PROACT® RCA : Taking Failure

Analysis to the Next Level

www.reliability.com

27 July 2022
For over 50 years, we’ve been
on a mission to help teams
develop cultures of
exceptional reliability.
 Reliability Center Incorporated

www.reliability.com
• 1958 – Charles Latino began conceptual research to implement reliability principles within a
Fortune 50 chemical corporation
• 1972 - Established as the corporate reliability R&D center for Allied Chemical Corporation (AdvanSix
today)
• 1983 – Started publicly providing reliability engineering information on Equipment, Process
and Human Reliability
• 1985 - Became Reliability Center, Incorporated (RCI). Able to spread Reliability Concepts and Methods
to all industries
• Currently based in Richmond, Virginia USA. RCI has provided reliability training for the past 35+
years to over 30,000 students in 30+ countries

©1985 - 2022 Reliability Center Inc. All rights reserved 3

PROACT® Root Cause Analysis
An integrated problem-solving engine
 Definitions

How do you define Reliability?

• The ability of a system or component to function

under stated conditions for a specified period of time.
(Institute of Electrical and Electronics Engineers)

• Through our 50 years of experience, we’ve simplified

this definition…..

• The absence of errors.

©1985 - 2022 Reliability Center Inc. All rights reserved

 The Goals of an RCA

Problem Elimination
Problem Documentation
Regulatory Compliance
Employee Safety Publish
a Formal Report

High Reliability / ROI!

©1985 - 2022 Reliability Center Inc. All rights reserved

 Definitions

What Problems do RCA’s Solve?

• Sporadic (low volume, high cost/impact): Usually a dramatic
event; Demands urgent attention; occurs infrequently;
time-consuming to restore; known financial impact.
• Chronic (high volume, low cost/impact): Demands immediate
attention; small element of time to restore; high frequency,
with low impact per individual occurrence; financial impact
absorbed in budget; accepted as part of the routine.
• Unnoticed: Additional opportunities to improve Reliability
and ROI through proactive problem solving.

©1985 – 2022 Reliability Center Inc. All rights reserved

 Journey to Reliability and ROI

What is the formula for

developing exceptional
Reliability and ROI?

Solve Sporadic Problems + Identify Chronic

Opportunities + Eliminate Causes of Unnoticed

©1985 - 2022 Reliability Center Inc. All rights reserved

 Where to Start?

For Chronic Incidents/Events, how do we

prioritize which event(s) to investigate?

• Failure Modes & Effects Analysis (FMEA)

• Opportunity Analysis (OA)
• Decision by Pairs (Ordered according to
importance to decision maker)
• 3 x 3 Priority Matrix

©1985 - 2022 Reliability Center Inc. All rights reserved

 Top 10 Characteristics of a Successful
RCA
• (PR)ESERVE
1) Appropriate data retained when incident occurred.
• (O)RDER
2) Analysis participants provide appropriate diversity and knowledge.
3) Core investigative and decision-making team is limited to 3-5 members.
4) Adequate time allotted to complete the investigation.
• (A)NALYZE
5) The analysis depth and breadth match the severity and recurrence (risk) of a well
defined (fact based) issue.
6) Investigation development proposes and explores causal possibilities.
7) All the proposed possibilities are verified with data, either initial incident or follow-up
investigative data.
8) Completed analysis identifies cultural influences when incorrect human actions/decisions
are uncovered

• (C)OMMUNICATE
9) Accurate ROI projections and justifications provided for each recommendation.
• (T)RACK
10) Each recommendation is accepted, supported and completed.
©1985 - 2022 Reliability Center Inc. All rights reserved
 The PROACT® Problem Solving Engine

©1985 - 2022 Reliability Center Inc. All rights reserved

 Key Investigative Questions

• What data to obtain?

• When to obtain the data?

• How to obtain the data?

• Why to obtain the data?

