Category Archives: Root Cause Analysis

Por qué la metodología del análisis de causa raíz (RCA) de Apollo puede reducir el impacto del error humano.

Una pregunta que me formulan constantemente como entrenador de análisis de causa raíz (RCA) de Apollo, es esta: “¿Cómo ayuda Apollo con el desempeño humano?”Male and Female Industrial Engineers in Hard Hats Discuss New Project while Using Tablet Computer. They're Making Calculated Engineering Decisions.They Work at the Heavy Industry Manufacturing Factory.

Sabemos que siempre habrá inconsistencias entre lo que se instruye a las personas y cómo lo hacen (desempeño humano). También sabemos que las empresas necesitan gestionar y reducir estas diferencias tanto como sea posible. Cuando se producen diferencias significativas, descontroladas o repentinas, y como resultado surgen problemas costosos, se sabe entonces que se necesita un análisis e investigación para identificar qué hay detrás de las diferencias.

Dentro de la metodología de Apollo RCA, el término “Causado por” nos lleva a un viaje de eventos causales o un camino causal. Una vez que se hayan documentado todas las causas, podemos aplicar soluciones efectivas para que el problema no vuelva a ocurrir. La metodología de Apollo no solo es robusta, sino que también es lógica y variable.

Las fallas relacionadas con los seres humanos se encuentran en casi todos los tipos de problemas en algún punto a lo largo del espectro, pero principalmente en problemas basados ​​en eventos.

En un sistema basado en el desempeño humano, se requiere que un empleado u operador realice una tarea determinada o múltiples tareas variadas. Para cada tarea realizada hay un resultado requerido.

La metodología de análisis de causa raíz (RCA) de Apollo nos obliga a investigar no solo las acciones realizadas o no realizadas (inacciones), sino también las condiciones existentes que rodean las acciones o inacciones. Sabemos que las acciones son momentáneas y las condiciones existen a lo largo del tiempo. Cuando las acciones y las condiciones se unen en el mismo punto en tiempo y en espacio, el efecto principal o el problema definido es presentado.

Si registramos el problema (efecto primario) como “Error del operador”, debemos investigar qué causó el error y las causas subsecuentes a mayor detalle. Una lista completa de las acciones o inacciones y condiciones nos permitirá crear caminos causales más profundos basados ​​en relaciones de causa y efecto. En muchos casos, encontramos que las causas de un “Error del operador” son sistémicas.

Teniendo en cuenta que la mayoría de la gente va a trabajar para hacer lo correcto, es lógico pensar que cuando sucede algo incorrecto puede haber otras fuerzas en acción. Si simplemente nos deshacemos del operador por cometer un error, entonces los problemas reales no se eliminan, porque no los hemos considerado durante la investigación. Incluso con un nuevo operador, es muy probable que ocurra el mismo error junto con los impactos asociados (tiempo, pérdida de producción, lesiones, pérdida financiera).

Al utilizar el proceso estructurado de la metodología de análisis de causa raíz de Apollo, usted puede descubrir las causas fundamentales de los problemas de desempeño humano de manera efectiva y consistente, brindándole una visión más profunda de las causas sistémicas. Posteriormente, puede implementar una solución que evite que se repita el “Error del Operador”.

 

El artículo anterior de nuestro blog describió la estrategia de capacitación recomendada para el desarrollo de su programa de análisis causa raíz (RCA).bigstock--210386155

El siguiente paso para lograr un programa de RCA exitoso es asegurar que el liderazgo entienda su función y tenga las herramientas para asegurar la duración del programa y su efectividad.

Para garantizar el éxito de su programa de RCA, el liderazgo debe tener un interés personal y asumir la responsabilidad no solo de desarrollar y supervisar las funciones del esfuerzo de RCA, sino también de supervisar el estado de los análisis individuales y las soluciones asociadas. Este control lo realiza normalmente el Comité Directivo en conjunto con sus otras responsabilidades estratégicas.

