GS02003 Root Cause Analysis Tcm 12-75931

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Root Cause Analysis

Root Cause Analysis

Motivation, Process, Tools and Perspective

Summary

Root Cause Analysis (RCA) is a structured investigative process that aims to identify

the true cause of a problem, and the actions necessary to eliminate, or mitigate that

problem.. The trigger to start an RCA can be a major accident or incident, or an overall

improvement program in the areas of safety, quality, or production/maintenance. The

article starts with an example of a major railway accident whereby root causes needed

to be investigated. A discussion of the RCA process is next, followed by an

investigation of available RCA tools, and the role of RCA in improvement programs.

The article ends with references for further reading on this subject.

SKF Reliability Systems

@ptitude Exchange

5271 Viewridge Court

San Diego, CA 92123

United States

tel. +1 858 496 3400

fax +1 858 496 3511

email: [email protected]

Internet: http://www.aptitudexchange.com

GSO203

Gerard Schram

16 Pages

Published May 2002

Revised September 2004


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Table of contents

1. ........................................................................... 3 Introduction

2. ................................................................. 4 Importance of RCA

2.1. ................................................................... 4 Example: Railway Accident

3. ........................................................................... 6 RCA Process

4. ................................................................ 7 RCA Tools/Methods

4.1. ..................................................... 7 Problem Identification/Understanding

4.2. ................................ 7 Possible Cause Generation and Consensus Reaching

4.3. ........................................................ 7 Problem and Cause Data Collection

4.4. ........................................................................ 8 Possible Cause Analysis

4.5. ........................................................................... 9 Cause-Effect Analysis

4.6. ....................................................................................11 Tool Selection

5. .............................................. 11 The Wider Perspective of RCA

5.1. ....................................................................................11 Role in HAZOP

5.2. ......................................................................11 Role in TQM / Six Sigma

5.3. ........................................................................................12 Role in TPM

5.4. ...................................................................12 Role in Asset Management

5.5. ..................................................................................12 Role in (S) RCM

5.6. ...........................................13 A Survey among Maintenance Professionals

6. .................................................... 13 The Consequences Of RCA

7. ............................................ 14 Commercial Methods/Software

7.1. .............................................................................................14 PROACT7.2. .............................................................................................15 Taproot

8. ............................................................................ 15 Conclusion

9. .............................................................. 15 Acknowledgements

10. ........................................................................... 15 References

Root Cause Analysis © 2012 SKF Group 2 (16)


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1. IntroductionThe greatest tragedy underlying errors and

resultant failures is that many of them are

avoidable. Yet, one of the best effectiveconcepts for improving reliability in

engineering is often neglected. That concept is

the learning and continuous improvement

from (historical) case analysis. Well-studied

examples are failures in civil engineering

structures, such as the collapse of various

suspension bridges (Tacoma Narrows bridge in

oscillating mode due to wind, 1940).

Aeronautical and aerospace failures are also

the subject of much attention, especially inthe mass media. Nuclear and chemical

engineering incidents can have major impacts

too. Mechanical engineering failures generally

result in somewhat less life-threatening

situations, but can cause massive recall

campaigns and product liability suits. It is

obvious then, that recognizing and

understanding failure (or a near failure) plays

a key role in error-free design and operation.

This understanding is necessary to eliminate

the same causes and effects in the future.

Apart from physical failures, safety incidents,

quality defects, customer complaints, etc., can

be the reason for a thorough investigation into

their causes. In general, we can state that a

problem is a deviation from what is defined

normal, with negative impact. A problem is

not always recognized (it can be perceived as

normal). However, with an open-minded team

and/or internal or external benchmarking,

problems can be identified. Problem solvingconsists of identifying causes, and finding

ways to eliminate them and prevent them

from recurring. In other words, identifying the

cause/s is often half the answer.

A problem is often the result of multiple

causes at different levels. The root cause is the

“evil at the bottom" that sets in motion the

cause-and-effect chain and creates the

problem.

