I have been performing and reviewing some BDA’s (Break Down Analysis) events at sites and their RCA’s, Root Cause Analysis, are starting to be much better. What I have seen is that some of the countermeasures have failed to be implemented or once you walk the process, the countermeasure isn’t fulfilling the need. What I have suggested when this comes up is another RCA but on behavior or the process not the equipment. This takes some out of their element and doesn’t always come naturally to them.

Root Cause Analysis should be used for why the countermeasure didn’t work, why the employees aren’t using the centerlines, and why the supervisors don’t audit or use checklists. Same process. Different use.

The first key difference is looking at the critical behaviors that are causing the issue. This is similar to finding the failure mode of the component in the BDA process. This does not give you all the information that a FMEA would but you have a direction. It could be that when a Supervisor is supposed to do an audit, they have quality and safety documentation that takes up the time. A centerline isn’t followed because the employee doesn’t believe that it is correct, the countermeasure didn’t work because when setting up for the next run, the sequence is wrong and it isn’t set up correctly.

The next step is related to finding what is behind the behavior. This can be workload – What to say no to. This can be a process that was not fully understood when it was changed and implemented. It could be the set-up of equipment that did not have buy-in from operators or the informal leadership. This is really the root cause of the problem. But now what? Carrots and sticks and a little imagination.

The reason people aren’t following a process or doing what is needed is rarely because of intelligence or someone coming in and saying, I want to do stuff wrong today. There is always a kernel of truth behind deviation and that needs to be addressed and worked on. This becomes the carrot. Centerlines not being used – Is it because this has been tried before and it didn’t work or because the operator expressed their concerns and they were not empowered to move forward or something else. Deal with that small truth to win over the skeptics to the process. Also, if there is too much work to be done, it is your job to clean this up or at least force rank and develop if – then statements so that the individual can be successful without dealing with a 10 pounds of stuff with a 5 pound bag.

The stick is not nearly as fun but still important. This is the penalty if work is not performed correctly. I am all about making the work place a positive environment and that means ensuring that everyone is doing their work correctly and not creating more work for someone else. Didn’t perform centerline review or move them without notification. Retraining / discussion / discipline. Audit sheet not filled out? Retraining / discussion of the issues / discipline. I wish there was a way around this but I have not found one. It can’t be a surprise. This should be well understood what the path is for non-compliance. It should also be very clear and purposeful that the goal is the improved process. Also, it has to be absolute and for all. Not just the “bad” performers but Johnny has been here for 20 years, so let’s give him a pass. Everyone, everytime.

Imagination is for mistake proofing the process so it can’t be performed incorrectly again. This could be a permanent setting instead of a centerline. It could be an audit sheet that is tied directly to the other documentation that is already being performed so it flows the same way as before the process was changed. The process steps are now automated so that at a press of a button the equipment is lined up and ready to go.

Root Cause Analysis is a great tool for troubleshooting, training, and developing a continuous improvement mindset and it is not limited to the equipment but needs to be expanded to HR, QC, Safety and any other point that the business is impacted by.

 

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