GET IT RIGHT:

5 CRITICAL
COMPONENTS
IN YOUR RCA
PROGRAM
INCIDENT INVESTIGATION
AN IMPROVEMENT
PROCESS
Contrary to popular belief, Root Cause Analysis (RCA) and Root
Cause Failure Analysis (RCFA) is not a silver bullet. Neither is
nding the root cause a realistic expectation - if there was only
one cause, then it would be found easily. But there are steps
you can take to ensure that an RCA delivers the best possible
outcomes for your organisation.
Think of root causes in the same way that Olympic athletes work
out their weaknesses over a four-year span - making marginal
gains and small improvements that lead to a better result at the
next Olympics. Root causes are typically the same. You should
address a number of known faults to reduce an unwanted effect
to an acceptable level.
The right RCA tool is immensely powerful, but it should be
used in the right context, with the right people, and the right
support. The following pages outline how to develop a robust
RCA program that will make your current and future RCA
investigations more successful.
Defne
SET YOUR OBJECTIVES
& PROCEDURES
With this in mind, the rst stage of RCA is all about preparation. This should
happen in the background, long before any incident occurs. The more prepared
you are now, the better the outcomes if an incident occurs down the track.
Here are the key steps in dening your RCA process.
1. SET YOUR OBJECTIVES
Create trigger points to instigate RCA. These triggers should reect whats
important to your business, and most organisations would typically include:
Safety
Environment
Revenue
Cost
Reputation
Frequency
With each of these, ask what an unacceptable measure would be. For example,
any reportable safety issue, any reportable release to atmosphere, loss of revenue
of more than $30,000, costs of more than $10,000, any event happening more than
four times, and so on. Now, youve got something to measure yourselves against.
DEFINE - SET YOUR OBJECTIVES & PROCEDURES
Every business should have a clearly dened
RCA plan in place. Just in case. After all, the
last thing you need if an incident has occurred
is a scramble to appoint a facilitator, or
gather the tools needed to collect evidence.
DEFINE - SET YOUR OBJECTIVES & PROCEDURES
Be honest with your triggers. Its easy to develop a set
of triggers that would be right to do, world class,
or sending the right message. However, its very rare
for edgling RCA processes to operate at world class
standards.
Your triggers should match your facilitation resources
- the experience of your facilitators, the availability of
stakeholders to participate in the investigations, and
the resources available to deliver the improvements.
By getting this balance right, you can accurately
monitor performance, incorporate it into a continuous
improvement process and - when youre ready for it -
youll be world class.
2. IDENTIFY ROLES AND
RESPONSIBILITIES
Who is expected to do what? Make it clear what you
expect of each member of the team.
At the same time, encourage the team to follow the
lead of the best players. These people - typically
technicians and operators - will arrive at the RCA
investigation armed with timelines, trends, operating
instructions and manuals. They are focused and ready
for action.
Document what you expect to be brought to an
investigation and who is responsible for bringing it.
The quality of your RCA investigation depends upon the
causes being supported by evidence - so develop your
processes to support the collection of good evidence,
which will then be used during the investigation.
As a nal point, encourage and support your
facilitators to halt investigations with no evidence.
Break up the meeting, and use the time to get those
responsible to collect the data required.
Be honest -
rene your
triggers to match
your capabilities.
DEFINE - SET YOUR OBJECTIVES & PROCEDURES
3. SELECT AND TRAIN
INVESTIGATORS
The key to a successful RCA is having a great leader.
So what makes a good facilitator?
Appoint someone who:
Recognises the strengths and abilities of
individual group members and helps them to feel
comfortable about sharing their hopes, concerns
and ideas
Supports the group, giving participants condence
in sharing and trying out new ideas
Values diversity and is sensitive to the different
needs and interests of group members, such as
gender, age, profession, education, economic and
social status
Leads by example through attitudes, approach and
actions
Balance the number of facilitators with the capabilities
of the organisation. It may be tempting to train as
many facilitators as your budget allows, particularly
given the high turnover rate (unfortunately, many
facilitators quit after being trained - which often
boils down to a poor selection of facilitator, quality of
training or insufcient support post-training).
