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 Articles Index >> Root Cause Analysis

Find the Root Cause of Success

 As appeared in the May 2005 issue of Maintenance Technology 

hen report cards make their way home from school, some make the trip faster than others depending on their contents. A recent research study tackled

he topic of student report cards and how parents handle the not-so-stellar grades that s ometimes appear. It found that if a student brought home three As,

one C, and an F, only 6 percent of the parents concentrated on the As.

The study went on to say that parents who concentrated on the As as opposed to dwelling on the F saw the next report card improve by bringing up the F

while maintaining the As; the parents who concentrated on the F did see the F improve, but at the cost of the As.

Many maintenance organizations give out report cards or metrics too. Now a less-than-adequate reliability report card does not have the effects of sending

us to our room, cutting our allowance etc. , but it has the same overall effect both on morale and financial security.

In general people tend to punish for poor performance and dwell only on the negative metrics. Would someone execute a root cause analysis on a system or 

machine that performs flawlessly to discover why? The question then becomes what does ignoring the things done right cost companies in both metrics and

money.

Learn from the children

 Another example of this phenomenon known as positive deviance occurred following the end of the war in Vietnam. In this example from the recently

published book “Surfing the Edge of Chaos” by Richard Pascale, Mark Millemann, and Linda Gioja, the children of Vietnam’s poorer regions were suffering

from high levels of malnutrition compounded by a lack of clean water and good sanitation as well as poor health care.

orking with the Save the Children foundation, Monique and Jerry Sternin moved into Hanoi to develop a new method to end the malnutrition. They

embraced a concept from Tufts University called positive deviance that allowed them to facilitate the people of Hanoi in discovering their own solution to the

problem. The process they used included understanding the culture and the knowledge it contained. They worked with the locals and studied not only the

sick children but also the healthy ones.

They analyzed the living conditions and diets of the healthy children and concluded that the difference was that parents of the healthy children were doing

some things differently— supplementing the rice-based diet with freely available fresh water shrimp, crab, and vitaminrich sweet potato leaves and feeding

heir children more times per day than the malnourished children. Once this discovery was made it was easily leveraged across the culture in that area

because it was developed from within; it was Hanoi’s solution. After six months two-thirds of the children had gained weight and the program was a

sustainable success.

There are three points to take away from these examples:

Study and learn from the good actors and not just the bad

Develop and leverage the solutions from within the applicable area for buy in and sustainability

Celebrate and encourage the successes and learn from the failures through true understanding of the issues.

Look to the successes

Reliability improvement efforts traditionally look at equipment that has high levels of vibration, oil contaminates, or elevated temperature levels. Then when

he equipment fails technicians complete a root cause failure analysis (RCFA) to understand why it failed. With this mentality the organization is looking at

half of the information that is available. This shows only the failures and why they happen. What about the successes? Why did the successes happen?

One suggestion is to change the use of the RCFA process by moving the format to a root cause analysis-type process that can be used to understand both

failures and successes in the same format. This one small change will allow companies to capture more solutions from their process. If there are 26 pumps

in an area and only five have repetitive failure history why do the others charge on?

This is where the different way of thinking comes into play. Complete a root cause analysis on one of the good actor pumps to understand why it is so

successful. Use the five whys or any of the other available root cause tools to insure finding the root cause of success. What might be found is a solid

operating procedure, a good design, a best demonstrated practice, a better rebuild procedure, or any number of positive deviants that have led to a success

instead of a failure. In many cases there may be preconceived notions as to what the solution might be, but the key becomes letting those go and chasing

he data as a group until the solution is discovered corporately.

Use the affected group

Once uncovered, these good practices are much easier to leverage because they are internal, proven, and owned just like the dietary changes in Hanoi.

There is no easier change to make than the one that was developed by the people making the change. They trust the information the change is based on

because it is their information. They know it will work because they have seen it with their own eyes. They will force it to succeed because it has their 

names on it. When solutions are developed that do not involve the group that is affected, they lack the buy in and data this process provides and success is

a difficult goal to attain. This applies to reliability metrics in two ways—one, it provides solutions that improve metrics like overall equipment effectiveness

(OEE) and mean time between failure (MTBF) and two, it provides a tool to use to address and leverage areas that excel in certain metrics. Do not forget to

ask the question “Why am I succeeding?”

 As it becomes apparent who is causing the posit ive deviance make sure to apply positive public feedback to encourage the practice to continue and

propagate, basically focusing the light on what people are doing right. It has been proven that one should give three or more positive comments to every

corrective one; this RCA philosophy provides an excellent vehicle to make that happen.

Because RCFA conclusions always lead to a human error if they are taken to completion this can easily turn them into a negative tool. The error may be

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with the equipment vendor’s design team, start up contractor’s installer, production’s operator, maintenance’s technician, or management’s supervisor.

Some organizations use the RCFA or RCA findings as whipping sticks to punish people instead of as training and policy correction tools. This defeats the

purpose and robs the program of the support and information that it is based on.

 Always remember that no matter what contributing factors are found during the root cause investigation, at least one if not all of them is directly due to

management or its policies. It may be that management chose to run the equipment above rated speeds, postponed preventive maintenance, did not provide

he proper amount of training, or did not enforce the rules consistently as well as many others. With that said it is hypocritical and ignorant for management

o use the RCFA findings to punish the offenders.

Make analysis a positive tool

Make the findings a positive tool by supplementing the failure investigations with the root causes of success process and find out who is promoting success

in the facility. Make sure the RCAs are recognized as a positive tool that leads to praise and change within the organization. After learning from bothsuccesses and failures and implementing the discoveries, find a way to ensure that others want to be involved in these types of improvements.

 Aim to constantly develop new ideas. Create energy around the RCA findings by celebrating successes with stakeholders. It is important to tailor 

celebrations to the team or even the individuals in some cases to get the most benefit. It may be different with each group of stakeholders but it has to make

hem want to do it again.

Remember that the positive things going on day to day are just as important to success as the failure you try to eliminate. Many times the solutions to the

failures are right in front of you hidden by the day-to-day fires you fight.

Look at the forgotten equipment. Why are you able to forget about it? Why does it run so well? What are you doing or what was done right? These are the

locator questions for many of the solutions to the reoccurring problems that tear away at the reliability of equipment as well as the bottom line. These

solutions discovered from within the organization have the buy in and sustainability that is so often a struggling point for many outside solutions or cookie

cutter approaches.

Once the home grown, supported, sustainable solution has been put into place and the sweet smell of success is in the air make sure to celebrate theaccomplishment with all the stakeholders in the way that satis fies them the most. This becomes the fuel for many more examples of positive deviance that

can change an organization into a more reliable and profitable enterprise.

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