing it before
  • 36. Sustainability • Examples –CMMS –GE • Why 3 years?
  • 37. Audit • How to ensure it never changes? • Possible measures – Number of investigations – Action items – % reduction in trigger – Adherence measures – ROI
  • 38. Conclusion Establish your plan for the program based on a minimum of 3 years Review the 8 elements and modify to fit your needs Involved Sponsor Clear Resourcing Plan Set triggers Evidence Preservation Standard reporting Establish an action tracking system Review for common causes Track the value of the savings Make it all sustainable! Oh and don’t forget your other job either!
  • 39. KEVIN STEWART Reliability Advisor Instructor/Facilitator – Apollo Root Cause AnalysisTM Methodology kstewart@armsreliability.com Questions?