PROACT®

RCA System

The PROACT® RCA Investigation

Management System

Bob Latino, CEO, Reliability Center, Inc.

© 2016 Reliability Center Inc. All rights reserved. 1

 PROACT®
Presentation Agenda RCA System

►PROACT® Process Overview

►Making the Business Case for Proactive RCA
Candidates (FMEA/Opportunity Analysis)
►The PROACT® RCA Methodology
►PReserving Evidence
►Failure Scene Investigation
►Ordering The Team
►Analyzing the Event
►Human Performance/Human Factors/Human Error Reduction
►Knowledge Management Templates
►Determining Causation
►Communicate Findings and Recommendations
►Tracking for Bottom Line Results
►The PROACT® Investigation Management System

© 2016 Reliability Center Inc. All rights reserved.

 The PROACT® Root Cause Analysis (RCA) Approach 
Quick Reference Guide

5 PReserve Event Data (Evidence)
4 Desired State
Loss Metric

3 The GAP
2 Actual State
1

Reliability = Priority + Proaction + Focus
0 Order the Analysis Team (Unbiased)
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Gap In Performance of Any Kind

Analyze The Data (Logic Tree)
80% 20%
Losses or Risk

SCA
Shallow Cause 
Analysis
Communicate Findings & Recommendations

Failure Modes
RCA
Opportunity Analysis (OA) & FMEA

Tracking Bottom‐Line Performance 3
© 2016 Reliability Center Incorporated
 PROACT®
RCA System

Making the Business Case for Proactive RCA

Candidates (FMEA/Opportunity Analysis)

Losses or Risk
80% 20%
SCA
Shallow
Cause
Analysis

Failure
RCA Modes
Opportunity Analysis (OA) & FMEA

© 2016 Reliability Center Inc. All rights reserved. 4

Where Do Candidates for RCA Come From PROACT®
Now? RCA System

Proaction Reaction
FMEA Opportunity Regulatory
Analysis Events

OA
FMEA

SRE

Root Cause Analysis

© 2016 Reliability Center Inc. All rights reserved. 5

Making the Business Case for RCA - PROACT®
FMEA (Risk) RCA System

Probability X Severity = Criticality

Item Failure Effect on Effect on Severity Probability Criticality

Mode Other Entire System (S) (P) (C = S x P)
Items

Crude Unit Bearing Vacuum Crude Unit 7 3 21

Failure Pump Shut Down
Failure

© 2016 Reliability Center Inc. All rights reserved.

Making the Business Case for RCA - PROACT®
Opportunity Analysis (OA) RCA System

Sub Event Mode Frequency Cum. Impact Total Annual

System /Yr Per Loss
Occurrence

Vacuum Unexpected Bottom 5/Yr $1.431M $7.15M USD*

Column Column Pump USD
Shutdown Failure

Distillatio Environmenta Relief 1 / 5 years $500,000 $100,000

n Column l Release Valve USD USD
Failure
* Case Study: Root Cause Analysis: Improving Performance for Bottom-Line Results (Latino & Latino)

Apply Loss Formula:

Frequency X Sum of Impacts = Total Annual Loss

© 2016 Reliability Center Inc. All rights reserved.

Determining the “Significant Few” PROACT®
The Pareto Split RCA System

Sub  Event Mode Frequency Impact Per  Total 

System Occurrence or  Loss/Yr
Severity

Grand Total = $1000
Pareto Cut = x .80
The Pareto Split
Significant Few = $ 800
80 / 20 (or less)
% $$$ % EVENTS

© 2016 Reliability Center Inc. All rights reserved.

Determine the “Significant Few” PROACT®
Making The Business Case for RCA RCA System

100%
90%
% of Loss

80%
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5 6 7 8 9 10
RCA Events SCA
Significant Few

© 2016 Reliability Center Inc. All rights reserved.