©1985 - 2022 Reliability Center Inc. All rights reserved

The “5-Ps” for Data Collecting Data

• Parts
• Paper
• Position
• People
• Paradigms

©1985 - 2022 Reliability Center Inc. All rights reserved

 Tangible Evidence
Parts - Paper - Position - People - Paradigms

Parts:
Physical or tangible items to support the investigation findings.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Examples
Parts - Paper - Position - People - Paradigms

Physical parts
• Failed components
• Comparison components
• PPE
• Tools

©1985 - 2022 Reliability Center Inc. All rights reserved

 Examples
Parts - Paper - Position - People - Paradigms

Sample

• Process materials
• Good and Reject
• Contaminating substances
• Spilled material
• Lubrication
• From supplier
• From on site storage
• From point of usage

©1985 – 2022 Reliability Center Inc. All rights reserved

 Solid Documentation
Parts - Paper - Position - People - Paradigms

Paper:
Documents and files to support the investigation
findings.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Examples:
Documents
Parts - Paper - Position - People - Paradigms

Documents
• Drawings
• Manuals
• Specifications (Equipment and
Process)
• Correspondences
• Test Results
• Logbooks
• Work Orders
• Procedures
• Policies
• Permits

©1985 - 2022 Reliability Center Inc. All rights reserved

 Examples: Computer Data
Parts - Paper - Position - People - Paradigms

Computer Stored Data

• CMMS History
• DCS Process Trends
• ISO, MOC, PSM recordkeeping
• Calibration records
• Predictive Maintenance Records
• Vibration
• Oil Analysis
• Infrared Scans
• Ultrasonic
• Additional Technologies
• Weather Trends
• Training records
• Shift schedules
• Employee Time Clock Reports

©1985 - 2022 Reliability Center Inc. All rights reserved

 Situation Location
Parts - Paper - Position - People - Paradigms

Position:
The locational aspects of the incident to support the investigation
findings.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Situation Location
Parts - Paper - Position - People - Paradigms

Capture the Physical Location

• Of the Incident
• Of the Personnel
• Of any Equipment and Parts
• Of any Damage
• Of any Marks from an Impact or
Supervisor Shovel Operator
Contact
• Of any Indications of Wear
• Of the Contamination or Spill 16 ft 18 ft
45 ft
Produce a Detailed Mapping of the
Incident Scene Rigger
25 ft
• Crane turret failure scene
Crane Operator

©1985 - 2022 Reliability Center Inc. All rights reserved

 Time of the Event
Parts - Paper - Position - People - Paradigms
Look beyond the time on the clock
Place the specific Time of the Event into perspective.
Did it happen:
• On a specific shift?
• During or right after a shift change?
• After lunch?
• Near quitting time?
• Just before or after a break?
• Returning from or preparing for a vacation?
• During a process or equipment start-up event?
• Before, during, or after a major outage or shutdown?
• While an unrelated distraction took place?
• After long hours of work?
• Before, during or after a meeting?
©1985 - 2022 Reliability Center Inc. All rights reserved
 Situation Location
Parts - Paper - Position - People -
Paradigms

Location in Time
• Event Sequence
• Previous related events

Construct a timeline:
• Communications
• Decisions
• Actions
• Events
• Observations
©1985 - 2022 Reliability Center Inc. All rights reserved
 Constructing the Timeline
Parts - Paper - Position - People - Paradigms

©1985 - 2022 Reliability Center Inc. All rights reserved

 Conditions around the Incident
Parts - Paper - Position - People - Paradigms

Weather
• Hot – Cold
• Humid - Dry
• Dusty - Foggy
• Lightening
• Hail - Snow - Rain - Sleet
• Sunny – Cloudy - Clear

Lighting and Visibility

• Nighttime – Daylight
• Well Lighted – Dim - Shadows

Surface Traction
• Slippery – Wet - Icy
• Solid – Soft
• Loose - Sticky

©1985 - 2022 Reliability Center Inc. All rights reserved

 Action or Decision Source
Parts - Paper - Position - People - Paradigms

People:
The source of event actions and decisions that support the
investigation findings.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Identifying those with Information
Parts - Paper - Position - People - Paradigms

Who?
• Eyewitnesses
• Specific Knowledgeable Employees
• Subject Matter Experts
• Outsourced service providers
• Vendors
• Operators
• Mechanics
• Electricians
• Technicians
• Engineers, Supervisors, Managers
©1985 - 2022 Reliability Center Inc. All rights reserved
 Thought Influencers
Parts - Paper - Position - People - Paradigms

