Presentation on Incident investigation using RCA tools like FTA, Fishbone diagram, Why-Why analysis, etc.

1. Presented by: B. N. JadhavPresented by: B. N. Jadhav
Before opening the book, Let us understand

2. FA, RCA, RCFA: What’s the difference ?
• Failure Analysis (FA):
 Stops at physical root cause
 Physical root is at a tangible level, usually component level
• Root Cause Failure Analysis (RCFA):
 Comprehensive analysis down to all of root causes
o Physical, Human, Latent
 Generally associated with Mechanical failures only
• Root Cause Analysis (RCA):
 Full blown analysis. Identifies Physical, Human and Latent root causes
 Includes safety incidents, quality defects, customer complaints
Incident Investigation –
• What is RCA?
 A tool designed to help identify not only what and how an
event occurred, but also why it happened.
 A process designed for use in investigating and categorizing
the root causes of events with safety, health, environmental,
quality, reliability and production impacts
 Specifies workable corrective measures that prevent
recurrence of the event

3. Incident Investigation –
• It is an Improvement Process …
 RCA and RCFA is not a silver bullet to solve all your problems instantly
 It only can be ensured that RCA delivers Best Possible outcomes for
organization
• RCA: Reactive or Proactive
 Not necessarily good for predicting failures
 Lagging measure to prevent recurrence.
 However recommendations can be implemented to similar equipments
and events.
 Thus can be a proactive measure
Incident Investigation –
• What is a Root Cause?
 Specific underlying cause
o Specific questions about Why the incidence occurred
 Reasonably identifiable
o Must be cost beneficial to identify
o Use structured RCA tools
 Can be controlled by Management to fix it
o Causes should be specific enough to allow management to make effective
changes to prevent recurrence.
o Avoid using general cause classifications such as operator error, equipment
failure or severe weather.
o Management should have control on it.

4. Incident Investigation –
 Effective recommendations for preventing recurrences
o Recommendations should directly address the root causes identified
during the investigation.
“Improve adherence to written policies and procedures,”
o This is vague recommendations
o Indicates a basic and specific enough cause is not found
o Need to expend more effort in the analysis process.
Incident Investigation
Set your Objectives and Procedures
Evidence Collection and Assessment
Finding Root Cause/s and Effective Solutions
Reporting, Generating proposals, Tracking System
Evaluate Performance of RCA, Create Business Process Map

5. Define
o The key steps in defining RCA process ‐
• Set your Objectives
 Create trigger points to instigate RCA
 Triggers should reflect what’s important to your business:
o Safety, Environment, Revenue, Cost, Reputation, Frequency
 Triggers should be specific
 Triggers should match your facilitation resources –
o Experience of your facilitators
o Availability of stakeholders to participate in the investigations
o Resources available to deliver the improvements.
Sample Trigger System
Reportable
Incident
Loss of
Containment
> 1M Loss of> 1M Loss of
Profit
> 0.5M
Expenses
Customer
Complaint
> 4 times per> 4 times per
year
No RCA Required
Share Results &
Continue Monitoring
Results
Acceptable
Assemble Team
Conduct Analysis
Implement Solutions
Monitor & Measure
Results
Incident
Safety
Environment
Revenue
Cost
Reputation
Frequency
Yes No
Yes
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes

6. Define
• Identify Roles and Responsibilities
 Who is expected to do what? Make clear.
 Encourage the team to follow the lead of the best players
 Quality of RCA investigation depends upon the causes being
supported by evidence
o Encourage collection of good evidence
o Specifications, Maintenance history
o SOPs, DCS Trends,
Define
• Select and Train Investigators
 Balance the number of facilitators with the
capabilities of organization.
o Appoint fewer facilitators but choose them
well
o Ensure they get access to quality training
from experienced trainers
o Post‐training, give them strong support,
particularly in initial investigations.
o Allow them to build their skills and
confidence

7. Define
 A good Team Leader –
o Recognizes the strengths and abilities of individual group members
o Supports the group, giving participants confidence in sharing and trying out
new ideas
o Values diversity
o Is sensitive to the different needs and interests of group members, such as
gender, age, profession, education, economic and social status
o Leads by example through attitudes, approach and actions
 It’s a bonus if the Leader fits by function, technical
ability or discipline, too.
Define
• Prepare the Go-Bag
 Have a “Go‐Bag” ready for the RCA team to go out and collect evidence.
o Tape measure o Notebook
o Camera o Magnifying glass
o Evidence Check
list
o Pens, pencils,
highlighters
o Torch o Permanent Marker
o Vernier Calipers o Clear Plastic bags

8. Measure
• Collect Data and Assess it’s Significance
 Know how “Big” the incident is?
 Decide how much effort to put into the solution
 Data collection shouldn’t just scrape the surface
 Use a data collection checklist to guide the collection
 Don’t get tempted by “Quick Fix”
 Conduct tests or recreations, if there is minimal
or no evidence to collect
 Capture the key events
Measure
• RCA Check List
 Preserve evidence at the scene
o Retain the failed component, if possible
o Have photographs
 Interview Witnesses
 Start Data Mapping
o Maintenance Data, Immediate Vibration levels
o Immediate Process Conditions, Computer (DCS) Trends
 Review Documentation
o Lubrication history, Condition Monitoring history
o Process data sheets (PFDs and P&IDs), SOPs
o Management of Change history

