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You are here: Home / Archives for Articles / on Systems Thinking

on Systems Thinking

A listing in reverse chronological order of articles by:



  • JD Solomon — Communicating with FINESSE series

  • Robert (Bob) J. Latino — The RCA series

by Robert (Bob) J. Latino Leave a Comment

A Personal History of the Art and Science of Reliability

A Personal History of the Art and Science of Reliability

By Charles J. Latino

Foreword By Robert J. Latino: I wanted to dust off this impactful paper written by my father before he passed, and ask for your opinions about how far we have really come in the field of Reliability Engineering, based on your experience?

You are the ones that carry on the Reliability torch today. Based on Charles’ reflections about his Reliability career, how far has your facility come and what hurdles do you still face? [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Corporate Memory: Capturing Employee Experience Before They Retire in Hawaii!

Corporate Memory: Capturing Employee Experience Before They Retire in Hawaii!

Why do our Generally Accepted Accounting Principles (GAAP) dictate that equipment is an asset and our employees are liabilities? Don’t our executives always tell us ‘our people are our greatest assets?’ How come our financials don’t support their assertion? [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Root Cause Analysis: Investment or Expense?

Root Cause Analysis: Investment or Expense?

In times that promise to be a financial challenge for many corporations, we must make decisions as to where to invest our scarce dollars and where to cut from our current operations.  When faced with these decisions, we must be realistic and pragmatic about how short-term decisions impact our long-term goals.  Yes, when times are hard, how well positioned will we be when the economy picks up (and keep the faith, it will pick up)? [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Top Reason RCA Won’t Work…Where I Work!

Top Reason RCA Won’t Work…Where I Work!

Does this paradigm apply at your workplace?:

“We NEVER seem to have the time and budget to do things right, but we ALWAYS seem to have the time and budget to do them again!”

While this article was written for manufacturing many years ago, is it any less applicable today, in any industry?

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Human Factors in Design Error?

Human Factors in Design Error?

As I headed to work this morning in my Chevy Silverado Truck, this message appeared on my dash console.

As if there aren’t enough distractions these days built into our vehicles (i.e. – GPS, telephones, use of our various electronic devices, iTunes, Email, Text, etc.), do we really need a warning message to read while driving, that is telling us to focus on the road?  [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Panning for Gold: Analyzing Chronic Failures

Panning for Gold: Analyzing Chronic Failures

The majority of times that a Root Cause Analysis (RCA) is ‘required’ is often due to some type of threshold of pain being met. Someone is hurt, we’ve had an environmental excursion, we lost a lot of money in throughput or equipment damage, we violated some regulation, etc. Essentially, when the ‘suits’ show up, something bad has happened and we will do an RCA whether we like it or not. This is the basis of ‘reactive RCA’, where we respond to an incident that has already met certain defined requirements, often called ‘triggers’. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Root Cause Analysis: The Justification Game

Root Cause Analysis: The Justification Game

In last month’s introductory article, we discussed some of the barriers to selling not only the concept of Root Cause Analysis (RCA) but also the recommendations generated as a result of these analyses. We also laid the framework for making better predictions by generating and accessing better data—namely predicting our Mean Time between Failure (MTBF) and Mean Time to Restore (MTTR) earlier and, therefore, implementing a fix faster.

Given this background, let’s explore how we can now justify conducting a RCA and implementing the recommendations as a result of the analysis. By and far, conducting a true RCA is viewed as luxury not a necessity. Think about the objections we hear when we offer the idea of gathering RCA teams. What follows is a list of common objections to RCA accompanied by rational justifications that any manager can employ. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Viewing a Hospital as a System: A Reliability Perspective

Viewing a Hospital as a System: A Reliability Perspective

Veteran professionals in the Reliability field view every business as a system. All systems have 1) inputs, 2) a transformation of those inputs in some form or fashion and 3) outputs. Just think about that for a minute; think about your schools, banks, manufacturing plants, small businesses…they are all systems. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Don’t Healthcare Workers Fatigue Like Anyone Else?

Don’t Healthcare Workers Fatigue Like Anyone Else?

Fatigue regulations and guidelines have been long established in aviation, transportation and the nuclear industries (just to name a few). The science is solid supporting the correlation between human fatigue, and poor decision-making/poor responsiveness.

So why aren’t such fatigue regulations required in healthcare as a matter of standard like in other industries? Is there something different about the physiology and/or anatomy of a healthcare worker versus a pilot, truck/bus driver or nuclear operator? [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino 1 Comment

‘De-Flate Gate’ & RCA

‘De-Flate Gate’ & RCA

[Editor: originally posted Jan 23, 2015]

For those that are football enthusiasts and looking forward to the upcoming Superbowl, we are intrigued by the recent scandal in the NFL. The scandal involves the allegation that somehow the New England Patriots’ footballs used in the game against the Colts last week, were deflated and did not meet the minimum PSI requirements of the NFL to be ‘legal’ for game use. The allegation involves the possible tampering of the NE footballs to attain that ‘deflated’ state. Conceivably this would make it more desirable to throw and catch in the conditions of the game. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

What’s Wrong With A Questioning Attitude?

What’s Wrong With A Questioning Attitude?

What’s Wrong With A Questioning Attitude?

As a key attribute of High Reliability Organizations (HRO), what’s wrong with a questioning attitude? One the surface it would seem like this is something we would encourage all of our employees to do. Certainly they ask such questions because they seek legitimate answers, right? We wouldn’t want to discourage that behavior, would we? [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino 1 Comment

The Top 11 Signs of a Shallow Cause Analysis (SCA)

The Top 11 Signs of a Shallow Cause Analysis (SCA)

We might be doing a Shallow Cause Analysis (SCA) if … [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino 2 Comments

Understanding the Principles of Reliability

Understanding the Principles of Reliability

The Reliability Approach… “Something understood and practiced by engineers and highly specialized technicians,” is apt to be the first reaction of the line supervisor, “certainly not an area where I can be expected to become involved.” Although this reaction is understandable; nothing is farther from reality. Let’s explore why in this paper. Please read until the surprising end (I know it is lengthy) and you will find that these Reliability Principles apply to any industry, any where at any time! [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Turning RCA into ROI in Healthcare? – Part 3 – Unknown Benefit…Intellectual Capital

Turning RCA into ROI in Healthcare? – Part 3 – Unknown Benefit…Intellectual Capital

The Greatest Benefit of RCA is Generally an Unknown…Intellectual Capital

Because business is measured based on credits and debits, this is how we must express effectiveness of initiatives in reality. However, the physical costs are NOT the greatest benefit derived from RCA when done properly. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

by Robert (Bob) J. Latino Leave a Comment

Turning RCA into ROI in Healthcare? – Part 2 – A Case Study

Turning RCA into ROI in Healthcare? – Part 2 – A Case Study

Measuring the Effectiveness of RCA in an Organization

Understanding now what perspective the executives have of an RCA initiative, how should RCA efforts be designed to report their results to the “C” level? Many would like to say “to express the results in a manner that demonstrates an increase in patient safety”. In a perfect world that would be nice, but what single metric expresses an increase in patient safety? Is there a line item on the Income Statement (IS) or Balance Sheet (BS) labeled “patient safety”? Not likely. [Read more…]

Filed Under: Articles, on Maintenance Reliability, The RCA

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