Los elementos críticos a seguir en relación a la realización del RCA incluyen:

  • Fecha del incidente
  • Fecha de iniciación y asignación del RCA
  • Fecha estimada de finalización del RCA
  • Días vencidos
  • Actividad de seguimiento
  • Fecha de Terminación

Los elementos críticos a seguir en relación con las soluciones que se implementarán incluyen:

  • Fecha de terminación del RCA
  • Fecha de iniciación y asignación de la solución
  • Fecha estimada de finalización de la solución
  • Días vencidos
  • Actividad de seguimiento
  • Fecha de terminación
  • Frecuencia de recurrencia del incidente
  • Ahorro anual / reducción de incidentes HSE

Una vez que se haya completado el análisis de causa raíz, el equipo de RCA desarrollará una lista de posibles soluciones y la enviará al Comité Directivo a través del Programa Campeón o su representante para su aprobación. El Comité Directivo luego asigna estas soluciones a los individuos para completarlas y las coloca en un formato de plan de acción con fechas de vencimiento asignadas. Estas acciones deben completarse en el menor tiempo posible, de lo contrario el proceso se desvanecerá rápidamente. El Comité Directivo debe monitorear el estado de los RCAs abiertos, el progreso de la implementación de las soluciones para garantizar la finalización oportuna y la efectividad de las soluciones implementadas previamente (según lo medido por las recurrencias de los incidentes originales). Los nuevos análisis no deberían iniciarse si aún quedan soluciones por implementar.

Se le debe asignar a una persona la responsabilidad de monitorear el progreso y la recurrencia. La persona adecuada para esta responsabilidad puede ser diferente para distintas organizaciones. Se realiza un monitoreo del progreso mostrando el número o el porcentaje de soluciones completadas. La recurrencia se rastreará midiendo la repetición del incidente.

Algunas organizaciones ya tendrán un software y métodos para rastrear tareas, como un CMMS. Si este es el caso, también puede ser considerado para un RCA y seguimiento de soluciones. Sin embargo, si no hay un sistema existente o no satisface todas las necesidades de monitoreo de RCA de la organización, le recomendamos que considere el software de RCA de RCProTM para empresas. Este permite la generación de una lista de acciones, fechas de vencimiento y comentarios de cada análisis para compartir con los miembros del equipo. También proporcionará informes detallados sobre el estado actual de la investigación, el seguimiento de las acciones, los elementos pendientes y los problemas sistémicos de la organización.

Aquí es donde entra en juego la revisión y el apoyo del Comité Directivo. El equipo de liderazgo debe revisar el estado del RCA, la implementación de la solución y los resultados finales como parte de las responsabilidades regulares del Comité Directivo. La función principal del Comité Directivo es garantizar que los RCAs se completen de manera oportuna y que las soluciones resultantes se implementen y se rastreen para su efectividad.

Hasta ahora, esta serie de blogs ha cubierto:

Los Pasos Clave para Diseñar Su Programa

Definición de Objetivos y Estado Actual

RCA y Seguimiento de Soluciones y Roles y Responsabilidades

Estructura de Equipo RCA Recomendada

Responsabilidades de los Seis Roles

Estrategia de Capacitación

Mapeo de Procesos

Plan de Gestión del Cambio Humano (por sus siglas en Ingles HCM) 

Y, Supervisión y Gestión

 

Casual man pointing the finger at you, isolated on white backgro

By Bruce Ballinger, RCA Instructor, ARMS Reliability

Most organizations today have a well-defined, reliable Management of Change process for things like the addition of new equipment or changes in the manufacturing processes, to ensure the transformations are implemented smoothly and with minimal disruption.  However, fewer organizations put much effort into how best to prepare the workforce for the changes they will be having to make within their duties, roles, and responsibilities. Yet, research by the Human Change Management (HCM) specialist organization, Prosci, validates that more projects or programs fail from not addressing the impact and changes that will occur for the organization’s employees than from technical flaws in the initiative itself.

