Root Cause Analysis

RCA of RC(F)A

When you first start a Root Cause Analysis , it is like starting out to solve a new puzzle. The pieces of information as you begin to sort through the process seem jumbled, out of order, and seemingly in total disarray.

The challenge is to try and put all the pieces of the puzzle into play, and get them on the board. As we collect evidence, and take photographs, meet with witnesses to get their statements, we can begin to under stand how the puzzle might take shape.  Even as we gather the corners and the edges to frame up the limits of the task, we still have just begun to complete the work needed to truly understand what cause(s) were at play.

One of the challenges as we begin to look through the emerging picture is to just jump to a fast conclusion,  as we think we can see enough of the problem to solve it, but this is like peering through the morning mist, and trying to see what the mid afternoon tea weather "might" look like.

Staying the course and putting aside the temptation to jump to conclusions is paramount to solving the root cause(s), and the process of putting together the puzzle must continue. The challenges continue as we begin to refine the process, and begin to realize there are no silver bullets and often we have multiple roots and causes.

The confluence of many roots leads us to understand there is not ONE root cause, but there can be many, and often are several root problems just like there is never just one root of a plant.

The key to a Root Cause Analysis is to understand that there is most likely more than ONE root cause, and that we need to continue to dig into the dirt to look for more. When we understand these simple concepts, we can progress forward more successfully.

Using a simple method like Apollo Root Cause Analysis (ARCA) we can drill into one or many roots to understand the real causes.

Kitting Up your Work

KIT UP

Kit up is a simple concept, and is one whereby you preassemble work packages and  prepare them for execution off line to the repair, so that when the craftsman engages the work activity, they have every thing they will need in their kit.

Measurement of the kit up rate is an excellent metric, because in order to produce a kit up, the reliability of the planning, scheduling and warehouse methods must be high. It is thus a good thing!

To demonstrate why the reliability of the subordinate processes must be high, we need to examine the serial nature of the process of producing a kit.

The work request must be complete, and contain all the needed information including all the parts, tools, permits, drawings, etc.. If it is not, the planning effectiveness will be lower, and more likely that the planner over time will not be able to completely plan in every way.

If the spare parts policy is lacking, the needed parts either are totally unidentified, or at the very least not on hand or out of stock. As a result, the probability that a work order will arrive in the field without a needed part is higher iif the storeroom management and procurement function is less than adequate.

If the warehouse management is poor, and the warehouse stock integrity is low because the operation is not secured, or does not cycle count, when a needed part is shown in stock, it will not be found, and the probability that a kit will arrive on a job without a needed part increases.

A simple kit up success diagram is shown.

This implies that 9 out of every 10 work orders with materials would have a kit produced.

Rs= 0.97*0.99*0.95*0.99 = 0.90

Or, ONE of every 10, I will send my craftsman looking for a part, somewhere, and as a result, they will not be doing actual work to remove a defect from my plant.

The key is that each sub process must be perfect, just to get 9 out of 10 kits prepared.,

In reality, very few organizations achieve kit ups, fewer reach 90% successful kit up delivery, which is apparent due to the serial reliability nature of the reliability of the support systems.

Very few organizations receive work requests 97% of the time that contain all relevant information.

Very few organizations plan 99 out of 100 work orders with materials or special tools.

If your stock out rate is 10%, you cannot deliver parts 98% of the time,

Many organizations understand the importance of kit up’s as it relates to work efficiency.

Very few understand the compounding effect of the maintenance processes required for kit up to successfully release the maintenance effectiveness possible.

By focusing on producing kits, you will uncover the weakness of your planning, scheduling and warehouse practices.

This alone affords the opportunity to improve.

Simply put, the more kits you CAN produce is an indirect measurement of the state of health of your underlying processes.

If I want to improve, we need to focus our activities on the area that will unleash the largest improvement.

Too know where this opportunity is located we need to measure what is our bottleneck operation.

The measurement of a maintenance bottleneck can be found through the use of a CMMS, and categorization of all open work orders into exclusive states.

The state with the largest amount of work orders usually contains the most work, and is by default then the bottleneck.

Is NORTH true NORTH?

A good friend once told me “If you don’t know where you are going, any road will take you there.”

As we start a journey to talk about the reliability business, first we must talk about “direction” and recount some thoughts I wrote into a recent book on Business Performance Management  (The Maximo Managers Guide to Business Performance Management).

Reliability Roadmap

At the same time – let’s occasionally mix in a balance of some science and our life to keep things light so as to keep our journey together both interesting and enjoyable.

So, to start us off, let’s ask one simple question.

What is “True North”?

In the scientific sense the term “True North” refers to the axis of the earth or the North Pole. Magnetically there is a slightly different pole, or center spot near the North Pole where the Earth’s magnetic fields converge and this “convergence” occasionally contribute to wonderful late night light shows called “Aurora Boriallis”.

