1. Root Cause Analysis –
Think Again!
Presented by Kevin Stewart

2. Table of Contents
• Introduction
• Key elements of a sustainable root cause
analysis program
• Sustainability
• Audit

3. Poll 1
• Does your company truly identify the “root cause” of
problems or does it jump to solutions?
– We have a process and get to the root cause
– We have a process but don’t get to the true root
cause
– We don’t have a process but continually find the real
root of our problems
– We don’t have a process and continue to have
repetitive problems

4. Introduction
• A new way of thinking
– Definition of Insanity
• “Doing the same thing over and over and
expecting different results”
• “Doing different things all the time and
expecting the same results”
– Time to change or stay in our rut

5. Involved or Committed?
A new way of thinking

6. SAP BiModal distribution
Software
installation
(involved)
New
maintenance
paradigm
(committed)
Failed Successful

7. Introduction cont.
• It is not
– Quick
– Easy – if it was you would already have it done
– Going to be successful if it is done the same way
as other initiatives that failed
• It is
– Hard
– Time consuming (multi year)
– Necessary to communicate
– Necessary to track and show value
– Very, very valuable to your organization

8. Introduction summary
• The definition of insanity continues to apply
• Think differently about implementing Root
Cause Analysis
– Not everyone knows what you know so
tell them
– Decide to be Committed
– Long term focus
• Program
• Cultural shift where everyone gets
involved

9. Poll 2
• Does your company have a formal written process for
performing and sustaining a Root Cause Analysis
process?
– Yes
– We have a process but it isn’t written or formalized
– No it is not documented
– No we don’t have an RCA program

10. Elements of a Root Cause Analysis Program
1. An involved Sponsor, or program
champion
2. A Resourcing plan complete with a
program champion and trained
investigators
3. Clear trigger mechanisms to clarify
exactly what needs to be
investigated.
4. Clear protocols for the collection
of and preservation of evidence
and information.

11. Elements of a Program
5. A standard reporting process to assist with
further analysis and cost savings
6. An ironclad tracking system that forces resolution
of the action items through escalated emails or
other methods
7. A process to review the investigations for common
causes and possible missed or improvement
opportunities
8. Tracked value of the RCA program

12. 1) An involved sponsor
• Sponsor – Target - Change Agent

13. Recognize this?
Sponsor
TargetChange
Agent
Apparently there must be some mistake?

14. Better?
Sponsor
Target
Change
Agent
Excellent Alignment!

15. An involved sponsor
• Sponsor must be involved
– Show up at meetings
– Ask about progress
– Ask to see analyses
• Actions speak louder than words
• Program difficulties without

16. 2) Resourcing Plan
• Who do you need?
• What are their duties and responsibilities?
– Program champion
• Overall program success
• Training strategy and implementation
• Coaching and counseling facilitators
• Tracking and reporting metrics
• Assisting with difficult or sensitive Analysis
• Depending on size may also be a facilitator

17. Resourcing Plan (cont)
• What are their duties and responsibilities(cont.)?
– Facilitator
• Facilitate incidents based on triggers or as
asked
• Manage the entire investigation
• Continually improve their skills
– Participants
• Provide pertinent information to further the
analysis, as many times they are the ones
with the “causes” of problems

18. Resourcing plan cont.
• Time commitment?
– Program Champion
• Half to Full time to start (plan for a year)
– Can’t afford it? WRONG! (insanity?)
• Tapers off over time as program takes hold
– Facilitators
• Varies – rule of thumb about ¼ of time or
about 1 detailed analysis per month
– Participants
• Need should be spread but similar to
facilitators be careful to not get them involved
in multiple analyses from multiple facilitators
• Schedule their time

19. Resourcing plan cont.
• How do you pick these people?
– Lottery?
– The way you’ve picked everyone else?
• Suggestion
– Define skill set first and look for specific skills
then train them (the Toyota way)
• Tenacity
• Work Ethic
• Proven long term commitment
• People skills (empathy, communication, etc.)

20. Resourcing Plan (cont)
• What training do they need?
– Champion
• Root Cause analysis, advanced topics (master
facilitator), facilitator training, team building
or management, public speaking, interviewing
– Facilitators
• Root Cause analysis, advanced topics (master
facilitator)
– Participants
• Training in the process chosen
• Who should do the training?