HCM is often defined as, “the people side of project management.”  A new initiative may be the best answer to a problem or the right thing to do to improve the organization.  However, if the employees impacted by the change aren’t supportive or properly prepared, then the effort is in grave risk of failure.  The HCM process requires an organized, objective methodology for defining the degree to which a formal HCM effort may be required and identifies where and upon whom the HCM effort should be focused to greatly improve chances of initiative success.

In short, a few key components must be addressed by the methodology:

  1. The first is visible executive sponsorship of the initiative to develop an environment where the change can happen. As is said, “If it isn’t important to the boss, then it won’t be important to anyone that works for the boss.”
  2. Second, is identifying the positions that may be either negatively or positively affected by the change. Those affected negatively will be provided assistance throughout the change period using training, mentoring, and coaching until such time they have successfully transitioned from current state into the future state.
  3. Last is future follow up and monitoring to guard against regression back into the old ways.

For major projects, the HCM process can be very important for a successful outcome. For example, if employees are to have a complete role change by perhaps becoming a full-time RCA facilitator and problem solver, then an HCM plan would be vital.  However, in the case where RCA facilitation is simply a minor change in duties (say, changing from a mix of RCA methodologies to standardizing on one), then an informal, less rigorous effort should suffice.

Regardless of the magnitude of the change, organizations need to consider and detail the HCM process to ensure the new initiative is successfully deployed by preparing and informing all stakeholders of how the change will affect their daily roles, processes, and working environment.

So far in the RCA Program Development series we’ve covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

Training Strategy

Oversight and Management

Process Mapping

And, Change Management

Stay tuned for our next installment on Implementation Tracking.

An often-overlooked element of implementing any new initiative is the process mapping exercise. The more intricate the initiative, the more valuable the process map becomes. Although launching a root cause analysis implementation plan is usually fairly straight-forward, it is still worthwhile spending some time mapping out how the work flows from a triggered event all the way through tracking the effectiveness of implemented solutions. It’s an effective way of ensuring that everyone has a clear understanding of their role and where it fits into the process.

Process mapping is usually done in two-steps commonly known as the brown paper/white paper exercise. The brown paper mapping step creates a diagram representing how RCAs are currently managed throughout the system. Once the existing workflows are clearly understood and charted the white paper charting is performed. This diagram documents the desired workflow and systematically identifies gaps between the current and desired future state. Identifying the nature and magnitude of these gaps allows the Facility Leadership Team and/or RCA Steering Committee to dedicate the resources needed to make the change over.  It also clearly defines the roles and responsibilities of affected departments and positions in the RCA program.

As seen in the example below, different symbols and colors are used to represent various steps and components. The steps are laid out from left to right and top to bottom. A start or stop point is usually designated with an oval or rounded rectangle, a regular step is a rectangle and a decision point is a diamond. All steps are connected by lines and arrows.

Example RCA Process Map- Click to download enlarged PDF

RCA Workflow

When done properly, process mapping leaves no room for misunderstanding of what needs to be done when or voids in roles/responsibilities, resulting in efficient and effective implementation of the RCA initiative and ultimately, operational improvements.

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

Training Strategy

Oversight and Management

And, Process Mapping.

Stay tuned for our next installments on Change Management and Implementation Tracking.

bigstock-Leadership-74184760The previous article in our blog series described the recommended training strategy for your RCA program development. The next step in achieving a successful RCA program is to ensure leadership understands their role and has the tools in place to ensure the longevity of the program and its effectiveness.

To ensure the success of your root cause analysis program leadership must have a vested interest and take responsibility not only for developing and overseeing the functions of the RCA effort, but also monitoring the status of the individual analyses and associated solutions. This monitoring is typically done by the Steering Committee in conjunction with its other strategic responsibilities.