The NASA defines so called "direct" or

"proximate" causes as:

The event(s) that occurred, including any

condition(s) that existed immediately before the

undesired outcome, directly resulted in its

occurrence and, if eliminated or modified, would

have prevented the undesired outcome.

Regarding an "undesired outcome", the NASA

provides examples such as: failure, anomaly,schedule delay, broken equipment, product

defect, problem, close call, mishap, etc. Then

as definition of root cause, the NASA states:

One of multiple factors (events, conditions or

organizational factors) that contributed to or

created the proximate cause and subsequent

undesired outcome and, if eliminated, or

modified would have prevented the undesired

outcome. Typically multiple root causes

contribute to an undesired outcome.

NASA defines Root Cause Analysis (RCA) as:

A structured evaluation method that identifies the

root causes for an undesired outcome and the

actions adequate to prevent recurrence.

The American Society for Quality (ASQ) defines

Root Cause Analysis (RCA) as:

RCA is a structured investigation that aims to

identify the true cause of a problem, and the

actions necessary to eliminate it.

In fact, RCA is a collective term used to

describe a wide range of approaches, tools,

and techniques used to uncover and model



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causes to problems. RCA is a method that

helps professionals determine what happened,

how it happened, and why it happened. It

allows learning from past problems, failures,

and accidents. RCA can be applied to any

organizational, production, and administrative

(etc.) problem.

There exist slightly different terms, including

Failure Analysis (FA) and Root Cause Failure

Analysis (RCFA). Failure Analysis refers to the

observation, categorization, and possibly

documentation of a failure. As such it does not

necessarily intend to find the root causes that

resulted in that failure (how it failed). RootCause Failure Analysis includes the investigation

towards root causes, but is somewhat limited

to the term "failure." The term “failure” is

biased to physical failures, while root cause

analysis is applicable to many more situations,

such as safety incidents, quality problems,

etc.

Finally, Failure Mode Effect Analysis (FMEA) is a

more hypothetical analysis to determine how a

component or process could fail (failure

modes), including their risks and

consequences. FMEA can be considered a

proactive way to avoid problems that have not

occurred before. On the other hand, RCA is

generally initiated when an unplanned

problem is happening. It then focuses on

preventing reoccurrence in the future. The

preventive action’s effect on risks and

consequences are generally not taken into

account.

2. Importance of RCA

Why perform a RCA? If achievements from

eliminating the problem and its consequences

are larger than the efforts put into a RCA, this

seems obvious. Although eliminating risk of

recurrence of similar situations looks

admirable, it could be perceived as the

"program of the month." Resolving

emergencies when they occur, while RCA aims

to eliminate root causes and reduce the

maintenance person’s responsibilities, may

recognize a maintenance person.

Therefore, it is extremely important to align

everyone in the same direction, both at

management level and production and

maintenance personnel. Creating the right,

open environment for learning from failures is

essential [Latino, 2001].

2.1. Example: Railway Accident

A real example shows how small root causes

can lead to serious damage. This example

originates from SKF Belgium. A goods train

traveled from Antwerp harbor to a factory in

France. After 30 km the train passed a station

where the temperature of the axle boxes is

measured to detect possible hot boxes.

Everything was normal. 35 km further the

train derailed. 8 wagons were destroyed, and

damage was done to the rails and overhead

electrical cabling. The goods traffic was

stopped for several hours.

The accident happened in Belgium, the goods

were French owned, and the railway wagons

were property of the German State Railways.

The wagon in question was overhauled just

before the accident. (By international

agreement, the Belgian Railways paid

damages: > US $1,000,000.)

Figure 1. Relevant Locations within Belgium.

The remains of the failed axle box, equipped

with two spherical roller bearings SKF 229750

J/C3R505 (Y 25 bogie – 20-ton axle load

design) are shown in Figure 2. We are looking

for the root cause, as we want to eliminate

this problem forever!

derailmen

Hot box

Starting point

50 km



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Figure 2. Remains of the Axle Box Bearings.