 PROACT®
The PROACT® RCA Approach
RCA System

•Error-Change Phenomenon
PReserve Evidence •The 5-Ps of Evidence Collection
•Failure Scene Investigation (PROACT FSI)

Order Team •The RCA Team

•Roles & Responsibilities

•The Logic Tree Top Box/Body of Tree

Analyze Data •Root Cause System/Human Error/Human Factors
•The Utilization of External Logic – RCA TEMPLATES

Communicate •The RCA Report

Findings & Recs •The RCA Presentation

Tracking for Bottom- •Measuring RCA Effectiveness on Bottom-Line

Line Results

© 2016 Reliability Center Inc. All rights reserved. 10

PReserving Event Data PROACT®
The 5 – P’s Data Collection Strategy RCA System

1. Parts
2. Position
3. People
4. Paper
5. Paradigms

© 2016 Reliability Center Inc. All rights reserved. 11

Ordering the Analysis Team PROACT®
Managing Bias RCA System

►Technical expert should not

always lead the analysis
►Team members should be
cross functional
►Team members should have
diverse work backgrounds
►Team members should
comprise a “whole brain”

© 2016 Reliability Center Inc. All rights reserved. 12

Analyze the Event PROACT®
Germination of a Failure RCA System

Undesirable Outcome

Physical Root Causes

Human Root Causes

Latent Root Causes

Policies & Human Communicati Management

Technology Training
Procedures Factors -on Oversight

Deficient Organizational Systems

© 2016 Reliability Center Inc. All rights reserved. 13

Analyze the Event PROACT®
The PROACT® Logic Tree RCA System

Root Cause Analysis: The establishing of logically complete, evidence-based,

tightly coupled chains of factors from the least acceptable consequences to the
deepest significant underlying causes (www.rootcauselive.com)

logically complete
HOW COULD? vs WHY?
Categorical vs Cause-
How Could?
and-Effect
tightly coupled
How Could? evidence-based
Verification Log
How Could? Verification Method –
Verification Outcome –
How Could?
Responsibility –
Why? Due Date -
© 2016 Reliability Center Inc. All rights reserved. 14
Analyze PROACT®
Failure Scene Investigation® (FSI) - Evidence RCA System

Erosion

Corrosion

Fatigue

Uniform Loss
of Metal
Overload

Pitting
(Electrical
Phenomena) Cyclic
Failure

Source: Reliability Center Advanced FSI Lead Investigator Series

Instantaneous
http://www.reliability.com/failure-scene-investigation.html Fracture
© 2016 Reliability Center Inc. All rights reserved.
15
Analyze PROACT®
Human Error Reduction Techniques RCA System

Top 10 Traps Resulting In Human Error *

The Top 10 Human Error Traps

►Time Pressure
►Distractive Environment
►High Workload
►First Time Evolution
►1st Working Day After Days Off
►½ Hour After Wake-Up or Meal
►Vague or Incorrect Guidance
►Over-Confidence
►Imprecise Communications
►Work Stress

Source: Reliability Center Human Error Reduction Techniques (HERT) Workshops

http://www.reliability.com/human-error-reduction.html

© 2016 Reliability Center Inc. All rights reserved. 16

Analyze the Event PROACT®
Where Does Knowledge and Experience Come From During an RCA? RCA System

Expanded
Primary Learning Knowledge/Capacity
RCA Team Published PROACT®RCA
Member SME’s Internal RCA’s Knowledge Template
Library

RCA Int. RCA

SMEs
RCA Template Library
Temp- 1. Mechanically Related (147)
lates
2. Electrically Related (42)
3. Human Error Related (53)
4. Operationally Related (23)
Root Cause Analysis 5. Quality Related (32)
Logic

© 2016 Reliability Center Inc. All rights reserved. 17

Corporate Memory – PROACT®
Institutionalizing Knowledge from People to RCA Systems RCA System

Experience/SME
Logic Map
Database
Key Word Search
Engine
Your Screen!