Instead, appoint fewer facilitators but choose them
well. Ensure they get access to quality training from
experienced trainers, and have enough training
sessions to build their skills and condence. Post-
training, give them strong support, particularly in
initial investigations.
Its a bonus if
the facilitator
ts by function,
technical ability
or discipline, too.
By training fewer facilitators, you may have budget left over. Run a shorter
overview or participants course for the other people who will take part in RCA
investigations, such as operators, 1st line managers, technicians, drivers and so
on.
4. PREPARE THE GO-BAG
Your goal with RCA is to right something when it goes wrong. To do this, you need
to collect as much evidence as you can. Have a go-bag at the ready for the RCA
team to go out and collect evidence.
This bag should contain:
Tape measure
Camera
Evidence check sheet
Torch
Clipboard
Calipers
DEFINE - SET YOUR OBJECTIVES & PROCEDURES
Notebook
Magnifying glass
Generic PPE
Pens, pencils, highlighters
Permanent Marker
Clear plastic bags (for evidence)
Measure
COLLECT DATA & ASSESS
ITS SIGNIFICANCE
MEASURE - COLLECT DATA AND ASSESS ITS SIGNIFICANCE
Data collection shouldnt just scrape the
surface. Members of the RCA team should
know their responsibilities and head straight
out to collect the data needed for a thorough
investigation.
Dont be tempted by a quick x
When an incident occurs in the workplace, your rst thoughts are, What are we
going to do? and What do we need to know?
As a starting point, you need to know how big the incident is - that is, how far
from normal, how signicant? This will tell you how much effort to put into the
solution. To nd out how big it is, you go and measure it. Then, you look for
immediate solutions, backed up by a few more measurements.
You implement the solutions, the status quo is restored,
its a job well done. Right?
Not quite.
To future-proof a x, you need more than start-up data
To ensure that the incident does not reoccur, you need more than just surface
data. Digging a little deeper doesnt take much longer - but it does take
commitment.
Youve set up your roles, responsibilities and procedures; and your go-bag is at
the ready. Use a data collection checklist to guide the collection, and appoint the
person/s to go out and collect it.
MEASURE - COLLECT DATA AND ASSESS ITS SIGNIFICANCE
A typical checklist looks like this:
Preserve evidence at the scene
Photographs - work with operations to try and get
photographs prior to and during the incident
Retain the failed components, if possible
Interview witnesses
Initiate data mapping
CMMS data
Immediate vibration levels
Immediate process conditions
Computer trending
Review documentation
Condition monitoring history
Lubrication history
Management of change history
Process data sheets
Plant line diagrams
Procedures and manuals
Conduct tests or recreations, particularly if there is
minimal or no evidence to collect. In keeping with
your safe practices or under Management of Change
procedures, plan the start-up or steady state process
with a view to capturing key events or measurements.
Your initial data collection will invariably lead you to
some conclusions or at least hypotheses. These can be
tested if circumstance permits.
Analyse
EMBED YOUR CHOSEN
ANALYSIS METHOD
Trust in the
process.
The big picture
will take care of
itself.
CONDUCT THE ROOT CAUSE ANALYSIS
ANALYSE - EMBED YOUR CHOSEN ANALYSIS METHOD
With the evidence collected, your RCA team is
ready to start analysing the data, and arriving
at potential solutions. This component relies
on a no-holes-barred attitude, where all ideas
are captured as you journey towards the x.
Dene the problem
Devote about a quarter of the RCA investigation to dening the problem. The more
clear and precise this denition is, the quicker the cause and effect chart will be
built.
Use post-it notes in the denition as well as the chart building. Its surprising how
often one of the signicant items becomes the problem itself.
