Failure Analysis/Problem Solving Methods
Written by Charles J. Latino
President & Founder of Reliability Center, Inc.
     I challenge people to open their minds to envision how they can reduce their work load by looking at situations from a different perspective. How much time is spent on performing the same repair on the same piece of equipment, over and over again?
     I recently heard this referred to as the Chinese definition of "Insanity"... "When we do the same thing over and over again and expect a different result!" When we see how much of our time is spent on repetitive work, we understand the need to seek out ways to reduce or eliminate it. By doing so, time is freed up to perform proactive work; that is, work that improves operations and predicts and prevents failures from occurring in the first place.
     Applying higher levels of precision to our work will increase quality and equipment life. In addition, repetitive failures can be mitigated or eliminated by performing Root Cause Failure Analysis (RCFA.) This term is widely used but it often means something different to each person. RCI once held a series of seminars for a single company and passed out 3" x 5" cards asking each person to write down, in one or two sentences, their definition of Root Cause Failure Analysis. These 600 people, all from the same company, provided 599 different answers. This points out the need to focus on "What is RCFA?" in order to be successful in eliminating the most important failures.
     RCFA is a disciplined vertical problem solving methodology used to determine levels of root causes of specific failure events. The following process is necessary to implement a successful RCFA effort. 
    Prioritize - Determine what is most important to work on.
    Analyze - Analyze the failure event to determine root causes.
    Recommend - Develop recommendations as solutions to the causes discovered.
    Prioritize - Determine What is Most Important to Work On.
     We live in working environments where it is difficult if not career limiting, to say "no" to job assignments from bosses and colleagues. This inundates plant people with satisfying the reactive requests of others. We feel that it is important to prioritize work assignments in a way that identifies the job events that will provide the greatest return. Because the demands on plant people's time is so great, they need a tool to assist them in this prioritization. The Impact/Effort Priority Matrix can serve this purpose.
     Plant people should record repetitive failures they see while in the field. Plant personnel know best which jobs prohibits them from doing their best work. Therefore, it is only appropriate that they prioritize their work according to what they believe is most important to themselves. This will translate to greater productivity for the company, more ownership for plant people and a shift in focus from reaction to proaction. As part of our Failure Analysis/Problem Solving Methods? course, we provide such a tool for the field people to use to prioritize their work in this fashion. 
Analyze the Failure Event to the Root Cause
     Once the user is focused and has used a disciplined methodology to determine priority, he or she can take the failure events selected to work on and start to build a "Logic Tree." A logic tree is a tool that uses deductive logic to guide thought processes used to draw correct conclusions. Therefore, a logic tree is a disciplined methodology that prompts the user to answer questions that will eventually identify the root causes of a failure event.
     The first step in building a logic tree is to properly define the failure event to ensure that the analyst is truly working on the problem and not the symptoms. To do this, he or she must identify the failure event in the top block, and the modes of the failure event on the second level of the tree. 
     At this point, the user has clearly defined the failure and can now analyze its root causes. He or she must look at which failure mode is occurring most frequently and follow that leg of the tree to its roots. If printer failures are occurring 80% of the time, naturally this is the first leg the user would want to pursue. 
     Questioning to build the logic tree is simple and consistent. The user keeps asking "How can the preceding event occur?" In this case, "How can the printer fail?" The user must strive to come up with two all-inclusive possibilities as to how the printer could fail. He or she starts out very broad getting more and more specific as they vertically extend the tree. 
     As the user continues to each level and keeps asking the same question of "How Can?", he or she forces themselves to look at all the "cause" possibilities instead of looking only at the most likely possibility. As these possibilities are explored it is necessary to verify whether they actually occurred or not. If they did indeed occur the analyst would go to the next level by asking "How Can" again. The process of hypothesizing and verifying continues until the various root causes are discovered. 
     Component Roots (or Physical Roots) are the tangible things that fail. These are the machine parts that generally fail, and these are typically the roots that are most familiar to us. The Human Roots are the points of inappropriate human intervention. This is generally where a human did something wrong or forgot to do something. However, we do not recommend stopping here. That would be witch hunting and this stops the flow of information needed to complete the Logic Tree. For this reason it is necessary to ask "why did the person decide to do what they did?" What was the rationale for the decision? People do not generally wake up in the morning and say, "I think I will go to work today and fail miserably!". The answer lies in why people do what they do. What about the systems in which we operate, allowed the person to do what they did? The answers to these questions are defined as the latent roots or the organizational system roots.
Develop Recommendations
     At this point the user or analyst will want to develop recommendations that will be acted upon. All of the users efforts will have been useless unless the plant acts on the findings. It is important that the people, who do failure analysis and develop recommendations, understand what the expectation of management is with regards to their recommendations. Will they only accept a recommendation with an ROI of 20%? Will the recommendation have to align with a root cause? This is the type of information that should be laid out up front before recommendations are made. This will allow the failure analyst to understand the "rules of the game" before playing.
     Because facilities are plagued with repeat failures that become accepted as the norm, it is imperative that plant people have the proper tools and skills to identify and solve their own problems. Failures cost American manufacturing billions of dollars a year and are draining the productivity potential of the nation. With failure analysis we have a tool that can materially help to achieve significant benefits.
     RCl's Failure Analysis/Problem Solving Methods? course for plant personnel was developed, designed and marketed for plant personnel. Plant personnel were used in the development of the course material. This course takes into account plant people's time constraints and what is "realistic" to expect from someone working in the field. The methodology provides documentation for compliance to ISO 9000 Standards for "corrective action" as well as portions of OSHA's 1910.119 Process Safety Management standards. If you would like more information please call 804/458-0645 or email
RCI Offers the full range of Reliability Consulting Services and Training Programs for Industry. We conduct facilitations, reliability assessments, FMEA & Root Cause Failure Analysis Training - Public & On-Site.
For more information contact:
Reliability Center, Inc.
P.O. Box 1421
Hopewell, Virginia 23860
Phone: (804) 458-0645
Fax: (804) 452-2119
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