The PROACT root cause analysis: quick reference guide

✍ Scribed by Latino, Kenneth C.; Latino, Mark A.; Latino, Robert J

• Publisher: CRC Press
• Year: 2020
• Tongue: English
• Leaves: 95
• Edition: First edition
• Category: Library

✦ Synopsis

"ROOT CAUSE ANALYSIS or RCA, What is it? Everyone uses the term, but everyone does it differently. Given that, how can we have any uniformity in our approach much less accurately compare our results? At a high level, we will explain the difference between a Root Cause Analysis and a Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence. In this book we will get down to basics about 'RCA', the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Those common investigation steps include : Preserving evidence (data)/not allowing hearsay to fly as fact Organizing an appropriate team/minimizing potential bias. Analyzing the events/reconstructing the incident based on actual evidence. Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented. Tracking bottom-line results/ensuring that identified, meaningful metrics were attained. We explore why don't things always go as planned. When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive root cause analysis based on our 3+ decades of applying RCA as we have successfully practiced it in the field. The book is written as a "how-to" guide to effectively apply the PROACT RCA Methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application. This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH & S, maintenance, reliability, quality, engineering, and operations to name just a few"--

✦ Table of Contents

Cover......Page 1
Half Title......Page 2
Title Page......Page 4
Copyright Page......Page 5
Table of Contents......Page 6
Preface......Page 10
Authors......Page 12
What Is Root Cause Analysis (RCA)?......Page 14
Summary of the PROACT® Investigation Management System......Page 15
Why Do Undesirable Outcomes Occur? The Big Picture......Page 16
What Are the Elements of a True Root Cause Analysis System?......Page 17
RCA Team Process Flow Diagram......Page 19
The 5-P’s Data Collection Concept......Page 20
Parts......Page 21
Positional Data Related to Physical Space......Page 22
Positional Data Related to Time......Page 23
People......Page 24
Paper......Page 27
Paradigms......Page 28
Tale of a ‘Team’......Page 33
The Principal Analyst (PA)......Page 35
Vendors......Page 36
Principal Analyst Characteristics......Page 37
Promote Listening Skills......Page 38
Team Charter/Mission......Page 39
Team Critical Success Factors (CSFs)......Page 40
Analytical Tools Review......Page 41
Pros......Page 42
The Traditional Fishbone Diagram......Page 43
Cons......Page 44
Pros......Page 45
Cons......Page 46
Cons......Page 47
The Germination of a Failure......Page 48
Constructing a Logic Tree......Page 49
The Event......Page 50
The Mode(s)......Page 51
The Hypotheses......Page 53
Verifications of Hypotheses......Page 54
Human Root Causes (HR)......Page 56
Latent Root Causes (LR)......Page 58
Breadth and All-Inclusiveness......Page 59
Verification Techniques......Page 60
Confidence Factors......Page 61
The Troubleshooting Flow Diagram......Page 62
Developing the Recommendations......Page 65
Developing the Report......Page 66
The Executive Summary......Page 67
The Technical Section......Page 68
The Detailed Plan to Execute Recommendation......Page 69
The Verification Logs......Page 70
The Final Presentation......Page 71
Strategize for the Meeting by Knowing Your Audience......Page 72
Have an Agenda for the Meeting......Page 73
Develop a Clear and Concise Professional Presentation......Page 74
Coordinate the Media to Use in the Presentation......Page 75
Prioritize Recommendations Based on Impact and Effort......Page 76
Determine Next Step Strategy......Page 77
6 Tracking for Bottom-Line Results......Page 78
Getting Proactive Work Orders Accomplished in a Reactive Environment......Page 79
Sliding the Proactive Work Scale......Page 81
Developing Tracking Metrics......Page 82
Exploiting Successes......Page 84
Conclusion......Page 86
Case Study: North American Paper Mill......Page 88
Index......Page 92

✦ Subjects

Root cause analysis