Page 13 - Root Cause Failure Analysis

4 Root Cause Failure Analysis

deviation modes. These tables list the common symptoms of machine and process-
related problems and identify the probable cause(s).

PURPOSE OF THE ANALYSIS
The purpose of RCFA is to resolve problems that affect plant performance. It should
not be an attempt to& blame for the incident. This must be clearly understood by the
investigating team and those involved in the process.
Understanding that the investigation is not an attempt to fix blame is important for
two reasons. First, the investigating team must understand that the real benefit of this
analytical methodology is plant improvement. Second, those involved in the incident
generally will adopt a self-preservation attitude and assume that the investigation is
intended to find and punish the person or persons responsible for the incident. There-
fore, it is important for the investigators to allay this fear and replace it with the posi-
tive team effort required to resolve the problem.

EFFECTIVE USE OF THE ANALYSIS
Effective use of RCFA requires discipline and consistency. Each investigation must be
thorough and each of the steps defined in this manual must be followed.

Perhaps the most difficult part of the analysis is separating fact from fiction. Human
nature dictates that everyone involved in an event or incident that requires a RCFA is
conditioned by his or her experience. The natural tendency of those involved is to fil-
ter input data based on this conditioning. This includes the investigator. However,
often such preconceived ideas and perceptions destroy the effectiveness of RCFA.

It is important for the investigator or investigating team to put aside its perceptions,
base the analysis on pure fact, and not assume anything. Any assumptions that enter
the analysis process through interviews and other data-gathering processes should be
clearly stated. Assumptions that cannot be confirmed or proven must be discarded.

PERSONNEL REQUIREMENTS

The personnel required to properly evaluate an event using RCFA can be quite sub-
stantial. Therefore, this analysis should be limited to cases that truly justify the expen-
diture. Many of the costs of performing an investigation and acting on its
recommendations are hidden but nonetheless are real. Even a simple analysis requires
an investigator assigned to the project until it is resolved. In addition, the analysis
requires the involvement of all plant personnel directly or indirectly involved in the
incident. The investigator generally must conduct numerous interviews. In addition,
many documents must be gathered and reviewed to extract the relevant information.