The critical elements to track in relation to conducting the root cause analysis include

  • Incident date
  • RCA assignment date and lead
  • Estimated RCA completion date
  • Days past due
  • Escalation activity
  • Actual completion date

The critical elements to track in relation to the solutions that are to be implemented include

  • RCA completion date
  • Solution assignment date and lead
  • Estimated solution completion date
  • Days past due
  • Escalation activity
  • Actual completion date
  • Frequency of incident recurrence
  • Annual savings/HSE incident reduction

steering committeeOnce a root cause analysis has been completed, a list of potential solutions will be developed by the RCA team and submitted to the Steering Committee via the Program Champion or his/her designee for approval. The Steering Committee then assigns these solutions to individuals for completion and puts them into an action plan format with assigned due dates. These actions should be completed in the shortest time possible, otherwise the process will quickly fade away. The Steering Committee must track the status of open RCAs, the progress of implementing the solutions to ensure timely completion, and the effectiveness of previously implemented solutions (as measured by recurrences of the original incidents). New analyses should not be started if a large number of solutions remain to be implemented.

An appropriate person needs to be assigned the responsibility of tracking progress and recurrence.  The right person for this responsibility may be different for different organizations. Progress is tracked by showing the number or percentage of completed solutions. Recurrence will be tracked by measuring repetition of the incident.

Some organization will already have software and methods for tracking tasks, such as a CMMS. If this is the case, it can be considered for RCA and solution tracking as well. However, if a system does not currently exist or does not fulfill all the organization’s RCA tracking needs, then we would recommend considering RCProTM enterprise RCA software. It allows for the generation of an action list, due dates, and comments of each analysis to be shared with team members. It will also provide detailed reports on current investigation status, action tracking, outstanding Items, and view systemic issues across the organization.

This is where the Steering Committee review and support really comes in to play. The leadership team should review RCA status and solution implementation and final results as a regular part of Steering Committee business. The Steering Committee’s main role is to ensure that RCAs are completed in a timely fashion and that resulting solutions are implemented and tracked for effectiveness.

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

RCA Program Development Training Strategy

And, Oversight and Management.

Stay tuned for our next installment on RCA Process Mapping.

bigstock-Training-Courses-on-Ring-Binde-121847267_Resized.jpgThe previous article in our blog series on RCA Program Development described the responsibilities of the six roles required for your program to function well. The next step in achieving a successful RCA program is to develop a comprehensive RCA training strategy that will ensure sustainability of the effort to reduce the frequency and severity of undesirable incidents into the future.

A common mistake is to under-train, primarily RCA facilitators, in relation to the trigger diagram which we discussed in an earlier blog post.  You may recall that in developing the trigger diagram, a 3-year baseline of triggering events is reviewed to ensure an adequate balance of events and trained facilitators. Assuming the RCA facilitation responsibilities will be an addition to the existing position responsibilities, one would expect a facilitator would be leading a triggered RCA on average once per month with a series of less important ad hoc RCAs in between to stay current on skills.

There should be at least one Super User at each facility and at the corporate level. Likewise, all personnel that may be either a first responder to a triggered event or expected to participate in the RCA should be trained to an appropriate level as outlined in the table below (click photo to enlarge).

 RCATrainingPaths_ProcessFlowGraphic_Rev1.jpg

A “Refresher” course should also be undertaken as needed. An often overlooked element of a training program is the need to maintain optimum skill levels over time, especially if there are prolonged periods where the skill may not be practiced. This can often be the case with triggered events because of their random nature. This creates a danger that skills and knowledge may not improve at the same rate as other jobs skills. This is especially true for Facilitators, First Responders, and Participants. Records should be maintained that track the number of facilitated RCA, first responses, and RCA participations and reviewed at least annually. If Facilitators have gone six months, or Participants/First Responders one year, without using these skills then consideration should be given to the refresher training.

Training is an essential component for all personnel involved with an organizations’ RCA program. Having the right roles with the right skills and ensuring those skills stay fresh over time is important to the overall success of your RCA effort. ARMS Reliability leads world-class training to assist you in every stage of your RCA journey. Learn more about the required and recommended courses, and contact us for more information.

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

Responsibilities of the Six Roles

And, RCA Program Development Training Strategy.

Stay tuned for our next installment on RCA Effort Oversight and Management. 

