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Jack Jager AMPEAK 2014 Presentation - 6 steps for a successful root cause analysis

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Jack Jager's Presentation at AMPEAK Perth 2014 on "6 Critical Steps for a Successful Root Cause Analysis

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6 Critical Steps for a Successful Root Cause Analysis
Success • Do we want it ? • How do we achieve it?
6 Elements • Information • Preparation • Conduct the RCA • Challenge what you know • Reporting • Success
Step 1……Information • 3 forms • Collected information • Stored information • Information that employees accumulate over time
Collected Information • Once an incident, an accident, an unwanted event has occurred how do we respond? • Information is critical! • How do we collect it? • This must be timely! • Misinformation • Someone must own it
Triggers • A clear understanding of what your risk matrix declares as investigation trigger points is vital.
Stored Information • Access your CMMS systems • How good is your information?? • Abbreviated or Generic descriptions • Electronic Data
Information that employees accumulate • People have experience and knowledge to share. • Ensure that you have the right people in the room
Step 2….Preparation • Room and amenities • People • Data, Reports • Visual stimuli • Who owns this task? • 7xP’s
Step 3 ….Conduct the RCA • Get the right facilitator • Trained/untrained • Experienced/inexperienced • Good at it/ ? • Who doesn’t have a vested interest in the outcome • Should it be the subject matter expert?
Facilitation • What are the attributes of a good facilitator? • Knows the process • Good listener • Keeps control of the group • Good communicator • Can remain neutral • Respects all contributions
Step 4….Challenge your charts • How do you know you have “got it”? • Review your cause and effect chart • Critical challenge is the key • Be consistent • Be logical • Follow the rules • Have evidence to support the information
Step 4….Challenge your Charts • Demand excellence in the cause and effect charts • The chart reflects what you know • It is an iterative process • A quality chart can be an effective learning tool • Be specific
Excellence in Charting • A lot can be gained from making the effort in trying to achieve the best possible chart. • Will it ever be perfect?.......Rarely • Opportunities for improvements can however be identified. • At the end of the day the chart becomes the validation for the choices made regarding corrective actions.
Step 5….Reporting • Effective communication is the key • Who should be able to read the report? • Time is valuable • Kiss principle
Reporting ….Key elements • Clear defining statement • The cause and effect chart and also the cause and effect summary • Corrective actions assigned to critical causes…..ownership needs to be given and due dates set • Attendees, cost information, appendices
Step 6…..Success • Easy to say….. hard to prove • Measure the impact of any changes that are implemented • Success breeds success • Advertise
Attitude to Root Cause Analysis Positive or Negative??? Blame? Time? Previous experience? Lack of support?
• LEARNING FROM THE INCIDENTS AND EVENTS THAT HAPPEN IS VITAL TO AN INDUSTRY TRYING TO MAKE IMPROVEMENTS. • THE NEED TO BE EFFECTIVE IN THE ART OF ROOT CAUSE ANALYSIS THEREFORE BECOMES IMPERATIVE.
• TO BE SUCCESSFUL IN THIS PURSUIT REQUIRES … • THAT EFFECTIVE STRUCTURES EXIST THAT GATHER INFORMATION CONTINUALLY AND ALSO IMMEDIATELY AFTER AN EVENT • STRUCTURES THAT SUPPORT AND ALLOW SOUND PREPARATION TO OCCUR ARE IN PLACE • THAT COMPANIES TRAIN EMPLOYEES TO THE LEVEL THEY NEED TO BE EFFECTIVE FACILITATORS • THAT THE IMPLEMENTATION OF CORRECTIVE ACTIONS IS ASSURED AND THAT WE MEASURE THE IMPACT OF THOSE CHANGES.
Acceptance • If you are willing to accept investigation reports that are less than what they should be ….then that is what you are most likely to get! • If it is worth doing then it is worth doing well!
Codicil • Success in the performance of Root Cause Analysis will happen more consistently when clear process structures are in place and when positive management support is given to the process!
Contact Details Jack Jager ARMS Reliability jjager@armsreliability.com

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Jack Jager AMPEAK 2014 Presentation - 6 steps for a successful root cause analysis

