Establish a Clear Trigger Mechanism

Foundation

After the sponsorship and training are in place and resourcing is defined, there is still no guarantee that any investigations will get done. (See the end of the article for links to the blogs about these needs) This is where the definition of insanity applies – “doing the same thing over and over – and expecting different results” – so something must change. If there is no reason to perform an investigation, then things will continue to happen as they always have. [Read more…]

A Plan to Provide Program Resources

Who

Sometimes we get so used to managing without things that it becomes the way things are done. An astronaut giving a presentation at a conference I attended referred to this as “normalization of deviance.” In other words, we get so used to the way things are, that either right or wrong, they become the norm! Unfortunately, the obvious is many times ignored – because it is obvious. If you intend to have a sustainable Root Cause Analysis program, then there are things that must be done. People must be trained, reports must be written, analyses must be performed, and progress must be tracked and reported. Until a program becomes self-sustainable, it must continue to be driven. [Read more…]

Committed Sponsor

As with other programs, an RCA program needs to be driven from the top and supported through all levels of the organization. This includes upper management, supervision or mid-management, and those on the front line doing the [Read more…]

This is the first in a nine-part series of articles. This first one will lay out what I think are essential characteristics of an RCA program. The other articles will follow up on each of the items in some detail.

[Read more…]

RCA Templates Can Be Used

In my last article,  RCA Templates Use or not?, I discussed templates and suggested that while beneficial for many things, they may not provide as much value for those doing RCA’s.  This is because for any specific effect, the variability in the cause tree is significant and difficult to predict.  This doesn’t mean that there are no options to utilize templates to help speed up the process, but perhaps not in the way that people might be used to. [Read more…]

The problem

Recently there was a power outage, that caused approximately 2,000 homes to lose power during a very cold day.  The paper headline read, “All-day outage caused by worn wiring”.

This seems like a reasonable comment and probably like many other newspaper headlines also seems to go a long way to explain what caused the 2,000 homes and business to lose power for 5 ½ hours, and the 300 that lost power for a total of 11 ½ hours. [Read more…]

Basic Reliability Definition

Occasionally, I like to step back and reflect on reliability in basic terms.

In that spirit, the basic premise of reliability is usually stated as “The probability that an item will perform a required function, without failure, under stated conditions, for a stated period of time.”

To use the reliability equation, the definition of failure must be defined, so you can tell if your equipment has indeed failed.  This way you can include it in the MTBF (Mean Time Between Failure) calculation.

After you have defined a failure and recorded them appropriately, you can plug the numbers into the reliability equation, R = e ^-(λ*t)  where λ is the failure rate which is defined as λ= 1/MTBF and come up with an objective value for the reliability. [Read more…]