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6 Elements
• Information
• Preparation
• Conduct the RCA
• Challenge what you know
• Reporting
• Success
Step 1……Information
• 3 forms
• Collected information
• Stored information
• Information that employees accumulate
over time
Collected Information
• Once an incident, an accident, an
unwanted event has occurred how do we
respond?
• Information is critical!
• How do we collect it?
• This must be timely!
• Misinformation
• Someone must own it
Triggers
• A clear understanding of what your risk
matrix declares as investigation trigger
points is vital.
Stored Information
• Access your CMMS systems
• How good is your information??
• Abbreviated or Generic descriptions
• Electronic Data
Information that employees accumulate
• People have experience and knowledge to
share.
• Ensure that you have the right people in
the room
Step 2….Preparation
• Room and amenities
• People
• Data, Reports
• Visual stimuli
• Who owns this task?
• 7xP’s
Step 3 ….Conduct the RCA
• Get the right facilitator
• Trained/untrained
• Experienced/inexperienced
• Good at it/ ?
• Who doesn’t have a vested interest in the
outcome
• Should it be the subject matter expert?
Facilitation
• What are the attributes of a good
facilitator?
• Knows the process
• Good listener
• Keeps control of the group
• Good communicator
• Can remain neutral
• Respects all contributions
Step 4….Challenge your charts
• How do you know you have “got it”?
• Review your cause and effect chart
• Critical challenge is the key
• Be consistent
• Be logical
• Follow the rules
• Have evidence to support the information
Step 4….Challenge your Charts
• Demand excellence in the cause and
effect charts
• The chart reflects what you know
• It is an iterative process
• A quality chart can be an effective
learning tool
• Be specific
Excellence in Charting
• A lot can be gained from making the effort
in trying to achieve the best possible chart.
• Will it ever be perfect?.......Rarely
• Opportunities for improvements can
however be identified.
• At the end of the day the chart becomes
the validation for the choices made
regarding corrective actions.
Step 5….Reporting
• Effective communication is the key
• Who should be able to read the report?
• Time is valuable
• Kiss principle
Reporting ….Key elements
• Clear defining statement
• The cause and effect chart and also the
cause and effect summary
• Corrective actions assigned to critical
causes…..ownership needs to be given
and due dates set
• Attendees, cost information, appendices
Step 6…..Success
• Easy to say….. hard to prove
• Measure the impact of any changes that
are implemented
• Success breeds success
• Advertise
Attitude to Root Cause Analysis
Positive or Negative???
Blame?
Time?
Previous experience?
Lack of support?
• LEARNING FROM THE INCIDENTS AND
EVENTS THAT HAPPEN IS VITAL TO AN
INDUSTRY TRYING TO MAKE
IMPROVEMENTS.
• THE NEED TO BE EFFECTIVE IN THE ART
OF ROOT CAUSE ANALYSIS THEREFORE
BECOMES IMPERATIVE.
• TO BE SUCCESSFUL IN THIS PURSUIT REQUIRES …
• THAT EFFECTIVE STRUCTURES EXIST THAT GATHER INFORMATION CONTINUALLY AND ALSO IMMEDIATELY AFTER AN EVENT
• STRUCTURES THAT SUPPORT AND ALLOW SOUND PREPARATION TO OCCUR ARE IN PLACE
• THAT COMPANIES TRAIN EMPLOYEES TO THE LEVEL THEY NEED TO BE EFFECTIVE FACILITATORS
• THAT THE IMPLEMENTATION OF CORRECTIVE ACTIONS IS ASSURED AND THAT WE MEASURE THE IMPACT OF THOSE CHANGES.
Acceptance
• If you are willing to accept investigation
reports that are less than what they should
be ….then that is what you are most likely
to get!
• If it is worth doing then it is worth doing
well!
Codicil
• Success in the performance of Root
Cause Analysis will happen more
consistently when clear process structures
are in place and when positive
management support is given to the
process!
Contact Details
Jack Jager ARMS Reliability jjager@armsreliability.com
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