Lets get one thing out on the table before we get started; perfection is unobtainable.
No matter how much we try, there will always be an unlimited capacity for personal improvement, for team improvement…so much more out there.   When we can accept this idea, the future becomes pretty exciting.

What does any of this have to do with Root Cause Failure Analysis (RCFA) you may ask?  I think that RCFA provides us with that opportunity for self-improvement; an excuse to get a little bit smarter, individually and as a team.

root cause analysis fish bone rcfa

The reason I bring this up is that as I travel around and ask people about their problem solving efforts, almost everyone understands the concept and can chunk out a fishbone diagram easily enough, but it is when I ask the question “when do you take the time to perform an RCFA?” that things get a little sideways.  I generally get some non-specific answer like “on all of the critical ones” or “for the really important issues.”  The problem is that I don’t really know what that means, and neither do you.

When to preform RFCA?

Of course when a huge catastrophic failure occurs and the old man is yelling at us, screaming “never again!” we will pull out our worksheet and slap together an analysis.  What about the times in between?  What about next week?  I think we are all missing out on an incredible opportunity to learn when we fail to make RCFA a habit.   I propose that we stop performing RCFA on the “critical” problems, and start making RCFA; start making continual learning, a habit.

What do I mean by making this a habit?  I mean we must set aside a portion of our time each week for problem solving.  And what if there are no problems you may ask? If we consider opportunities rather than problems there virtually exists an unlimited collection of ideas to go after.  This is where the idea of RCFA triggers comes into play.

RCFA Triggers

Triggers determine when we (as a team) will take action.   These are the rules we react to.  We need to move beyond addressing the “critical ones” or the “really important ones” to something that we can get our hands around.   They define those situations where we will take action and seize the opportunity to learn.

Here are a few tips regarding trigger points:

  • Trigger points are fluid and constantly changing.  They are set to drive a certain amount of activity per month.

Note: If we set the trigger point at “any delay > 60 minutes” and we have 25 events this month, we have set the trigger too low.  We will not have time to study 25 problems, find 25 root causes, and come up with 25 action plans to correct them.  We have to shoot higher.  For now, what does it look like if we set our triggers to “any event > 240 minutes?”  If we get something like 2 or 3 events per month that we can actually solve, we are on the right track.   You set the trigger to obtain a the desired level of learning and improvement.  If we go an entire month with no RCFA, time to change the triggers.

  • Trigger points are crystal clear and drive accountability.   They almost always contain a number.  If we have a trigger point, in writing of course, that states, “address the critical failures” I don’t know how you can hold a team accountable to that.
  • Trigger points always connect back to those things that are really important to us:
    • Product Quality
    • Cost Control
    • Safety and Environmental Performance
    • Throughput or Customer Delivery Capability
    • Employee Morale

Implementing RFCA Triggers

This is our job as leaders, to set the pace and to provide our people with opportunities to improve.  Trigger points are the physical manifestation of this idea.  They define when our people will act, and to be clear when I say “our people” I mean all of them.   Everyone needs an opportunity to learn, an opportunity for self-improvement, to be part of the winning team.   RCFA done by a small group of experts huddled in a back office solves little.  Drive everyone in your organization to action using RCFA triggers – especially those people on the front lines where the real action happens.

Once convince them to act, anything is possible.   Every RCFA exercise we do is an opportunity to learn, to make a previous problem a new skill set.   Lets be honest, you are not going to out perform your competitors by purchasing technology or equipment.  They shop in the same stores that you shop in.

Building a team of people, who can identify problems and solve them, as a habit, is something special and unique that cannot be purchased.  It is core skill that may be duplicated, but can never be taken away.

5 Responses to RCFA = An Opportunity to Learn

  1. Regina Cooper says:

    Wow! Such a simple concept and so profound at the same time. I will definitely be sharing this with the folks at work tomorrow.

  2. Thomas Nounezi says:

    Hi Mike,

    This is a very inspiring article. From this I would definitely say that,reliability is the philosophy of engineering. I love the way you make it practical so that it might be implemented and deliver measurable results’

    Still have a lot to say about this article


  3. Golden Chihumbiri says:

    This is great. If properly taken on board can yield wonders. Thanks for the information.

  4. Sonny nguyen says:

    Why is RCFA such a simple process but so hard to implement?
    I would say 70% of RCFA failed to achieve correct solution & permanently eliminate problem.

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