The wagons were equipped with “Y25” bogies,

with axle boxes with double spring

suspension. Maximum authorized axle load is

20 tons. The axle boxes incorporated spherical

roller bearings SKF 229750 J/C3R505.

Figure 3. The Wagons.

Figure 4. The Axle Box as part of the Boogie.

Figure 5. Technical Drawing of the Axle Box with TwoSpherical Roller Bearings and the Spacer Ring.

In the analysis of root causes, one can clearly

see that this was more than a hot runner. To

some extent, the inside bearing was

completely deformed from red-hot running. In

fact, there are clues to indicate what

happened:

There is a gap between the (inside

bearing) outer ring and the labyrinth seal.



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The inside bearing moved towards the

outside

In principle, this should not be possible.

For a 20 ton/axle arrangement, the

distance ring on the axle between bearings

is 35 mm wide, and regulates the precise

bearing location

The width of the distance ring - called the

spacer ring - was 14 mm

In fact, there are TWO different executions

of this axle box: 20 ton / axle payload -

axle box with a 35 mm spacer between

bearings. And, a 22.5 ton / axle payload, a

similar but slightly narrower axle box, with

a 14 mm spacer between bearings

Somehow, the maintenance personnel

installed the wrong spacer ring

The bearing assembly was allowed to slide

to the outside, which resulted in heavier

axle load, more axle bending, material

fatigue, and final collapse. The bearing

was running at more than red hot, and

was completely deformed.

The train derailed just for a spacer!

This example shows the necessity of finding

problem root causes with the goal of

eliminating them from recurring. Human

mistakes or erroneous procedures can be the

root cause, but we should acknowledge the

errors and learn from the mistakes.

3. RCA Process

The following steps are ‘generally’ found in a

RCA procedure:

Problem Identification: The problem shouldbe recognized and assigned a name. If a

problem is perceived as normal, it never

improves. In the case of engineering

constructions, the problem can be

identified by symptom analysis and

equipment inspections. In general, internal

or external benchmarking can also identify

problems (or opportunities)

Problem Understanding: It is necessary to

understand the nature, or essential failure

modes, of the problem

Root Cause Identification: Find the correctroot cause(s). This includes brainstorming

and investigating possible root causes, and

cause-effect relationships

Root Cause Elimination: Eliminate the root

cause(s) to prevent the problem from

recurring

Symptom Monitoring: Monitor symptoms to

show the presence or elimination of the

problem. Regularly take performance

checks

Generally, a team performs the RCA process.

As stated before, it is essential to create the

right environment for an open, trustful

approach. The following roles are

distinguished within a manufacturing plant

(2001):

Executives: Put a stamp of approval on

RCA, including expectations and time

lines. They should be fully educated in RCA

RCA Champions: Administer, support, and

ensure the RCA effort from a management

standpoint. They should be a mentor to

the drivers and analysts, and should have

the authority to protect persons in case of

politically sensitive facts. They set

performance expectations

RCA Drivers: Team leaders who organize all

details. The team meets, analyzes,

hypothesizes, verifies, and draws factual

conclusions. They develop

recommendations to eliminate root causes

Structured RCA effort intends to be a

proactive task, so it should reside under the

control of a reliability department. In the

absence of such a department, RCA should be

controlled by operations or engineering. The

RCA effort should not be placed under the



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control of a reactive maintenance department,

as their role is to respond to day-to-day

activities in the field.

4. RCA Tools/Methods

The American Society for Quality distinguishes

tools and methods by their specific purposes

(2000):

Problem identification/understanding

Possible cause generation and consensus

reaching

Problem and cause data collection

Possible cause analysis

Cause-and-effect analysis

We briefly mention the various techniques.

Please refer to detailed publications, such as

the original work of Ishikawa of the Asian

Productivity Organization.

4.1. ProblemIdentification/Understanding

Problem identification and understanding

includes tools to identify and gain solidunderstanding of the problem.