This is our sixth installment in our blog series on Root Cause Analysis Program Development. Earlier in the series, we introduced the six necessary functions within an RCA program and then outlined a recommended team structure to fulfill those functions. In this article, we’ll provide a detailed description of the part each of the six roles plan within an effective RCA program.bigstock-Teamwork-Of-Businesspeople-48286511.jpg

Let’s dive right in.

The RCA Steering Committee

It is the responsibility of the Steering Committee to develop and oversee the strategic functions of the RCA effort.  Steering Committee members should collectively have the authority to assign RCA roles and responsibilities, allocate resources to the effort, and most importantly, have a vested interest in the success of the program.  

Leadership teams of this nature usually already exist in almost all organizations and as such, can double as the Steering Committee by simply adding RCA program status review to regularly scheduled routine meetings as an agenda item. This avoids the creation of more bureaucracy and duplicate meetings.   Steering Committee responsibilities and functions are as follows.

Strategic Responsibilities:

  • Define the scope and breadth of the RCA effort
  • Assign RCA roles and responsibilities
  • Review and approve RCA resource requirements for annual budgeting purposes
  • Set and adjust program KPI’s (at least annually) to reflect improvements in the organization’s performance
  • Set and review threshold criteria (at least annually) to ensure proper balance between trained RCA facilitators and formal RCA demand
  • Sponsor a human change management plan where needed to ensure support from affected positions and departments.

 Tactical Responsibilities:

  •  Approve (or not) recommended RCA solutions for implementation including prioritization and resource allocation
  • Monitor status of open RCAs
  • Monitor and ensure timely implementation of approved RCA solutions
  • Monitor the effectiveness of implemented solutions

The RCA Champion

The Champion serves as a primary sponsor of the RCA effort.  The Champion’s key functions are to promote the RCA effort through sustained advocacy and to make recommendations to the Steering Committee for the resources necessary for the tactical maintenance of the program.  Primary responsibilities include the following.

Advocacy:

  • Monitor RCA solution impact on the program KPIs and regularly communicate these results throughout the organization
  • Promote a spirit of success by recognizing and celebrating specific RCA team’s accomplishments and contributions to the organization
  • Attract individual interest in having a role in the RCA effort by communicating its career enhancement value and benefits to the organization   

Tactical Resource Recommendations:

  • Make recommendations to the Steering Committee for RCA program resource requirements for the budgeting process (man hours, positions, training, etc.) necessary to sustain a successful RCA effort
  • Manage the organization’s overall RCA training schedule
  • Regularly track the status of open RCAs and solution implementation
  • Ensure the Steering Committee has accurate and up-to-date RCA and solution status data to make informed decisions regarding allocations of resources and action item prioritization.

The Super User

Depending on the size and structure of the organization, the role of Super User may be beneficial. The Super User is the level above Facilitator in terms of formal RCA training, experience, and expertise with both the RCA methodology and any supporting software. They will also have advanced group facilitation skills and should also be the most experienced facilitator on site.  It is not uncommon to combine the roles of Super User and RCA Champion. Super User responsibilities include the following.

  • Facilitate, or assisting in facilitating, the more significant events and complicated analyses for the organization
  • Performing critical quality assurance reviews of other facilitators’ analysis
  • Act as a mentor to new facilitators
  • Ensure that all facilitators use the proper RCA methodology
  • Deciding, in conjunction with the Champion, when to recommend bringing in facilitation assistance from impartial third-party experts.

