The Top Six Reasons Why RCFA Initiatives Fail
There are many reasons why organizations expend precious resources to train their people in the use of RCFA only to realize very little gain after a brief burst of activity. Briefly, here are the top reasons that RCFA initiatives fail.
1. RCFA is treated as a tool when it is really a process
Having a tool box full of shiny new tools and knowing how to use a few of them is not the same as having that car engine sitting in the corner overhauled. There are many RCFA tools available. However, most of the best practice RCFA processes consist of many steps, often the same steps, albeit sometimes grouped differently. The RCFA process starts with a trigger event or events and only ends when the corrective actions are implemented and the proposed solution has been measurably verified as being effective. Learn the tools, but implement an RCFA process if you wish to be successful. You don’t overhaul an engine without a repair manual do you?
2. One tool fits all problems approach.
That top-of-the-line gold-plated, laser-etched, flex ratcheting wrench in that tool box – no matter what the quality and no matter how skillfully you employ it – is not going to perform well when the task requires a screw driver. There are in excess of 100 discrete, documented RCFA tools available, and although they can be grouped into six general categories, they are not equally effective for solving all problems. And even if you have a “hammer” RCFA tool and a “nail” problem, it is inefficient and often ineffective to use a sledgehammer to drive a carpet tack. Problems have different fundamental characteristics that make them more readily solved with certain tools. Take the time to learn a few tools and when to apply them appropriately for effective and efficient problem solving.
3. Inadequate failure analysis and inaccurate information – fixing the wrong failure
Failure analysis is not root cause analysis. Failure analysis might tell you that a bearing failed due to axial overload, but it will not tell you what caused the axial overload. And the roots of that “what” may be several layers deep. Conversely, if you are looking for a lubrication failure root cause when the true failure mode was axial overload, you are unlikely to find an effective solution. The same applies if you fail to consistently preserve the evidence at the scene of a failure. You are reduced to memory and guessing about what happened and you may never find the root cause.
There are rare occasions where there is incomplete or insufficient information available to positively identify the root cause(s), but because of the severity of the event, you must identify the most likely cause(s) and take corrective action. For these events there are special tools and methods that can be applied. Again these are a special case. Avoid the general pitfall of solving the wrong failure mode by learning a few simple methods for performing failure analysis and be aware of the available resources. Develop procedures to obtain, protect and preserve evidence for effective investigation. Again, don’t fix the wrong failure mode! Millions of dollars and lives have been put at risk from “solving” the wrong problem.
4. Too many recommendations
Having too many corrective action recommendations is both a cause and an effect. Too many, often vague, recommendations are often the equivalent of not admitting “I really don’t know why it failed.” They are the effect of the absence or failure of one or more of the steps in your RCFA process. Or it comes from using either the wrong tool, or a right tool incorrectly. Implement a good RCFA process and learn to correctly use the best tool to solve the problem .
If you find and address the true root cause(s) but you bury the critical few corrective actions (the real fix) in a poorly designed wish list, it has several ill effects: resources are diluted, implementation is delayed, and you just may never get around to implementing the critical few. Part of an effective RCFA process is identifying the best alternatives from those critical few that can resolve the problem and prevent reoccurrence. Then opportunities identified to further improve can be executed based on their own merits. Do not confuse the essentials with a wish list. A good corrective action evaluation step in your RCFA process will prevent this from happening to you.
5. Poor execution
It is sad to be called to a site to perform an RCFA for a second failure, when the corrective actions from the RCFA for the first failure had not been implemented. It happens all too often. In fact, execution is universally recognized as a major weaknesses of U.S. industry. The objective of an RCFA is not a pretty report. The objective is auditable results - problem solved! How can a company fail to implement solutions after the significant expenditure of resources used to determine the cause? The answer is “it is easier than you think.” The most prevalent reasons are: too many RCFAs, too many recommendations, and no process steps for assuring follow up.
The second most prevalent reason is too many recommendations, as previously mentioned. You simply overload the system with the “want to haves” and can’t complete the “need to haves”.
The third reason is that there is no clear RCFA process step for identifying and assigning resources and accountability. And things just don’t get done. An effective RCFA process has steps to ensure that the best actions are picked, resources are assigned, priorities aligned, and completion occurs on time, every time.
6. Too many RCFAs
You have a new toy called RCFA. Of course you want to play with it often. After all, why else did someone spend a lot of money to send you to school? They want to see some action. So you apply it to every problem that comes along. You don’t consider if fixing this problem is a worthy use of the RCFA resources, let alone the resources to implement the corrective actions. The initial result is a lot of RCFAs and corrective actions. Then you start falling behind in resources to perform the RCFAs. Then you realize that you don’t have nearly adequate resources to implement all of those corrective actions. Then comes the collapse. Time for another program of the month.
RCFA is a business process. It involves expenditures of resources and expected returns on investment. Your RCFA process must have a clear process step to trigger when an RCFA will be performed, when it will not, and how many resources you can expend to still make a good return on investment. Absent this, the process rapidly breaks down from a resource overload and poor economics. You must decide which problems merit solving now, which merit later, and which do not merit any appreciable effort at all. You do have RCFA triggers, don’t you?
Design and implement an effective RCFA process that avoids these common pitfalls and see your production, quality, yield, safety, and cost performance improve.
Sam McNair is a senior consultant with Life Cycle Engineering (LCE). A Professional Engineer and Certified Maintenance and Reliability Professional, Sam has more than 32 years of experience in discrete manufacturing, chemical process industries, mining, machine processes, automation, aviation, construction, and utilities. Sam specializes in reliability engineering with a focus on the integration of maintenance and manufacturing functions. You can reach Sam at smcnair@LCE.com.
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