Innovation Through Root Cause Analysis

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Innovation Through Root Cause Analysis

• Presenters
• Rick Eldreth Quality Assurance Manager
• Doug Stroud Reliability Engineer
• Richard Siggins IT Project Manager
• Brian Bertelsen Reliability Engineer

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Innovation Through Root Cause Analysis

• The purpose of this presentation is to
  demonstrate how Root Cause Analysis can be
  applied to problem solving efforts across a large
  variety of business applications.
• Traditional Applications
• Safety / Environmental Incidents
• Equipment Failures
• Process Upsets
• Innovative Applications
• Quality Assurance Issues
• Financial Issues
• Information Technology Failures
• Customer Service Complaints
• Transportation Incidents
• Process / Product Development Problems

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What is Root Cause Analysis?

• Definitions
• Root Cause Analysis a systematic method for
  determining and eliminating the physical, human,
  and latent causes of a problem
• Physical Cause The agent or mechanism that
  caused the Equipment Failure / Injury / Customer
  Complaint / Etc.
• Human Cause Human errors that result in
  something being done incorrectly or errors of
  omission
• Latent Cause Reasons behind the Human Causes
  e.g. Lack of training, Poor communication,
  Ineffective Management Systems, etc.

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RCA and our Business Culture

• Performing RCA sends a message to the
  organization that we want our corporate culture
  to be one of continuous improvement.
• Culture
• Eliminate defects
• Every maintenance event must be looked at as an
  opportunity to improve the system
• Injuries are not acceptable
• Environmental spills and releases are not
  acceptable
• Procedures and checklists must be used
• RCA allows incidents and failures to be
  objectively analyzed so old ways of thinking
  about things don't cloud the outcome
  (familiarity, arrogance, assumptions, varying
  degrees of critical thinking)

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Root Cause Analysis Results!

• The measure of an effective RCA
• Must prevent problem from recurring.
• Must be actionable and within your control.
• Must not create other problems No significant
  unintended consequences to equipment / process /
  people.
• Must be good business decision (i.e. profitable).
  Must use resources efficiently to perform RCA and
  solution must be good for profitability.

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RCA Philosophies and Tools

• List of various RCA Philosophies and Tools
• Cause / Effect Diagram
• Why Tree
• Cause-Mapping
• Tap Root
• ROOTS
• PROACT
• Equifactor
• Kepner Tregoe
• Logic Tree
• Fishbone Diagram
• Ask 'Why' 5 Times
• Etc.

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Safety/Environmental RCA Accidental Discharge

• Description Acid overflowed from a tank out the
  conservation vent
• Potential or actual loss Wasted acid, cleanup
  costs,
• operation upset
• Physical Roots (1) False level alarms , (2)
  piping
• arrangement and control system (3) DCS screen
  displays
• Behavioral Roots (1) Assumed another false
  alarm, (2) Operator did not share change with
  other operator
• Latent (Management System) Roots (1) Level
  alarm unreliable, (2) Depend on operators to keep
  communicate changes
• Benefits The RCA was very effective at
  thoroughly investigating a spill that had been
  miss diagnosed. Revealed inherent control
  defects operators were having to work around and
  unreliable level sensor.

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Simple sketch of system
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Timeline of relative events
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Equipment RCA - Connecting Rod Bushing Failures

• Description A new reciprocating compressor was
  suffering from repeated failures of the
  connecting rod bushings.
• Potential or actual loss Potential production
• losses were several million dollars.
• Physical Roots Loss of oil film in the
  connecting
• rod bushing because the geometry of the bushing
• caused insufficient load capacity.
• Behavioral Roots Manufacturer did not have
  history of operation at this load level.
• Latent (Management System) Roots - Project team
  did not verify manufacturer had proven
  performance at this load level
• Benefits RCA approach identified the all
  potential root causes of failure which allowed us
  to decide what data needed to be collected to
  verify what the cause was.

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Quality Assurance RCA Off-Quality Product

• Description A chemical product was discovered
  to be off-color and contain insoluble
  crystallized sediment. The product was near the
  end of its stated shelf-life but had not exceeded
  it.
• Potential or actual loss Significant business
  could have been lost.
• Physical Roots High moisture in the product,
  elevated storage temperature, inaccurate
  shelf-life
• Behavioral Roots Proper consideration had not
  been given to processing conditions and operating
  specifications.
• Latent (Management System) Roots - Lack of
  adequate processes for managing critical quality
  information.
• Benefits Underlying causes to an on-going
  quality problem was corrected, reduced complaints
  and provided stability to the product line.

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Information Technology RCA Network Failure

• Description Failure of the local area network
  (LAN). This incident was the result of the LAN
  being flooded with bad traffic, making network
  services unreliable for most computer users.

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Information Technology RCA Network Failure

• Potential or actual loss Loss of productivity
  and significant number of IT hours to resolve.
  Potential losses include lost orders,
  manufacturing disruption, delays in product
  shipment/delivery, and loss of regulatory data.
• Physical Roots (1) Non-standard network
  switches caused bad traffic to flood network, (2)
  standard network switches failed to stop it, and
  (3) contribution by security software.
• Behavioral Roots (1) Employees were not aware
  of risks from using non-standard switches and (2)
  failure to timely install network safeguards.
• Latent (Management System) Roots (1) Lack of
  employee education on use of non-standard
  network devices, (2) implementation of planned
  corrective steps delayed due to budget
  restrictions..
• Benefits The RCA identified several root causes
  to be addressed. Interim corrective actions have
  been taken to reduce the risk of similar
  incidents without impacting the quality of
  service. The investigation validated the
  previously planned network projects to manage
  risk.

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For more information on RCA

• Root Cause Analysis Techniques / Training that
  Eastman RCA Practitioners have found to be most
  effective
• Tap Root
• Failsafe
• Proact
• Websites
• RootCauseLive.com
• Groups.yahoo.com/group/rootcauseconference
• TapRoot.com

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Insanity doing the same thing over and over
again and expecting different results. - Albert
Einstein
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Questions?