The RCA Facilitator

The RCA Facilitators, or methodology practitioners, are fundamental to leading the RCA team in discovering the causes of the incident under review and associated preventative measures or solutions. The Facilitator needs to be neutral in the process. Too often facilitation duties are assigned to positions or individuals because of their technical skills, which can be a mistake. Facilitation skills and technical expertise are two distinctly different talents. Quality RCA facilitators have a naturally engaging personality, logical thought processes, superior group management techniques, and mastery of the RCA methodology. They must create effective RCA team dynamics by ensuring that all team participants are heard, keeping dominate personalities in check, and avoiding group think. Technical responsibilities include ensuring the RCA methodology is accurately followed which includes:

  • Creating a clear and precise problem definition
  • Ensuring that all incident causes are identified and documented in the proper causal relationships
  • Encouraging “out of the box” thinking of the team members during the solution identification process
  • Summarize the results of the RCA with recommended solutions for submittal to appropriate personnel

The RCA Participant

The Participants’ primary role is to be an RCA team member when called upon to do so. They can be anyone from hourly employees, to upper level managers and every position in between. Participants need to receive a level of training on the RCA methodology such that they understand the terminology and the steps involved. Although the level of training is significantly less than that of the Facilitators, Participants often comprise the bulk of the trainees because of the diversity of the personnel requirements for the various RCA incidents. Responsibilities often include the following:

  • Maintain a fundamental understanding of the RCA methodology employed
  • Participate as an RCA team member when called upon
  • Apply their own specific knowledge, skills, and expertise in identifying incident causes
  • Assist in identifying and gathering incident evidence as directed
  • Participate in the solution identification process

The First Responders

The role of a First Responder is to gather as much information and preserve as much evidence as reasonably possible when a trigger incident occurs.  This role is especially important for 24/7 manufacturing operations. Since response time is often critical to preserving evidence, it is important that First Responders be readily available to serve in this role.  For such operations, typical First Responders are shift supervisors, lead hands, shift maintenance personal, etc. Activities of the First Responders primarily include:

  • Notifying appropriate personnel that a triggered RCA event has occurred
  • Securing incident information and evidence for the RCA team which may include:
    • Taking photographs if applicable
    • Identifying eye witnesses for debriefing by the RCA team
    • Securing electronic data related to the incident in question
    • Preserving any physical evidence relative to the incident

By understanding the responsibilities of each of these roles, you can ensure that the appropriate personnel are assigned to the proper roles, while at the same time, balancing existing position duties with any added RCA responsibilities. 

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

Recommended RCA Team Structure

And, descriptions of each of the six roles within an RCA program.

Next up – Training Strategy and RCA Effort Oversight and Management. Stay tuned for more.


Our previous article in this RCA Program Development blog series introduced the six roles required in your root cause analysis team in order cover all of the necessary functions. This installment in the series goes into more depth on the team structure and provides some important considerations for deciding whom should be involved.  

Roles and Responsibilities

The RCA effort in any organization will require a number of participants at various levels of the organization having distinct roles with very specific responsibilities.  Once the workflow processes are established it is time to assign these roles and responsibilities to specific individuals, determine training needs, and decide if a formal human change management plan will be desirable to assist employees in assuming their new assignments.  These responsibilities must be clearly understood to ensure that the appropriate personnel are assigned to the various roles which include the following:

 

RCATeamGraphic_72ppi.png

 

To assist in the above, it is helpful to review the nature and dynamics of a functioning RCA team.

The role of an analysis team is to apply the RCA methodology to a particular incident.  A predetermined set of conditions or triggers is used in determining what incidents qualify for a formal RCA.  The RCA Champion in collaboration with a designated Facilitator then decides through the problem definition process how much effort is to be expended on the analysis i.e. what skills participants will be on the team and how many of each, based upon the severity of the incident.  As a general rule, the cost of the resources expended should be significantly less than the potential benefit of a successful outcome.  In other words, the effort should yield a favorable ROI or greatly reduce the risk of a safety or environmental incident recurrence.  It is often useful to define threshold levels, or break points for minor, significant, or major RCA efforts to provide guidance.

The Facilitator leads the analysis process.  Teams should be cross functional and consist of 6 to 8 members depending upon the nature, complexity, and severity of the incident under investigation. When assembling an RCA team, the Champion or Facilitator has the option of including people directly involved in the incident being analyzed on the team, or involve them as interviewees only.  It is often beneficial to include a team member with no firsthand knowledge of the incident, but having familiarity with the process, equipment, etc. in order to help bring objectivity to the group and avoid “group think”. These members need to be carefully selected to ensure they add value. Having people assigned to the analysis team because they are available will only waste time. The team should also have at its disposal all the facts, evidence, and a timeline surrounding the incident.