Flowcharts: Many problems are connected to

business or work processes. A process

flowchart is an appropriate first step to

illustrate where problems occur, and to

provide an understanding of processes that

contain or influence problems.

Critical Incident: A method to explore the most

critical issues in a situation. A collection of

people from different departments or

functional areas is asked about most critical

incidents. The answers are collected, sorted,

and analyzed based on frequency. The most

critical ones are the starting point for RCA.

Spider Chart: The spider chart gives a graphical

impression of how the performance of

(business) processes compares with other

organizations or departments (benchmarking).

It compares and determines which problems

are most critical from an external viewpoint.

Performance Matrix: Used to illustrate the

performance and importance of problems and

causes. High importance, high performance

impact problems and causes are only selected.

4.2. Possible Cause Generationand Consensus Reaching

The following section covers idea-generating

tools to determine possible problem causesand tools to reach an agreement in case of

disputes or different views.

Brainstorming: Generic process of generating

a list of problem areas, consequences, causes,

and ways to eliminate them. It can be

structured or unstructured.

Brain Writing: Similar to brainstorming, brain

writing uses written cards or a gallery of white

boards or flip charts. It is preferred, as it

reduces problem complexity, dominating

people, or the possible anonymity.

Nominal Group Technique: A kind of

brainstorming in which all participants have

the same vote when selecting solutions /

causes. Ideas are first generated, and then

participants rank them individually. By totaling

the points, a consensus is reached.

Paired Comparisons: Instead of comparing

ideas all at once, they are compared pair-wise

to reach a consensus.

4.3. Problem and Cause DataCollection

Here we include tools and techniques to collect

reliable root cause analysis data.



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Sampling: Sampling draws conclusions about a

larger group based on a smaller sample. A

minimum understanding of statistics isrequired to perform reliable sampling.

Surveys: Used to collect data about attitudes,

feelings, or opinions, such as customer

satisfaction, needs, and/or expectations.

Check Sheets: A check sheet table used to

systematically register data.

Cause of

Machine

Trouble

Jan Feb Totals

per

cause

unbalance II I 3

misalignment I III 4

bearings II 2

….

Table 1. Example of a Simple Check Sheet.

A Computer Maintenance Management System

(CMMS) is another good source for data (data

entering is properly done). For example,

statistics may be derived on breakdowns andpossible causes. Again, a representative set of

data should be present.

Like the CMMS, other documentation on

health/safety/environmental (HSE) accidents

and incidents can be a valuable data source.

Possibly, extra fields can be added to these

systems to better trigger and track problems.

Relevant data may also be found in general

databases with reliability data (often referredto as RAM data). A few example databases:

OREDA for Offshore Reliability Data, with

turbines, compressors, etc.

http://www.oreda.com

Process Equipment Reliability Database

(PERD) of the American Institute of

Chemical Engineers http://www.AIChe.org

4.4. Possible Cause Analysis

Possible cause analysis covers techniques for

analyzing the impact of different causes.

Histogram: A bar chart used to visualize the

distribution and variation of a data set. The

diagram helps to identify patterns or

anomalies. The frequency of occurrence is

depicted vertically, while the classes are

ordered along the horizontal axis.

0

5

10

15

20

25


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1 0 0 %

0 %c a u s e 1

c a u s e 2

c a u s e 3

c a u s e 4

c a u s e 5

F r e q u e n c y

1 0

2 0

C u m u l a ti v e %

Figure 7. Pareto Chart Example.

Scatter Charts: Illustrate relationships between

two causes or other variables in a problem

situation. This is achieved by plotting at least

30 samples of data pairs in one figure.

Possible logarithmic axes may also be used.

The data may be generated by experiments of

changing variables and plotting the effects.

Paper thickness

"knob A"

Figure 8. Scatter Chart Example.

Relations Diagram: A tool to identify logical

relationships between different ideas or issues

in a complex or confusing situation. The

factors under investigation are distributed inan empty chart area, and arrows illustrate the

relationships between them.

