In some cases, indirect causes are obvious, and you can be thorough without doing a full RCA.
We recently wrote articles about simplifying RCA and identifying indirect causes. The following two examples demonstrate a specific point about temporary repairs and completing inspections adequately.
This RCA identified the following sequence of events from the work order system:
The outcome from the RCA included a redesign of the bolting system holding the plates. This is a very clear case where there is no need to change strategy or change the design of the system. Simply identify the failure mode, whether we have a task to manage that failure mode and where the current task is adequate but has not been implemented adequately then just communicate to everyone. It is essential that everyone knows when they do a temporary repair, which sometimes must occur, we raise a subsequent work order to repair to the correct standard at the next scheduled event.
A set of hydraulic stairs for a truck failed to operate causing 4 hours downtime for the truck to be repaired. The stairs failed to operate due to a failed hydraulic hose. The hose failed because it was oversized and the stauff clamp, used to secure the hose, created a rub point causing the hose to fail. The oversized hose was fitted previously as a temporary repair.
In both cases, just by looking at the parts, we realised there was no need to do a detailed RCA. It was obvious what had happened, and we had to communicate to everyone about the importance of raising a subsequent work order to correct temporary repairs during the next scheduled opportunity.
By David Archinal