Certain points in the analysis may require additional information that is not available within the organization.  For example, it may be necessary to contact suppliers or vendors concerning design issues. The incident owner will need to understand and encourage the follow-up on this type of information gathering.

When the RCA program is launched, it is recommended to focus on the quality of the analysis and not quantity. A few quick-wins are important to building momentum and confidence in the process.

Specific RCA team responsibilities include the following:

  • Review the facts, evidence, and timeline surrounding the incident
  • Interview eye witnesses or others that may have useful knowledge of the incident at hand but are not on the analysis team
  • Interview subject matter experts
  • Provide the technical expertise for problem solving including action and condition recognition and possible solution proposals
  • Perform an RCA analysis. The Apollo Root Cause Analysis methodology includes:
  • Validating the problem definition as previously determined by the Champion and Facilitator
  • Creating the cause and effect diagram using RealityCharting® software
  • Identifying conditions and actions that precipitated the incident under investigation
  • Proposing effective solution to eliminate selected conditions and actions that are realistic and under the control of the facility’s management
  • Summarize the findings in a report to the Champion to be presented to the Steering Committee. Be available to answer any question the Steering Committee may have regarding the report.

Once the roles and responsibilities are assigned, a comprehensive training plan covering the RCA methodology and any identified change management needs must be developed with a targeted timeline.

So far, this blog series has covered:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

RCA and Solution Tracking and Roles and Responsibilities

For the fourth installment in this blog series on the key steps of RCA program development we are covering step #5 – RCA and Solution Tracking Systems and #6 – Roles and Responsibilities. Remember, to have a successful implementation and adoption of your new (or redesigned) RCA program, it’s crucial to have all the elements of an effective and efficient program clearly identified and agreed upon in advance. RCA Program Roles and Responsibilities

Here’s what we’ve covered in this blog series so far:

The Key Steps of Designing Your Program

Defining Goals and Current Status

Setting KPIs and Establishing Trigger Thresholds

Now we’ll dive into the important aspects of tracking your RCA solutions and the responsibilities of each role that must be played within your RCA processes.         

RCA and Solution Tracking Systems

It is very important that the status of outstanding RCAs and solutions be monitored for two basic reasons: To assure timely completion of the tasks, and to measure their effectiveness in preventing recurrence of the undesirable incident.

When a formal RCA is triggered and assigned to a facilitator, the assignment should also include a reasonable completion date that is agreed upon with the facilitator. I emphasize the word “reasonable” because human nature is to cut ourselves short on schedule time leading to rushing and taking shortcuts, which in turn can result in an inferior work product.  I’ve not known anyone that has ever been admonished for completing a task ahead of time, so be sure the due date is readily achievable.

Once an RCA has been completed, a list of possible solutions will be submitted for approval.  As with the RCAs, solution implementation should have a realistic due date and a responsible party for completion. Progress towards meeting the due dates must be tracked to ensure timely completion. In addition, solution effectiveness, as measured by incident recurrence (or hopefully the lack thereof), should be monitored as well in order to demonstrate the value of both the individual RCAs and the RCA program as a whole.

When discussing action tracking, often the first thought is to create a new system. However, I suggest thinking about your existing systems and technology first and whether there is an opportunity (and if it makes sense) to integrate action tracking into those. Solution and action item lists can be exported from RealityCharting® to Excel® and then imported into your current action tracking system. If you don’t have an existing tracking system that will serve all your needs, then consider an enterprise RCA tool, such as RC ProTM.

Roles and Responsibilities

An effective, efficient, and sustainable RCA effort will require a number of functions to be fulfilled at various levels of the organization. There must be distinct RCA program roles to accomplish this, each with either a unique set of responsibilities or, in some cases, shared duties. The responsibilities of each role must be clearly understood to assure that the appropriate personnel are assigned to the proper roles while at the same time balancing existing position duties with any added RCA workload.