The 2 “poles” are actually not in exactly the same place which is why when you pick up an old compass and map you need to adjust slightly for the difference dependent upon where you are in the world and this is called the “declination” – or difference angle.  The advent of Global Positioning Systems makes the adjustment calculation almost a relic of folk lore. It serves to illustrate that even though you think you are going north, you might not be even if your “compass” says you are.

So what really is True North?

For each organization or company it is different.

In the context of business – True North is the direction your organization seeks to travel. Our business interests and directions or goals span the globe in both content and breadth. For each of us they are directionally correct for what our organization is working to accomplish and our reliability goals also have a north direction.

Our “reliability compass” (or business metrics), are considerably more complex and perhaps some might argue, more advanced, although I would offer still, some organizations cannot link their reliability metrics to the organizational strategic plan goals. Generally though our metrics, scorecards key performance indicators and analytics are made up of a suite of software tools which help us understand which direction we are headed.  But are they really more advanced than a magnetic compass?

Interestingly, our “Reliability Indicators” are not that much different from a compass in the 1700’s and surprisingly not always as accurate as the compass built in the 1700’s. We need to look into how our current reliability “compass” was made to understand why occasionally they allow us to sail a perils’ course.

First a little science.

Since the discovery of the compass in China in perhaps the first century, the compass design and craftsmanship has evolved with hundreds of years of care, and development to provide the most accurate of indicator performance. This development evolved under the watchful eye of master craftsmen and the every wary reminder of shipwreck and certain death as motivation for the diligence to avoid poor quality.

Recently I lived in Dalian China for 3 years, which today has a vibrant ship building business and is a corner stone of the global ship supply business. One only has to drive by to marvel at the wide array of ships and platforms under construction to understand the scale of global commerce.

It is still quite interesting from a reliability perspective that in an era of a ship borne arrays of satellite navigation equipment, all commercial ships built in the Dalian Shipyard by A P Moller-Maersk are still fitted with a ships compass says, Pedar Madsen of Maersk , Manager for Ship Engineering at the Dalian Shipyard.

Pedar shared with me that a considerable amount of special care to this day is taken in the design of this dated indicator including the surrounding ship’s metal (Stainless steel and brass), and indicator placement on the ships centerline which ensures in turbulent seas, the ships compass still reads true and reliably.

I found it quite interesting to learn that once a ship is commissioned each day thereafter, the crew daily logs the difference between the sophisticated Electronic array and the ships compass to ensure the “digital Indicators” are still “pointing north”.  While this is checking every day to ensure you don’t end up on the rocks, it also is a predictive inspection task,  that is quite simply checking to see if the ships sophisticated navigation circuits have drifted or failed.

You see the reliability of gravity outlasts all man made items.

So, how often do we check to see if our reliability and business metrics are still accurate?

Or perhaps a better question is – “Are your reliability indicators even accurate”?

Unfortunately, our reliability indicators receive far less scrutiny in their development and protection of the integrity of the indicator once placed into service. We often take a leap of faith that the data in our electronic world is accurate and complete.  Occasionally accept that the well published indicators are gospel, and in the pursuit of excellence, we often collect mounds of useless data for which we have no clear purpose.

The truth is our reliability and business indicators and analytics all too often are derived from data that is incomplete or damaged. Conversely, sometimes, as CEO of Business Objects, Bernard Lieutaud has said, “There is too much data and it is duplicated hundreds of times. The mistake companies make is that they start from the data they have”… and I’ll add – not the data they need.

So when some whiz kid develops your next set of business metrics by consolidating the needed data into a flashy dashboard, can you trust it?

If you have to hesitate to answer that question, you’re undoubtedly spending some time deciding whether the indicators you use today are trustworthy and complete and then deciding whether you can rely on the “north” indication they provide.

But when does data become “good data”?

I devoted a portion of my new book to develop the concept of a data integrity map. End to End data controls that ensure the business indicators you rely upon are built with at least as much care and devotion as a ships compass. If you are going to monitor and use any data set to indicate the organizational direction, should you not make sure the data points “north?”

So the next time you pick up your Reliability, key performance indicators, financials, or whatever they are called in your organization, ask yourself this simple question.

Does your reliability organization’s directional “North”  point “True North”?

Articles | The True Cost of Poor Lubrication | ReliabilityWeb.com: A Culture of Reliability

Articles | The True Cost of Poor Lubrication | ReliabilityWeb.com: A Culture of Reliability

This is a good article about why a lubrication excellence program is needed to alter the culture of an organization.

Cultural change within an existing maintenance or engineering team is a challenge, often difficult and never something that can occur overnight.

No silver bullets - just simple fundamental best practices put in motion.

Why do Work Instructions Fail?

Work instructions are written documents intended to convey how to do a job.

Recently I had the chance to interact with a talented team and discovered why work instructions often fail to produce the desired result  - which I will call a well executed job.

The challenge was to build a software model of a system using a leading software, after 12 hours of intense instruction on how to utilize the software, made easier by requiring each student to follow a written work instruction that was contained on 5 pages - including exact screen shots of the finished product, and intermediate step results. The written work instruction also included screen shots of database view of the data required to be populated into the software model so the users of the document could self check their data input.