At this point, the facilitator should encourage the participants to get the
storytelling out of their system. While they are speaking, the facilitator should be
collecting causes on post-it notes and parking them next to the chart or in the
holding area for the rst pass review.
Identify evidenced causes and effects
The goal here is to create a common reality on
your cause and effect chart. Starting this process
can seem scary, particularly for those who are
new to the RCA process. These people are staring
at a large sheet of brown paper with a primary
effect on it, and a blank post-it note in their hand.
They have no idea where the chart will go.
To help maintain the ow, drive the caused by case
and go back and repeat the causal chain when it starts
to dry up. Keep demanding evidence, and trust that the
participants will know the difference between actions
and conditions. Write the causes verbatim - curses
and all - to keep things rolling and to really capture the
meaning. Language can always be cleaned up for the
nal chart.
Successful RCAs often move beyond the brown paper.
Walls and windows get covered in notes to maintain
the ow. Participants will have the mental capacity to
join in the lines that arent there; however, if it looks
like its getting untidy then take a short break and tidy
it up.
Identify effective solutions
This is the most creative - and enjoyable - part of the
process. While the subjects of most investigations are
very serious, the RCA itself shouldnt be too sombre.
Rather, it should be professional - and this relies on
creativity. Within the wacky solutions are clever ones
waiting to be discovered.
Dont constrain yourself to one solution per cause and
pay extra attention to those conditions you perceive to
be the norm.
Select the best solutions
Use your organisations solution criteria to the best
effect and avoid turning it into a form-lling exercise.
For example, passing the problem on to someone
outside the team is a sure-re way of not getting it
implemented. Instead, use a solution assessment
process to prioritise similar solutions - which also
helps with team buy-in.
Improve
SET STANDARDS
FOR REPORTS
CONDUCT THE ROOT CAUSE ANALYSIS
IMPROVE - SET STANDARDS FOR REPORTS
This is what its all about, right? Improving
business processes so that incidents are less
likely to occur, and triggers are less likely to
be set off. Here are the proven ways to ensure
the hard work from the RCA gets put to
good use.
Write a meaningful report
Most people will read the Problem Denition and Executive Summary, and only
skim through the solutions. They are busy, and have other priorities.
With this in mind, write a strong and concise Executive Summary. Cover the key
causal paths leading to the root causes, and the number of solutions identied
and implemented. This demonstrates that youve got a back-up plan in case those
selected do not deliver the full benets. Plus, outline timeframes and estimated
costs.
Develop proposals
Every business does this differently. Whatever the process in your organisation,
keep in mind that youve already compiled the whys and wherefores - use the
power of cut and paste when applying for funding to pay for the solutions identied
in the RCA. After all, you have already created an incident report (which should
be written in such a way that allows for cutting and pasting into other systems or
processes with minimum effort).
To implement the best solutions and actions, manage
a tracking system
Again, the process for this step is specic to individual
organisations. What matters is that you have a
process. The biggest single reason for RCA failure is
when the solutions arent implemented - which comes
down to a lack of process.
The most successful RCA programs have in-depth
tracking systems in place to ensure solutions, action
items and whole RCAs are tracked and shared with
others in the organisation. There are many way to
accomplish this using databases and tools which allow
managers to view a company-wide RCA snapshot
showing outstanding actions and solutions that have
or have not been implemented. A good RCA software
tool will also have the capacity to share results
easily across the organisation and track changes and
comments relating to RCA charts, solutions or reports.
Share key ndings
Youve put a lot of work into the investigation. Do
the work once, and use it many times. Whether you
use the cause and effect chart itself, the Executive
Summary, the photos and trends, or any other data
collected - there are many opportunities to put the
investigations ndings to work in other areas of the
business.
IMPROVE - SET STANDARDS FOR REPORTS
Control
MEASURE THE SUCCESS
OF YOUR PROGRAM
CONTROL - MEASURE THE SUCCESS OF YOUR PROGRAM
To obtain ongoing support for your RCA
program, you need to provide the proof that it
works. You need quantiable, demonstrable
measures of outcomes. There are a range of
tools and methods that you can use in this step.
