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.