Paradigm:
A generally accepted standard, perspective, or set of
ideas which provide support to the investigation
findings.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Understanding the Behavior
Parts - Paper - Position - People - Paradigms

Paradigms will be the by-product of an analyst’s interaction

with the people interviewed during the data collecting
process.
• Defined as:
• “A framework containing the basic assumptions, ways of thinking, and
methodology
that are commonly accepted by members of a given community”
(www.dictionary.com)

• Apparent as:
• Repetitive themes
• Common statements
• Conditions of the work environment
• Patterns in the way people work together

©1985 - 2022 Reliability Center Inc. All rights reserved

 Examples Statements
Parts - Paper - Position - People - Paradigms

Paradigms are often expressed by employees in their

everyday language…..on and off the job

• “I’m just an operator.”

• “Breakdowns will always happen with equipment.”
• “We are overworked and understaffed.”
• “Management doesn’t care about the issue.”
• “We are not paid to think.”
• “They tell us safety comes first; but the reality is
production has the highest priority.”
What are some Paradigms spoken within your workplace?
©1985 - 2022 Reliability Center Inc. All rights reserved
 Truths about Data

Drivers for a successful analysis!

► Data is essential to the accuracy of the

analysis to find the “why?” (latent roots)

► The amount of Data determines the

speed of the analysis

► It is impossible to perform the analysis

verifications without the necessary Data

©1985 - 2022 Reliability Center Inc. All rights reserved 2

9
Surround the RCA Conclusions with Facts
5-Ps Data works together to support the conclusions

Parts

Paradigms Factually
Paper
Supported
RCA
Conclusion
s
People Position

©1985 - 2022 Reliability Center Inc. All rights reserved

 Support the Recommendations
Data justifies the spending

Photos
Testing Data

Parts data People data

Paper data

Trend data

Positional data

Secure the needed Resource Allocation to implement the

Recommendations
©1985 - 2022 Reliability Center Inc. All rights reserved
Who should be on the RCA Team?
Core Team
• 3-5 members
• Full or part time RCA specialists
• Part time RCA participants

“As Needed” Team Members

• Topic specific
• Brought in to assist Core Team
• Limited involvement

©1985 - 2022 Reliability Center Inc. All rights reserved

Selecting the right RCA approach

Severity Matrix

Tool to Consider
5-Why
Fishbone
Basic Failure Analysis
PROACT® Root Cause Analysis

Impact
©1985 - 2022 Reliability Center Inc. All rights reserved
Comparison of Analysis Techniques

©1985 - 2022 Reliability Center Inc. All rights reserved

 Evaluating Analytical Tools

©1985 - 2022 Reliability Center Inc. All rights reserved

 Analysis Tool Review – Recap

5-WHYS FISHBONE LOGIC TREE

1. Uses Cause-And-Effect 1. Does NOT Use Cause- 1. Uses Cause-And-Effect
And-Effect
2. Modes are dependent 2. Modes are dependent
upon each other 2. Modes are NOT upon each other
dependent upon each
3. Uses linear path by 3. Seeks all Possibilities by
other
asking WHY? asking HOW CAN?
3. Uses Brainstorming
4. Potential to use 4. Uses Evidence to prove all
Opinion as Fact 4. Potential to use Opinion Hypotheses
as Fact
5. Could limit Findings to 5. Involved and potentially
a single Root Cause 5. Causes can be Limited to time consuming, labor
within the Categories intensive process
Selected
6. Identifies decision making
Errors and Systems flaws

©1985 - 2022 Reliability Center Inc. All rights reserved

 The PROACT® Logic Tree
A process for solving complex
events
LOGIC TREE
Event
1. Uses cause-and-effect

Mode Mode 2. Modes are dependent upon

each other
How Can? 3. Seeks all possibilities by
Hypothesis Hypothesis asking HOW CAN?
How Can? 4. Uses evidence to prove all
Physical hypotheses

How Can? 5. Involved and potentially

time consuming & labor
Human
intensive process
Why? 6. Identifies decision making
Systemic Systemic
errors (Human) and systems
(Latent) (Latent)
shortcomings (Systemic)
©1985 - 2022 Reliability Center Inc. All rights reserved
 Constructing the Logic
Tree
7 Step Process The Top
Box
1. Describe the Event