The purpose of the exercise limited to 1.5 hours was to type the data into the software - reinforcing the previous training provided on how to utilize the software, and then build upon the base model to enhance some fundamental concepts about reliability.

The work instruction document on further examination had been through the following developmental processes.

1. It had been developed by a knowledgeable Engineer - from a working version of the model to be built.
2. The exercise had been run 2 other times - and the results of those exercises used to refine the document's accuracy.
3. Prior to use, 2 more engineers reviewed the documents proof reading it for errors and found none.

Question One - What level of reliability do you think the document had? (0 to 100%)?

The work instruction document required the input of a simple 5 location reliability centered maintenance analysis that included weibull failure parameters (provided in work instruction) cost of spare parts, cost of each labor hour (weighted cost), down time effects in cost and operational criticality and safety criticality.

Student Questions that surfaced during the data entry phase indicated their prior training was reasonably successful and thus revealed 4 typo's in the work instructions existed. These were countered by verbal work instructions during the work performance to alter the written work instructions during work performance.

After data was entered the basic task was to prove their software model was equal to others thus - 12 students performed a 10 year life simulation to estimate the effects and costs associated with the base strategy.

If all data had been entered the same - 12 identical results would be obtained.

Question Two - How many correct results were there?

If you say less than 12 - why?

RCM studies on LEAN bottlenecks?

RCM and LEAN

Do they mix or are they like Oil and Water?

RCM studies are a pain - usually because they take so much effort and so many steps that it is common they often never finish. When a cool tool comes along to make that process easier - well even "easy?", that is worth blogging about.

LEAN guys and gals profess you need to reduce WIP, expose rocks, push faster harder be more responsive to the market.

RCM studies all too often are not performed where they matter. They are time consuming processes, that sometimes never actually finish - wasting a lot of time money and effort.

LEAN often exposes too many "Rocks in the Creek" - those rocks being the inherent and maintained reliability of the assets, and when we remove WIP (Work in process buffers between machines) that help to smooth over the impact of breakdowns and lower reliability, we expose the true reliability of each machine.

The goal of a RCM study is to produce the best maintenance strategy for that asset, and THEN implement that strategy. All too often the strategy development never gets into the hands of the value add technicians, and thus we deliver little or no value from the RCM effort to our process.

Only when we complete the RCM journey can we "reliably expect to be successful in draining the creek to  go LEAN."

Going LEAN to expose the inherent reliability (the reliability of the machine no amount of maintenance can make better) is just fools play, and is the reason many LEAN implementations fall over, resulting in late deliveries, lost sales, and EBIT challenges associated with refilling WIP buffers to a strategic level.

Simple Tank, Pump and Filter Availability and Capacity Model

When we combine the power of RCM and LEAN,  with Availability and Capacity Modeling we engage an incredibly powerful tool set that helps use identify where the bottlenecks in our production processes are easily exposed, and more importantly we can FOCUS our RCM efforts on the bottleneck where high quality maintenance results in higher throughput, allowing greater sales from teh same asset base, and thus increases EBIT.

The combined model of RCM generated Maintenance task instructions, with LEAN WIP buffer modeling and EBIT impact cost reporting puts into ONE tool, the value and focus ability that most LEAN managers wish they had.

Identify your bottleneck, build the RCM, Availability Capacity and EBIT model.

1. Evaluate your current maintenance practice
2. Evaluate the capacity improvement by installing an optimize RCM Maintenance strategy
3. Evaluate how to improve the inherent reliability of the bottleneck through various options;
1. Redundancy in specific areas.
2. Redesign of critical parts of machine generating the most LEAN resistance.
4. The model your WIP buffer and tune it to the optimal strategic level using a combined model.

Once you are done, you have the full team focused on bottleneck breaking using the worlds best tool set for LEAN and RCM.


Then you must put those new maintenance strategies into practice.

The combination of Isographs Availability Work Bench and ARMS Reliability Integration tool allow you to nearly one click produce load sheets for your CMMS and Word documents with pictures for your Document management System work  instruction files.

Read more about it here:
http://www.thereliabilityblog.com/2012/09/20/implementing-the-outcomes-of-rcm/

Check Out our Book on Maximo and Business Performance Management

AVAILABLE AT:

http://www.amazon.com/MAXIMO-Managers-Business-Performance-Management/product-reviews/098322580X/ref=dp_db_cm_cr_acr_txt?ie=UTF8&showViewpoints=1

It has been one of those books that you can open any chapter and find value to apply to any one of the 10 projects an EAM consultant normally is on. 

I have been able to add more value in a shorter period of time for both existing as well as new implementations. Converting data to information that is relevant to your business is paramount to having a true return on investment. 

This book was all about using KPI's, Scorecards, or Dashboards to get a visual representation of your data that allows you to put the answers to critical issues right in front of you. It is not about mining for that data but using the standard reports and reporting features within Maximo to help your business plan and attain goals. 

I highly recommend this book from a Maximo, an EAM, an IWMS or CMMS implementers guide to putting your client on the right track to a better return on investment.