Affinity Diagram: A chart approach that helps

identify seemingly unrelated ideas, causes, or

other concepts so they might collectively be

further explored. A way to handle and

brainstorm about causes in a qualitative way

rather than quantitative.

4.5. Cause-Effect Analysis

The last stage is the cause-effect analysis. A

few tools are mentioned here.

Cause-Effect Chart: This is a well-known

technique used to relate possible causes to a

problem. It is also called the Ishikawa diagram

or fishbone diagram.

After completing the cause-effect diagram,

examples / facts can also be entered. These

illustrate the relationships, and provide an

idea about their strength.

The cause-effect diagram shows that multiple

causes can result in the same problem. The

diagram can be used as a discussion aid to

determine which causes are considered the

primary (root) causes of the actual problem. If

enough data is available, a probabilistic

approach could yield the most likely root

causes.



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Figure 9. Cause-Effect Diagram (Fishbone).

Fault-Trees: Another visual way to represent

cause-effect relationships. The fault tree starts

with faults / problems. Causes (can be

different layers) are then depicted with arrows

indicating the relationships.

Matrix Diagram: A visual technique for

arranging possible causes by their contribution

to the problem. Problem characteristics are

ordered vertically, and possible causes

horizontally. The contributions of the cause to

problem characteristics are depicted in the

matrix. By accumulating individual

contributions, you get an idea of which causesare most significant. It is also sometimes

referred to as a cause-effect matrix.

Five Whys: The main purpose is to keep asking

"why" when a cause is identified. Each cause

is questioned whether it is a symptom, a lower

level cause, or a root cause. The chains of

causes can be drawn in a simple chart. The

rule of thumb is that the method often

required five rounds of the question “why.”

Advanced Tools: There are various other ways

to model cause-effect relations based on

(statistical) correlations or regression

techniques. However, they fall outside the

scope of this introduction article on RCA.

Other advanced techniques stem from artificial

intelligence, such as artificial neural networks,

fuzzy models, logical decision trees, and other

network representation. The cause-effectnetworks are used to reason forward or

backward. The network, together with

reasoning capacity, forms a so-called expert

system, or knowledge-based system.

These tools can be tuned by both "data" and

"heuristics." For example, the Bayesian

network is used to model cause-effect

relations, where the strength of the

relationship is modeled as probabilities. SKF

applies the Bayesian network to supportbearing failure or damage investigations.


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Figure 10. A Bayesian Network Used to Model Relations Between Causes and Effects. The Arrows Denoterelationships, While Numbers and Red Bars Denote Probability of Occurrence.

4.6. Tool Selection

These tools and methods are aids to get to the

goal, rather than the solution. In the general

RCA process, the tools support problem

understanding and root cause identification

steps. The American Society for Quality

further outlines the particular strengths and

weaknesses of the tools (2000). In general,

the selection is very situation dependent.

Doggett (2004) concludes after investigating

three RCA tools (Cause and Effect Diagrams,

Interrelationship Diagrams, and Current

Reliability Trees), that none of the tools were

perceived significantly better in terms of

finding root causes. On the other hand, the

complexity of the tools varies, and as such the

training requirements.

5. The Wider Perspective ofRCA

Root cause analysis can be used after a major

incident or accident like the railway problem

outlined earlier. However, RCA can also be

part of a bigger improvement program, such

as safety, quality, or maintenance

improvement programs. RCA identifies

problems (opportunities to improve) and finds

root causes.

5.1. Role in HAZOP

A Hazard and operability (HAZOP) study is a

methodical review of a defined operation

system to identify potential hazards and

operability problems. It identifies and defines

process and design deficiencies, the potential

for, and consequences of human and

organizational error, accidents from

neighboring plant or activities, natural

occurrences and catastrophes, and the

possibilities of equipment component failures.

As such, many RCA tools and methods can

play a role in a HAZOP study.