Here are the necessary functions:

  1. Steering committee – What existing management team will oversee the RCA effort?
  2. Program Champion – Who will be the RCA sponsor that brings legitimacy to the effort?
  3. RCA Methodology Expert – Who will quality-check completed RCAs or facilitate the most difficult ones?
  4. RCA Facilitators – How many and who will be trained as standard RCA facilitators?
  5. First Responders – When a triggered event occurs, who will be responsible for preserving evidence?
  6. Skills Participants – What people will participate in RCAs?

We will go into more depth on each of the above in our next blog installment.

Learn more about our recommended facilitated workshop that covers all 11 of the key steps, and contact us for more information.

 

bigstock--165000134.jpgAs outlined in our previous blog article, “RCA Program Development: The Key Steps of Designing Your Program”, there are 11 key steps to a successful RCA program. Last month we introduced the first two steps – Defining Goals and Current Status. In this article we’ll break down steps 3 and 4 – Setting KPIs for your RCA program and establishing trigger thresholds to initiate an RCA.

  1. Key Performance Indicators

Key Performance Indicators, or KPIs, are the benchmarks used to measure the success of a program or effort. They can generally be divided into two categories: leading indicators and lagging indicators.  Both of these measure the degree to which progress is being made in achieving a specific goal.  Leading indicators tend to be objectives that progress you towards achieving the ultimate goal. They can be measured over a short period and act as mileposts to gauge how you’re tracking towards your goal. Lagging indicators are often the goals themselves.  If the relationship between the two is correctly defined, then achieving the short-term (leading) indicators virtually guarantees achieving the long-term goals.

To provide perspective in measuring progress using KPIs, a baseline must first be established.  Baselines for the selected KPIs should be at least 3 years of historical performance. Once these are established, then goals or targets for improvement should be set for a period of time, say 3 years, going forward. This process should be reviewed at least annually with baselines and targets adjusted accordingly.

  1. Formal RCA Threshold Criteria

An effective incident prevention program will have RCAs being performed at two levels: 1) On an informal or ad hoc basis for smaller, nuisance-level problems that may be specific to individuals or departments; and 2) on a formal level where challenges to the organization’s goals exist.

Leaders must communicate the organizational trigger criteria but they should also encourage and support teams and individuals to set their own trigger criteria as well.  When your employees can solve smaller day-to-day problems more effectively, your organization will realize the benefits of pro-active problem solving because many smaller problems will be rectified before they can manifest themselves into larger organization-level problem.

For RCA to be a core competency at all levels of the organization, and for people to be proactively preventing organizational problems, it is important to have clear guidance for formal RCAs. This is the function of the Trigger Criteria diagram. High-level challenges should be formally identified and assigned a threshold that when exceeded will automatically trigger a formal RCA.  Triggers should generally be leading indicators of some form or another and derived from specific organizational goals, or KPIs.  They are the trip wires to engage the RCA process for finding solutions to problems that are inhibiting organization goal achievement.

Organizations at higher levels of maturity will most often have triggers for multiple categories including safety, environmental compliance, revenue loss, unbudgeted costs, production loss, and sometimes repeat incidents.

For a deeper dive into the topic of trigger thresholds and scaling your RCA investigation, check out our whitepaper “Matching the Scale of Your RCA Investigation to the Significance of the Incident

In this blog series, we’ve now covered:

And

  • Setting KPIs and Establishing Trigger Thresholds

But of course, there is more to setting up your RCA program for success. ARMS Reliability’s RCA experts can assist you with designing your complete RCA program or reinvigorating your current one. This of course includes assisting with determining the status of your current RCA effort, walking you through the process of establishing and aligning goals, helping you set KPIs for your program, and establishing trigger thresholds that make sense for your organization. Learn more about our recommended facilitated workshop that covers all 11 of the key steps, and contact us for more information.