Management Perspective Root Cause Analysis, as a maintenance troubleshooting method that would anticipate and control the systemic causes of maintenance problems, has occupied the thinking and planning of maintenance professionals for decades.
Implicit in maintenance troubleshooting activity is a fundamental understanding of the systems functioning within equipment. With that understanding of the principles and the sequential process involved, maintenance professionals can develop and apply effective step-by-step maintenance troubleshooting procedures. However, once the equipment operator and the organization become part of the equation, the process of maintenance troubleshooting becomes less defined and less effective without appropriate methods and tools.
This article is intended to provide maintenance professionals with an understanding of the maintenance troubleshooting capabilities of the REASON Root Cause Analysis method. Detailed are a brief history, examples of application, and an explanation of how REASON Root Cause analysis works both to view the big picture, and to pinpoint the systemic root causes to maintenance problems that exist within the organization.
Root Cause Analysis Put To The Test
Root cause analysis theory and REASON maintenance troubleshooting method began the long and detailed process of validation in the early 1980’s. Many national organizations participated in the Beta testing, including Texas Instruments, Brown and Root, Delta USA, and Marathon LeTourneau. The testing environments ranged from the manufacture of computer chips to the pouring of molten steel.
In one testing company, the maintenance and engineering director placed the REASON Root Cause Analysis troubleshooting method in the hands of maintenance men and tool pushers on the company’s drilling rigs.
Every time something threatened to stop the drilling bit, on any one of their drilling rigs across the nation, an analysis of the threat was created with REASON and sent to their corporate offices.
Literally hundreds of operations improvements were quickly achieved throughout the inventory of rigs through this quick and efficient means.
We found out that these maintenance professionals and tool pushers on the rigs liked the REASON Root Cause Analysis no nonsense, straightforward approach.
They liked not being required to go out on a limb with guesses, when they didnt have an answer. They liked being able to check their information for accuracy at each step . . . on their own.
When we asked them for ideas for improving the REASON Root Cause Analysis Software, we found out right away that what they liked most about REASON was that it provided strong guidance, that it tapped into their experience, but did not rely upon them to have special insights and perceptions, or to make assumptions that might generate expensive projects based upon their assumptions.
These professionals were interested in an efficient and effective maintenance root cause analysis troubleshooting system. As the method has been developed to provide additional reporting and analyzing capabilities over the years, those early comments have guided us to assure that REASON Root Cause Analysis Software has remained a practical tool for maintenance troubleshooting and root cause analysis.
Later the maintenance and engineering director brought the company’s maintenance crews and tool pushers to their corporate training center for training in REASON Root Cause Analysis Maintenance Troubleshooting. He commented that REASON had transformed his maintenance crews into diagnosticians.
Troubleshooting Root Causes of A Multimillion Dollar Problem
One of the problems upon which REASON was used during early testing was experienced by a leading oil drilling company that was suffering a rash of premature bearing failures within a large inventory of new diesel engines. To provide a constant level of power to the drilling bit, the company had installed four new diesel engines on each of their portable drilling rigs.
The engines were setup in a computerized, slave/master configuration to provide constant power regardless of the conditions encountered by the bit during drilling. This inventory of new diesel engines for over 60 portable drilling rigs represented a major investment. Each engine was state of the art for the early eighties, with a full array of protective devices including high and low temperature, high and low pressure, and autoclave units that centrifugally forced any metal particles in the engine’s oil against a magnetic screen that triggered alarms and controlled shut downs. Oil testing and usual safeguards had not stopped the problem nor revealed its source.
A team of engineers from the engine manufacturer flew to the drilling company’s headquarters, where one Saturday morning the company’s maintenance personnel and the team of engineers produced a causal model with the REASON Root Cause Analysis method and tools. From that exercise came visibility of many controllable root causes within both the company and the manufacturer.
The list of root causes read like a design for failure: sensing devices that were so sensitive that alarms were continually sounding and shutting down the rig, alarm systems being disconnected to keep the rig on line, failure of the manufacturer to provide key maintenance change bulletins to the company, and numerous other root causes.
Root cause analysis details from that maintenance study were soon to combine with data from other loss events to reveal a critical risk factor that existed broadly within the company, and that was producing losses routinely throughout the company’s operations. Within a three-week period, two other significant loss events occurred in that company, and were analyzed with REASON Root Cause Analysis. Because the company did not yet view such data as company knowledge to be managed as a resource, the information from the loss sites would normally never have come together for analysis. The cases appeared to be different problems, and would usually have been treated as such. One event involved the failure of a new man lift when the lift cable failed; the other involved a fatality when the stabilizers on a mobile crane shifted in the soil and caused a steel structure that it was supporting to swing against a worker.
Pervasive Root Causes
Because REASON Root Cause Analysis was being tested under a development agreement, the two other loss events were also investigated and analyzed with REASON. The three models that were produced by the root cause analysis process found their way to the Operations Director who had insisted upon being personally involved in the test.
Although each root cause analysis had produced several different root causes and prevention options, the Operations Director immediately perceived within the three REASON models one root cause that was shared in common between the seemingly dissimilar loss events: an equipment maintenance problem, a field design problem, and a safety problem. Under normal circumstances, the data from these different cases would have come together only in a loss report column. But with the visibility of all root causes provided by the unique REASON Root Cause Analysis data, the Operations Director was able to correct that one shared root cause with a phone call to the corporate director of purchasing.
He was instructed that in the future no purchasing clerk would have the authority to substitute a product that was equal to or better than without a criterion for comparison, or a clearance from the requisitioner. It seems that three different purchasing agents in three different offices elected to substitute better than products that resulted in losses to the company: a premature fatigue failure of a wire rope cable on a man lift that achieved faster acceleration by reducing the diameter of a pulley wheel, the rental of a bigger and heavier duty mobile crane with more lifting capacity that sank into the soil at a critical time, and more efficient oil filters that worked so well that they filtered out essential synthetic lubricants from the oil of those new diesel engines.
