Don’t stop your RCA half-way through. Turbo-charge your learning.
In our previous article, we went through the process of identifying indirect causes. For many people, their failure investigation stops there. How many times have you heard things like:
“The root cause was that the maintainer didn’t properly tighten the bolt.”
“The root cause was that the maintainer didn’t do the inspection properly.”
“The root cause was that there was no subsequent notice raised to manage the defect found in the condition monitoring report.”
There’s a major problem with these sorts of statements: none of them are root causes. At best, they’re indirect causes – factors that are specific to the failure being investigated. If you fix these causes, you might stop this specific failure from recurring. But what about other, similar failures: where’s the turbo-charged learning? We talked about this in an earlier case study: if we’ve missed one condition monitoring task, what else have we missed? And, is there a deeper reason for why we’re missing these condition monitoring tasks?
Asking these questions in an RCA is about looking for systemic (or root) causes. Root causes are the fundamental factors in an organisation that enable the indirect causes to occur. They are often deep-seated, sometimes difficult to measure or quantify, and can take a lot of work to correct. They’re also confronting when you find them (or alternatively, they’re used as opportunities to pass the blame to someone else and avoid responsibility yourself). But when you fix them, the benefits can flow through to many other parts of your business.
The process of identifying root causes is the same as for the other parts of our model (below). We’ve classified them into four systemic causes that you can work through: we’ll briefly explain each below.
Capabilities refers to a combination of knowledge, skills and attitude that lead to an action being performed incorrectly (or completely omitted). Key questions to ask are:
To be clear, this is not about blaming individuals for the failure. Deficiencies in individual capabilities can’t exist without a deficiency in the organisation itself. It’s important to look at aspects of training, leadership etc that have contributed to the individual’s actions.
This is the confronting part – looking at how the organisation itself works. There are certain fundamental factors that explain why individuals behave they way they do, and whether they have the capabilities, resources and information to do their job. We’ve learned to look for three key factors:
Systems of work simply means the processes, information and business systems that describe how an organisation works. Key factors to look for include:
In our experience, looking at the available resources should be the last part of the failure investigation process, because it’s all too easy to shift blame onto your tools (just like the old proverb!) However, there are a couple of factors to look at:
Again, a skilled workforce with an effective culture can often achieve great reliability without these resources. However, giving your maintainers the tools they need to do their job increases the likelihood of consistent quality by minimising the impact of variation in their skills and reducing the prospect of human error.
Getting to the root cause is never easy. However, we’ve learned to apply the following principles:
An RCA is only of value when it feeds your defect elimination process; there needs to be improvements that address each of the indirect and root causes. Indirect causes are generally easy to fix – just change a tactic or service sheet, or update a drawing or master data. Process changes are also fairly straightforward. But it’s the organisational factors, especially culture, that are hard to change.
Changing a maintenance culture is never easy, it requires constant effort, especially from leaders. It’s also hard to measure, and hard to put in place actions that fit the “SMART” model. We’ve found that working agreements, tied to effective pre-starts that focus on quality as well as safety, can be successful in sustaining reliability improvements by building a culture of mutual accountability.
To illustrate the value of getting to the root cause, we have one more case study. Hopefully the lessons we’ve learned over the years in conducting RCA’s are valuable, and we continue to learn every time we work with a client.
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