Event

2. Describe the Mode Mode

Mode Mode
Modes

3. Hypothesize Hypothesis Hypothesis

4. Verify the
Hypotheses
5. Determine Physical Roots Physical
Root
and verify
Human
6. Determine Human Roots Root
and verify

7. Determine Systemic (Latent)

Systemic
Root
Systemic
Root
Roots and verify
©1985 - 2022 Reliability Center Inc. All rights reserved
 Root Causes
Revisiting Definitions

Physical
• The Physical roots are contained in the tangible
evidence gathered after a failure and provide the
explanation of the failure mechanism.

Human
• The Human roots refer to inappropriate decisions, actions
or interventions that led to the development of the
Physical roots prompting the failure.

Systemic (Latent)
• The Systemic roots identify reasons why the
inappropriate human intervention was allowed,
supported, encouraged, undetected or unaddressed.

©1985 - 2022 Reliability Center Inc. All rights reserved

 Verification

How do you verify the

hypotheses?

©1985 - 2022 Reliability Center Inc. All rights reserved

 How to validate the Hypotheses
• Human observation
• Fractography
• Controlled experiments
• Computer simulations
• Mathematical modeling
• High speed photography
• Amplified Motion Video
• Laser or Optical alignment
• Vibration monitoring
• 3D precision measurement
• Laboratory analysis and testing
Click for amplified motion
video
• Task analysis
©1985 - 2022 Reliability Center Inc. All rights reserved
 Dangerous Thinking
Verification Methods to avoid:
• I already know that is not what happened.
• We looked at that last time and that wasn’t
it.
• That’s never happened before.
• There is no way that could ever happen.
• Trust me, I know; I have been working in the area for
over20 years.

These are not factual verifications!

©1985 - 2022 Reliability Center Inc. All rights reserved
 Verification
List

©1985 - 2022 Reliability Center Inc. All rights reserved

 Verification Confidence Factors
Scale:
0 = 100% certainty the hypothesis is NOT TRUE
5 = 100% certainty the hypothesis is TRUE
1 to 4 = The measure of uncertainty when the data does
not conclusively support the hypothesis as being either
TRUE or NOT TRUE

In other words, the Confidence Factor is a measure

of a hypothesis's Level of Truth based on the
verification data available.
©1985 - 2022 Reliability Center Inc. All rights reserved
 Fact Line
Top Box

All Fact
Event

Mode Mode Mode Mode

Fact
Line
Hypothesis Fact
Hypothesis Hypothesis

Verifications progress the Analysis from hypothetical to Factual.

©1985 - 2022 Reliability Center Inc. All rights reserved
 Why Verify – the last word?

• Verifications progress the Analysis from hypothetical to

Factual

• Without Verifications the Root Causes cannot be

confirmed 100%

• Recommendations for Corrective Actions cannot

be fully supported

• We start with facts, and finish with Facts

©1985 - 2022 Reliability Center Inc. All rights reserved

 Making the Recommendations
Increasing the effectiveness
• Fix the Part
• Fix the People

• Fix the System

Address the System; not the People

• Go beyond addressing just the Physical Roots
• Target the weaknesses in the organizational system
• Do not make recommendations for Human Roots

Change the System: make it easier for people to consistently perform

correctly
• Or, make it difficult (more painful?) to perform an error
• Automate to reduce the human decisions
• Standardize to promote consistent decisions
• Simplify to remove confusion when deciding
©1985 - 2022 Reliability Center Inc. All rights reserved
Recommendation Prioritization

2 x 2 Matrix Example:

©1985 - 2022 Reliability Center Inc. All rights reserved

RCA Recommendation Plan

©1985 - 2022 Reliability Center Inc. All rights reserved

 Tracking a Performance Metric
R
100 C Events
A

80

60

40

20

0
Oct-15

Nov-15

Jan-16
Sep-15

Feb-16

May-16
Aug-15

Aug-16
Jun-15

Jun-16
Apr-16
Dec-15
Jul-15

Mar-16

Jul-16
©1985 - 2022 Reliability Center Inc. All rights reserved
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