5.2. Role in TQM / Six Sigma

Total Quality Management (TQM) and Six

Sigma stand for a stream of programs aimed



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to tackle major causes of quality defects. We

can state that RCA originates from quality

improvement philosophies, and many RCA

tools / methods are present in TQM and Six

Sigma. Some RCA tools can be embedded in a

plant's quality procedures, as one main goal is

achieving a continuous process of quality

improvement. For example, critical incidents

investigation, performance spider charts, etc.,

can be done on regular basis.

5.3. Role in TPM

Total Productive Maintenance (TPM) stands for

an improvement program that covers both

production and maintenance functions. It is

founded on the concept of ownership and

complete integration of the production and

maintenance functions.

The prime driver for TPM is the concept of

Overall Equipment Effectiveness (OEE). The

philosophy hinges on making equipment

effectiveness the concern of everyone in the

organization. OEE requires strict attention to

the measurement and quantification of losses.

When identifying big losses and their root

causes, RCA tools play a useful role. As such,

RCA tools can be part of a TPM program.

5.4. Role in Asset Management

Asset Management (AM) tries to attain the

lowest life cycle cost with maximum

availability, performance efficiency, and

quality (maximum OEE). In other words, AM is

the systematic planning and control of a

physical asset throughout its life. An outcome

of AM is the defining what specific

maintenance practices need to be undertaken

while considering the optimum means of

implementing them. This is where RCA tools

can again play a useful role.

5.5. Role in (S) RCM

Reliability Centered Maintenance (RCM) and

SRCM are structured processes to proactively

identify equipment modifications and/or safety

devices required to avoid any significant

consequence as a result of equipment failure.

Consequences can be operational loss, safety,

health, or environmental. By RCM study, all of

the potential modes of failure are uncovered

and a maintenance strategy is devised to

mitigate the consequences of the failure based

on the criticality of the failure mode. In RCM,

these failure modes are identified as the root

cause(s) of the failure.

This is where the main difference lies. The

purpose of RCA is to uncover the underlying

reasons (root causes) why an event (not just

equipment related events, but any type of

event) is occurring so that the necessary steps

can be taken to eliminate the event in its

entirety. This is accomplished by analyzing

the modes (the point at which RCM stops).

RCA uses for example a logic tree that

stresses verification at every level. The

advantage is that the actual root causes that

are uncovered are facts that have been

derived from the verification process. RCM is

driven by deriving a maintenance strategy,

while RCA is driven by maintenance

prevention.

Within RCM, FMEA stands as the central

vehicle; however, the RCA tools and methods

can be of additional help when performing

FMEA in the need of deeper investigation of

the failure modes. Secondly, RCA is to be used

in the process of updating (on periodic basis)

the derived maintenance strategy from RCM

such that a continuous improvement of the

maintenance strategy is achieved.



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5.6. A Survey among Maintenance

Professionals

A survey of the use of RCA techniques by

maintenance professionals was conducted on

the Plant Maintenance Resource Center in

2000. See the results at:

http://www.plant-

maintenance.com/articles/rca-survey-01.shtml

The key findings are:

59% of respondents indicated that they

use some form of RCA process

Of those who indicated that they used

some form of RCA, 79% indicated that

they used formal, structured processes

Those using formal processes considered

that the overall effectiveness of their

approach was significantly better than did

those people using informal processes.

Supervisory and technical staff are more

likely to be involved in RCA than shop floor

personnel.

The greatest benefits appear to be in the

area of improved equipment availability

and reliability.


used external consultants to assist with

their RCA implementation.


used software to assist with their RCA

process.

The survey shows that RCA is quite wide

spread amongst maintenance functions, and

that the structured process of RCA is key to

make RCA become effective.

6. The Consequences Of RCA

To prevent the problem from recurring, the

root cause(s) should be eliminated. The root

cause investigation results necessary actions

are considered the outcome of RCA. It is

essential to know cause-effect relationships to

prevent problems from recurring.

The assessment of these actions is generally

not addressed within the RCA context. This is

typically the second part of an FMEA process,

whereby possible actions are assessed aftertheir effect, in terms of risk or consequence

decrease. It is worthwhile to consider this

approach when assessing alternative actions.