Systemic Causes: The Primary Reason We Conduct Root Cause Analyses
Root cause analysis should find all of the systemic causes of a problem.
The point of relating the circumstances of these early tests is to emphasize to you the importance of adopting a root cause analysis method that identifies all root causes when analyzing your problems. REASON Root Cause Analysis data provides decision-makers with an understanding of the entire system. It details all options, and provides the opportunity to analyze for causes that are shared in common between systems, as illustrated in this early test example.
The REASON Root Cause Analysis method provides an objective, standard operating procedure that teaches you how to ask the right questions at the right time, to get the right answers. All other root cause approaches rely upon someone’s assumptions of what should be done. These other approaches use gimmicks like checklists and cause lists to focus upon only a small portion of the causal system. The costly reality check comes when root causes and key prevention options go undetected and unreported, when prevention opportunities are lost, and when managers discover that their analysis system has induced them to make an unsound decision by filtering key data away from their view.
Without the opportunity to view the entire problem with all root causes identified, the likelihood of a manager finding shared causal factors existing in common among multiple events, as described above, is remote. It should be noted that these shared causal factors are the systemic root causes that are the primary target and goal of professional root cause analyses.
Root Cause Analysis Methods Comparison
The root cause analysis method with REASON is guided by rules of causal logic, and provides a logic check at each step in the analysis to make sure that all root causes have been accounted for. If you are now exploring and evaluating root cause analysis approaches for preventive maintenance applications, we invite you to our Evaluation Criteria for Comparison of Root Cause Analysis Methods article which is posted at this Web site as a companion article to What is REASON.
There you will learn that all other root cause analysis approaches rely for their results upon assumptions, and personal bias. Other methods attempt to drive the analysis to one major root cause, thereby allowing some root causes to fall through the cracks. Other methods ask the user to fill in the blanks, or to pick the major root cause from a list that purports to contain all of the possible causes of your problems. All of these gimmicks and pseudo-technologies simply cannot provide the kind of reliable data upon which maintenance procedures must be based.
Root Cause Analysis SOP Provided by REASON
Root cause analysis methodology as defined by the REASON process is a professional, step-by-step, standard operating procedure guided by four simple rules that construct an exact model of your problem. Results are complete and verifiably accurate. The REASON model can be measured to identify how much each root cause contributed to the problem. Thus, REASON is able to report which solution provides the highest level of prevention benefit.
Troubleshooting Maintenance/Construction Root Causes
The maintenance safety coordinator at Brown and Root Company’s Houston offices conducted another beta test of REASON in the early 1980’s. He had his team maintenance coordinators trained, and deployed the REASON Root Cause Analysis maintenance troubleshooting method to numerous construction sites.
In only weeks, he was reporting a decline in the problems that were being generated by third party contractors on-site. Improvements in operations were made possible because REASON Root Cause Analysis provided a view of all of the root cause sources, so that he was able to broadly and immediately deal with the many problems that were interfering with the projects. His maintenance coordinators became problem-solving facilitators working with the third-party contractors to improve policies, practices and procedures. They were able to show contractors how their actions were impacting other contractors at the site, and ultimately the success of the project. In 1982, Mr. Del English a corporate executive for Brown and Root Company reported their successful results with REASON Root Cause Analysis to the National Safety Congress in Chicago.
Root Cause Analysis Technology Proven
Since those early years, REASON Root Cause Analysis has continued to mature. It is now the method of choice for root cause analyses of major significance, such as the Northeast Electric Power Blackout of 2003. REASON is used by Los Alamos National Laboratory, by nuclear submarine bases, by DuPont, Allegheny Energy, TU Electric, Eastman Kodak, Sanders Lockheed Martin, Cooper Power,Suncor, CNRL, BG Gas and numerous other world-class companies. The Department of Energy in Richland today uses REASON to correct and validate the accuracy of root cause analysis reports received from site-contractors.
Logic Filters Out Irrelevant Details Root Cause Analysis in the past has typically relied upon subjective assessments to draw conclusions.
However REASON is a repeatable system that helps order what you know and what you can find out about a problem. It orders the data into a cause-and-effect model; but you can’t force data into the model just because you think it belongs there. REASON is a system that provides a test to make sure you don’t get off base because of some personal bias, assumption or misinformation. The resulting REASON Root Cause Analysis model is the exact system that had to be in place for the problem to occur.
Root cause analysis has traditionally been considered a risky business for maintenance operations because early approaches spoke only of possible causes, clues, probable risk and trial balloon remedies. Maintenance simply could not rely upon a system that would allow such inconsistent and vulnerable information to impact decisions and planning. To do so would have threatened to undermine the on-line reliability and availability of equipment. All of that has changed now with the REASON Root Cause Analysis objective, verifiable, and logical data.
REASON Root Cause Analysis Summarized
In summary, REASON Root Cause Analysis provides a maintenance management system that brings together essential information and analyses of the critical elements within the organization that affect the proper planning and implementation of successful maintenance programs. The root cause analysis maintenance troubleshooting method and tools are a mature system that has been validated in the field by maintenance and operations professionals. REASON Root Cause Analysis troubleshooting produces concrete results that can be validated, and does not rely upon assumptions, cause lists, or personal bias.
The automatic root cause analysis allows managers to verify prevention benefit and cost-effectiveness before allocating resources. The REASON Root Cause Analysis System provides growth potential for a cost-effective Lessons Learned system that acts as a planning and prevention resource by accessing existing REASON Root Cause Analyses.