© 2016 Reliability Center Inc. All rights reserved. 18

Template Breakdowns PROACT®
Common Key Word Search Guide – Mechanical Failures RCA System

1. AC Motor 19.Pipe Thinning

2. Bearing Failure 20.Piping System Failure
3. Boiler Tube 21.Rolling Bearing Failure
4. Bolt Failure 22.Seal Failure
5. Cable Failure 23.Shaft Failure
6. Canned Pump Failure 24.Transformer Failure
7. Capacitor Failure 25.Weldment Failure
8. Centrifugal Fan Failure
9. Circuit Breaker Failure
10.Component Fabrication
Failure
11.Coupling Failure
12.DC Motor Failure
13.Electric Motor Starter
Failure
14.Fuse Failure
15.Gear Failure
16.General Component
Failure
17.Heat Exchange Failure
18.O-Ring Seal Failure
© 2016 Reliability Center Inc. All rights reserved. 19
Template Breakdowns PROACT®
Common Key Word Search Guide – Electrical Failures RCA System

1. AC Motor Electrical Failure

2. Battery Failure
3. Cable and Wire Failure
4. Capacitor Failure
5. Centrifuge Fan Failure
6. Circuit Breaker Failure
7. DC Motor Electrical
Failure
8. Electric Motor Starter
Failure
9. Fuse Failure
10.Lightning Failure
11.Resistor Failure
12.Rolling Bearing Electrical
Failure
13.Transformer Failure

© 2016 Reliability Center Inc. All rights reserved. 20

Template Breakdowns PROACT®
Common Key Word Search Guide – Human Failures RCA System

1. Human Error
2. Injury
3. Procedural Failure
4. Program Implementation
Failure
5. Supervision Failures

© 2016 Reliability Center Inc. All rights reserved. 21

Template Breakdowns PROACT®
Common Key Word Search Guide – Operational
RCA System
Failures

1. Canned Pump Failures

2. Equipment Overload or
Rupture
3. Gas Turbine Failure
4. Steam Turbine Failure

© 2016 Reliability Center Inc. All rights reserved. 22

Template Breakdowns PROACT®
Common Key Word Search Guide – Quality Failures RCA System

1. Customer
Complaints
A. Labeling Issues
B. Packaging
Issues
C. Product Quality
2. High Warranty
Costs
3. Loss of Sales

© 2016 Reliability Center Inc. All rights reserved. 23

Communicate Findings & Recs PROACT®
Leveraging RCA Knowledge Across the Corporation RCA System

Shared
RCA Server
– Corp
Access

Input RCA
Successes
Into
Educational
Systems
RCA
Knowledge
Management
System
Leverage
Existing
RCA Logic

Preserve
‘Corporate
Memory’

© 2016 Reliability Center Inc. All rights reserved. 24

Tracking Bottom-Line Impacts PROACT®
Trending RCA Results RCA System

Sample Cause Categories

Organizational Culture Related PPE Not Readily
Available
Managerial Oversight Related
Physical
Policies/Procedures Related Root
Resource Management Related
Human Factors Related Respirator Out of
Reach of Driver
Environmental Factors Related Human Root
Inadequate Supervision Related
Canister
Intentional Violation Related Normal Practice
Respirator Not
Not to Wear
Skill-Based Errors Worn Due to
Respirator
Limited Protection
Rule-Based Errors Latent Root Latent Root
Knowledge-Based Errors
? ?

© 2016 Reliability Center Inc. All rights reserved. 25

Exploratory vs. Explanatory Logic Trees PROACT®
What’s The Difference? RCA System

E = Exploratory
M M M M
= Explanatory

H H
H H

PR H

PR
HR

HR
LR LR LR

LR LR

© 2016 Reliability Center Inc. All rights reserved. 26

Tracking Bottom-Line Impacts PROACT®
Measuring RCA Effectiveness – Metrics to Track/Analysis RCA System

© 2016 Reliability Center Inc. All rights reserved. 27

Tracking Bottom-Line Impacts (Trending) PROACT®
Measuring RCA Effectiveness – Metrics to Track/RCA DB RCA System

© 2016 Reliability Center Inc. All rights reserved. 28

PROACT Investigation Management System PROACT®
Software Demo RCA System

Opportunity Analysis – RCI Chemical Plant

RCA – IND – Pump 101 Failure (65)

© 2016 Reliability Center Inc. All rights reserved. 29

 PROACT®
RCA System

Thank You!
www.Reliability.com

© 2016 Reliability Center Inc. All rights reserved. 30