@ptitudeXchange provides articles on FMEA

for further reading.

In order to arrive at a continuous

improvement situation, RCA needs to be

embedded into the normal work processes. As

an example, within the SKF concept of

Proactive Reliability MaintenanceTM

(PRM), animprovement loop is defined (Figure 11).

Starting with an operational review, a

predictive maintenance program is set-up.

Where critical anomalies are detected, RCA is

applied, providing corrective actions to

prevent anomalies from occurring again.

Formulating a number of key performance

indicators monitors the process.

http://www.plant-maintenance.com/articles/rca-survey-01.shtmlhttp://www.plant-maintenance.com/articles/rca-survey-01.shtmlhttp://www.plant-maintenance.com/articles/rca-survey-01.shtmlhttp://www.plant-maintenance.com/articles/rca-survey-01.shtml


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Figure 11: Proactive Reliability MaintenanceTM

These types of work processes generally

need adjustment in the standard job plans.

For example, anomalies detected during

predictive maintenance should feed/start

RCA procedures. RCA results have to be

documented extensively (see e.g. Reed,

2003), and recorded appropriately in CMMSfor keeping good machinery history.

Corrective work (e.g., cleaning, repair) or

adjustments in maintenance strategy (e.g.,

preventive vs. predictive) needs to be

planned and scheduled.

In case of large changes, a change

management project may follow RCA. For

example, when changing organizational

structure or major responsibilities, a

structured management of change is needed(Schram & Yolton, 2004).

7. CommercialMethods/Software

Just two of the many tools are mentioned

here. Most commercial tools are tools with

which cause-failure trees can be made or

searched through, and then visualized. It

should again be emphasized that RCA is

more a process than a tool - the tool

supports the structuring of the process.

7.1. PROACT

Reliability Center Inc. offers a method calledPROACT accompanied with a software tool.

PROACT stands for:

PReserving event data

Ordering the analysis team

Analyzing event data

Communicating findings and

recommendations

Tracking for bottom line results

The method is clear, and a great deal of

attention is spent on human organizational

errors. Many other software tools only focus

on (modeling) the mechanical issues. More

information can be found at:

http://www.reliability.com/


http://www.reliability.com/http://www.reliability.com/http://www.reliability.com/


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7.2. TaprootSystem Improvements Inc. offers a software

suite called TapRoot.

The suite of tools includes Root Cause Tree

software, which provides the investigator

with a fairly comprehensive list of causes

that should be considered for any incident.

Each causal factor that contributed to the

incident should be analyzed one at a time. A

dictionary provides explanations and

definitions of each part of the root cause

tree. This allows for consistent, non-

overlapping root causes that create trending

in a database. It also includes a checklistthat ensures consideration of the most

frequently occurring human performance

contributors to an incident, which helps

narrow down the seven basic cause

categories. It also helps keep the

investigator's mind open and focused.

A second software, Equifactor was created in

cooperation with Heinz Bloch's equipment

troubleshooting techniques. These

techniques include:

Equipment Troubleshooting Tables

Component Troubleshooting Tables

FRETT Analysis

Equipment 7 Cause Categories

More information can be found at:

http://www.taproot.com/

Summary: PROACT is a process with anempty, supportive tool, while TapRoot is a

step-by-step search in a database with

tables and trees.

8. Conclusion

Root Cause Analysis (RCA) is a structured

investigation that aims to identify the true

cause of a problem, the cause-effect

relationships, and the actions necessary to

eliminate it. The trigger to start an RCA can

be a major accident or incident, or an overall

improvement program in the areas of safety,

quality, or production / maintenance. The

RCA process consists of problem

identification / understanding. The outcomes

of RCA are recommendations for change and

monitoring to keep the problem from

reoccurring. Several tools and methods

exists that can support the RCA process.

9. Acknowledgements

The author would like to thank Wayne Reed

for his contributions to this paper.

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