  • 1. 6 Critical Steps for a Successful Root Cause Analysis
  • 2. Success • Do we want it ? • How do we achieve it?
  • 3. 6 Elements • Information • Preparation • Conduct the RCA • Challenge what you know • Reporting • Success
  • 4. Step 1……Information • 3 forms • Collected information • Stored information • Information that employees accumulate over time
  • 5. Collected Information • Once an incident, an accident, an unwanted event has occurred how do we respond? • Information is critical! • How do we collect it? • This must be timely! • Misinformation • Someone must own it
  • 6. Triggers • A clear understanding of what your risk matrix declares as investigation trigger points is vital.
  • 7. Stored Information • Access your CMMS systems • How good is your information?? • Abbreviated or Generic descriptions • Electronic Data
  • 8. Information that employees accumulate • People have experience and knowledge to share. • Ensure that you have the right people in the room
  • 9. Step 2….Preparation • Room and amenities • People • Data, Reports • Visual stimuli • Who owns this task? • 7xP’s
  • 10. Step 3 ….Conduct the RCA • Get the right facilitator • Trained/untrained • Experienced/inexperienced • Good at it/ ? • Who doesn’t have a vested interest in the outcome • Should it be the subject matter expert?
  • 11. Facilitation • What are the attributes of a good facilitator? • Knows the process • Good listener • Keeps control of the group • Good communicator • Can remain neutral • Respects all contributions
  • 12. Step 4….Challenge your charts • How do you know you have “got it”? • Review your cause and effect chart • Critical challenge is the key • Be consistent • Be logical • Follow the rules • Have evidence to support the information
  • 13. Step 4….Challenge your Charts • Demand excellence in the cause and effect charts • The chart reflects what you know • It is an iterative process • A quality chart can be an effective learning tool • Be specific
  • 14. Excellence in Charting • A lot can be gained from making the effort in trying to achieve the best possible chart. • Will it ever be perfect?.......Rarely • Opportunities for improvements can however be identified. • At the end of the day the chart becomes the validation for the choices made regarding corrective actions.
  • 15. Step 5….Reporting • Effective communication is the key • Who should be able to read the report? • Time is valuable • Kiss principle
  • 16. Reporting ….Key elements • Clear defining statement • The cause and effect chart and also the cause and effect summary • Corrective actions assigned to critical causes…..ownership needs to be given and due dates set • Attendees, cost information, appendices
  • 17. Step 6…..Success • Easy to say….. hard to prove • Measure the impact of any changes that are implemented • Success breeds success • Advertise
  • 18. Attitude to Root Cause Analysis Positive or Negative??? Blame? Time? Previous experience? Lack of support?
  • 19. • LEARNING FROM THE INCIDENTS AND EVENTS THAT HAPPEN IS VITAL TO AN INDUSTRY TRYING TO MAKE IMPROVEMENTS. • THE NEED TO BE EFFECTIVE IN THE ART OF ROOT CAUSE ANALYSIS THEREFORE BECOMES IMPERATIVE.
  • 20. • TO BE SUCCESSFUL IN THIS PURSUIT REQUIRES … • THAT EFFECTIVE STRUCTURES EXIST THAT GATHER INFORMATION CONTINUALLY AND ALSO IMMEDIATELY AFTER AN EVENT • STRUCTURES THAT SUPPORT AND ALLOW SOUND PREPARATION TO OCCUR ARE IN PLACE • THAT COMPANIES TRAIN EMPLOYEES TO THE LEVEL THEY NEED TO BE EFFECTIVE FACILITATORS • THAT THE IMPLEMENTATION OF CORRECTIVE ACTIONS IS ASSURED AND THAT WE MEASURE THE IMPACT OF THOSE CHANGES.
  • 21. Acceptance • If you are willing to accept investigation reports that are less than what they should be ….then that is what you are most likely to get! • If it is worth doing then it is worth doing well!
  • 22. Codicil • Success in the performance of Root Cause Analysis will happen more consistently when clear process structures are in place and when positive management support is given to the process!
  • 23. Contact Details Jack Jager ARMS Reliability jjager@armsreliability.com