Create a business process map
Having read through the report, create a process map to help visualise and control
the outcomes of the RCA process. This is important - given the investment youve
made in people and resources to get this far. Have copies of the process map
available so that if the effectiveness of the program is challenged, you can easily
identify which parts of the process are failing.
Create leader standard work
The RCA champion should undertake daily, weekly or monthly tasks to help
support the process; and the champions manager should have similar goals. This
leader standard work leads to better performance in key players.
Some great examples of this work include:
Action tracking system - this is a leading measure
of your process. If the actions are getting
implemented you can be more condent that
improvements are being made.
RCA process critiques - look at things like the
number of actions versus conditions, with a good
chart exhibiting more conditions than actions (as
there are always a number of conditions in place for
any given action to cause an effect).
Adherence to the business process map - this is a
lagging measure. By selecting areas of the process
supported by documentation, audit from a quality
perspective. Alternatively, talk with key players in
the process to assess their understanding of their
responsibilities.
Performance against the triggers - another lagging
measure. Use your CMMS system to determine
costs and frequency rates; or your safety and
environmental systems for rates and severities.
Cross reference with the number of RCAs held
and keep track of the performance of these
RCAs to highlight savings from a reduction in
recurring failures, near misses, safety incidents,
and so on. You may even be able to tout these
accomplishments at your annual performance
review or if you are interviewing for a new position.
CONCLUSION
In this ebook, we looked at 5 critical components in building a
successful RCA program in your organisation: Dene, Measure,
Analyse, Improve, Control.
These components form the foundation of ongoing, iterative
improvements that lead to the main game that is, reducing or
eliminating unwanted incidents from your workplace.
Dene, Measure, Analyse, Improve, Control (DMAIC) is a
recognised, data-driven improvement cycle that will help you
improve business processes, and is a proven framework for
application in many different settings.
PUBLIC TRAINING COURSES
We hold public training courses in cities throughout the world. Learn
more about our 2 Day Facilitators Course
ONSITE TRAINING
All our training courses are available for delivery onsite at your
facility or a training venue of your choice. If you choose to book onsite
training, we highly recommend doing the 3 day Facilitator course which
offers students the opportunity to work on a real life problem from their
workplace under the guidance of one of our experienced trainers.

ONSITE TRAINING BENEFITS
Cost effective for a larger group size
Avoid travel expenses for attendees
Reduced time away from work for students
Schedule convenience - working around your availability and
schedule
Personalisation and customisation for certain courses to make it
relevant for students
Get all team members speaking a common RCA language
FACILITATION SERVICES
Sometimes there will be an issue of sensitivity that requires greater
objectivity and facilitation skills in nding out the root cause and
developing solutions. Click to learn how we can help.
Learn more about the Apollo Root Cause Analysis
TM

method at www.apollorootcause.com
About ARMS Reliability
ARMS Reliability is a service, software, and training organisation
providing a one stop shop for Root Cause Analysis, as well as Reliability
Engineering, RAMS, and Maintenance Optimisation for both new and
existing projects.
Since 1997, ARMS Reliability has been an authorised training provider of
the Apollo Root Cause Analysis
TM
methodology. In 2012, our agreement
went global and ARMS Reliability now provides RCA training, software, and
services throughout the world.
Apollo Root Cause Analysis
TM
Method
The Apollo Root Cause Analysis
TM
Method is an intuitive principle-based
root cause analysis process that:
Easily embraces all perspectives
Eliminates the usual frustration and arguments
Creates a common reality of your problem
Ensures buy-in from all stakeholders
Integrates a user friendly software application to create evidence -
based cause & effect charts
For more information on how ARMS Reliability can help, please contact us
at the ofce location nearest you (details below).
You can also make an enquiry on www.apollorootcause.com
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