21. Poll 3
• Does your company have a written plan documenting the
resource requirement for a Root Cause Analysis
program?
• Yes
• We have a plan but it isn’t documented
• No it is not documented
• No we don’t have an RCA program

22. 3) Trigger
When will you do an Analysis?
Informal
Trigger

23. Formal Trigger

24. Trigger Metric
0
1
2
3
4
5
6
7
8
9
Qrt 1-2 Qrt 2-2 Qrt 3-2 Qrt 4-2 Qrt 1-3 Qrt 2-3 Qrt 3-3 Qrt 4-3 Qrt 1-4 Qrt 2-4 Qrt 3-4
Hours
Quarter
RCA Downtime Trigge
or number of Non-compliances

25. Poll 4
• Do you have any kind of formal or informal process to
define when to do an official Root Cause Analysis?
– Yes
– No

26. 4) Preservation of Evidence
• Why is evidence thrown away?
• Failed bearings (physical evidence)
• Opportunities
– Establish parts graveyard
– Communicate
– Basic rules
– Train to comply
• Establish written policy

27. 5) Standard Report
• Standardization is key
– Report ID
– Report date
– Simple format
– Investigation details
– Significance
– Cost and Manpower
– Standard placement

28. 6) Tracking System
• Based on email
• Features
– Simple transference
– Alert proper people
– Due date
– Escalation features
– Others complete
– No deletion

29. Poll 5
• Does your company have any system to formally track
action items that may come from a Root Cause Analysis
to insure they are completed?
– Yes we have a system and it is used with success
– Yes we have a system and it somewhat utilized
– Yes we have a system but it isn’t utilized
– No we don’t track action items
– No we don’t have an RCA program

30. 7) Common Causes
• Equipment solution
• Systemic solution

31. 8) Tracking Value
• ROI
– Track manpower for analysis
– Track cost of solutions
– Track savings for each
𝑅𝑂𝐼% =
𝐶𝑜𝑠𝑡 𝑠𝑎𝑣𝑖𝑛𝑔𝑠 (𝑅𝑒𝑡𝑢𝑟𝑛)
𝐼𝑛𝑣𝑒𝑠𝑡𝑚𝑒𝑛𝑡 (𝐶𝑜𝑠𝑡 𝑡𝑜 𝑎𝑐ℎ𝑖𝑒𝑣𝑒 𝑟𝑒𝑠𝑢𝑙𝑡𝑠)
x100

32. Tracking Value
𝑅𝑂𝐼% =
𝐶𝑜𝑠𝑡 𝑠𝑎𝑣𝑖𝑛𝑔𝑠 (𝑅𝑒𝑡𝑢𝑟𝑛)
𝐼𝑛𝑣𝑒𝑠𝑡𝑚𝑒𝑛𝑡 (𝐶𝑜𝑠𝑡 𝑡𝑜 𝑎𝑐ℎ𝑖𝑒𝑣𝑒 𝑟𝑒𝑠𝑢𝑙𝑡𝑠)
X 100
Cost of investigation = team of 4 for 2 meetings of 4 hour
and 2 hours respectively $100 / hr cost of employee
Cost of solution = (purchase, install, implement,
troubleshoot, etc.) $2,000
Cost Savings = elimination of repetitive problem that was
costing $40,000 / year
Answer = 40000 / (2400 +2000) = 40000 / 4400 = 9.09 =
909% ROI

33. Total Savings
0
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
9000000
2008 2009 2010 2011 2012 Jan Feb Mar Apr May Jun Ju; Aug Sep Oct Nov Dec
Yearly Savings
Monthly Cumulative

34. Poll 6
• Does your company track the value of your RCA
program?
– Yes and it is widely known and reported company
wide
– Yes but it is not widely know company wide
– Yes but it is only know by certain individuals
– No we don’t know what value our RCA Program
provides
– No we don’t have an RCA program

35. Sustainability
• 2nd Order change defined
• Time required
Deciding - or being forced – to
do something significantly or
fundamentally different from
what we have done before.
The process is irreversible;
once you begin it is impossible
to return to the way you were
doing it before

36. Sustainability
• Examples
–CMMS
–GE
• Why 3 years?

37. Audit
• How to ensure it never changes?
• Possible measures
– Number of investigations
– Action items
– % reduction in trigger
– Adherence measures
– ROI

38. Conclusion
Establish your plan
for the program
based on a
minimum of 3 years
Review the 8
elements and
modify to fit your
needs
Involved Sponsor
Clear Resourcing
Plan
Set triggers
Evidence
Preservation
Standard reporting
Establish an action
tracking system
Review for common
causes
Track the value of
the savings
Make it all
sustainable!
Oh and don’t forget
your other job
either!

39. KEVIN STEWART
Reliability Advisor
Instructor/Facilitator – Apollo Root Cause
AnalysisTM Methodology
kstewart@armsreliability.com
Questions?