9. Analyze
• Define the Problem
 Clear and precise the definition  Quicker the cause and effect chart
 Use post‐it notes in the definition as well as the chart building
 All ideas captured, No‐holes barred attitude
• Identify evidenced causes and effects
 Create a common reality on cause and effect chart
 Start with a primary effect and drive the “caused by”
case.
 Go back & repeat the causal chain when it starts to
dry up.
 Keep demanding evidence
Analyze
• Identify effective solutions
 Most creative ‐ and enjoyable ‐ part of the process.
 Don’t constrain yourself to one solution per cause
 Pay extra attention to those conditions you perceive to be the norm.
• Select the best solutions
 Avoid turning the RCA into a form filling exercise
 Assess the solutions and prioritize them
 Don’t pass the problem on to someone outside the team
 Promote implementable solution

10. Improve
• Write a meaningful report
 Most people will read the Problem Definition and Executive Summary,
and only skim through the solutions
 write a strong and concise Executive Summary
 Cover the key causal paths leading to the root causes, and the number
of solutions identified and implemented
 Outline timeframes and estimated costs
• Develop proposals
 Use processes available in the organization(MOC/MAR)
 Apply for funds for the identified solutions
Improve
• Manage a Tracking System
 The biggest single reason for RCA failure is when the solutions
aren’t implemented because tracking process is not available
 Use databases or RCA software which allow managers to view a
company wide RCA snapshot showing outstanding actions and
solutions that have or have not been implemented
• Share Key Findings
 Share results across the organization and track changes &
comments relating to RCA charts, solutions or reports
 Any investigation’s findings can work in other areas of the
business

11. Control
• Provide the Proof that RCA Works
 Necessary to obtain ongoing support for your RCA program
 Need quantifiable, demonstrable measures of outcomes
• Create a Business Process Map
 Investment already made in people and resources to get this far
 Process map helps visualize and control the outcomes of the RCA process
• Evaluate Performance of RCAs
 Use your CMMS system to determine costs and frequency rates
 Highlight savings from a reduction in recurring failures, safety incidents
 Incident Rate /Severity Vs Number of RCAs
Tools used for RCA
• Fault Tree Analysis (FTA):
 A systematic deductive analysis approach to resolve the causes for an
event
o An undesired event is defined
o The event is resolved into its immediate causes
o This resolution of events continues until basic causes are identified
o A logical diagram called a fault tree is constructed showing the logical event
relationships
 Specific logic symbols are used to illustrate the event relationships
 Other than RCA, FTA is utilized to quantify Failure Probability, Risk
Assessment, evaluate potential upgrades to a system, optimize
resources

12. Fault Tree Diagram
 The top event should describe WHAT
the event is and WHEN it happens
 The OR Gate represents the logical
union of the inputs: the output occurs if
any of the inputs occur
 The AND Gate represents the logical
intersection of the inputs: the output
occurs if all of the inputs occur
 The terminating events of a fault tree
identify where the FTA stops
o Basic Event
o Undeveloped Event
Top Undesired
Event
OR
AND
Intermediate
Event
Intermediate
Event
OR
Undeveloped
Event
Basic
Event
Transfer
Gate
Tools used for RCA
• Cause - Effect (Fishbone) Diagram:
 The purpose is to identify probable causes of the problem statement
summarized in the box at the fish’s head.
o A straight line extends out from the fish’s head, or the problem statement.
o Diagonal lines are then connected to the straight line, each of which
represents one of the major causes of the problem.
o Additional lines are then added to the diagonal lines until finally, at the
lowest level, individual root causes of the problem are identified.
 Major categories of causes include policies, procedures, people,
equipment, work environment, measurement, management or money.
 Use any category that fits the situation and helps people think
creatively.

13. Ishikawa or Fishbone Diagram
Problem
Statement
Material
Measurement
Methodology
ManagementMachine
Man
Obsolete
Cost
Availability
Appropriate
Clear
Policy
Rules,
Regulations
Knowledge
Training
Calibration
faulty
Wear
Corrosion
Lubrication
Tools used for RCA
• Why-Why Analysis:
 For a problem, it is a method of questioning why, to identify it’s root
cause/s.
 Within 5‐why generally a root cause is identified
Why Question Answer Action Plan
#1 Why Why X happened? Because of Y …..
#2 Why Why Y happened?
#3 Why
#4 Why
#5 Why

14. Comparison of FTA with Other Approaches
 FTA is not a Fishbone analysis which is a more informal depiction of
event causes (informal deductive)
 FTA is not an FMEA which assesses different effects of single basic
causes (inductive)
 FTA is not Event Tree Analysis which assesses the consequences of given
initiating events (inductive)
 FTA is a formal approach for resolving the basic causes of a given
undesired event (formal deductive)
Fault Tree Vs Ishikawa Fishbone
 The fishbone is a loosely‐structured, brain‐storming tool for listing
potential causes of an undesired event
 Fault tree analysis is a stepwise formal process for resolving an
undesired event into its immediate causes
 The fault tree displays the stepwise cause resolution using formal logic
symbols
 Fault Tree requires expert knowledge
 Fishbone needs open discussion and agreement

15. It’s a Teamwork !