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1.004 JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

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  • DR WILLIAM CORCORAN
    Joe, I urge you to obey the Ten Commandments of Issue Investigation (aka Root Cause Analysis). The first one is: Make sure all facts stated in the Issue
    Message 1 of 1 , Sep 3, 2011
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      Joe,

      I urge you to obey the Ten Commandments of Issue Investigation (aka Root Cause Analysis).

      The first one is:

      Make sure all facts stated in the Issue Investigation Report (aka Root Cause Analysis Report (RCAR)) are supported by evidence.



      The rest are equally basic. They are all available at
      http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/database

      Be sure to click on the left hand column head to get the rows in the right order. Also not that a "printable report" is available by clicking on "printable report" above

      Also, I have added a little to Bob Nelm's excellent summary.

      Take care,
       
      Bill Corcoran

       
      William  R. Corcoran, Ph.D., P.E.
      Nuclear Safety Review Concepts Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      860-285-8779
      William.R.Corcoran@...


      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
      Method: Mastering Investigative Technology
      Message: A good investigation makes the despicable explicable.


       
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      --- On Thu, 9/1/11, Sam Hobbs <sam.h.hobbs@...> wrote:

      From: Sam Hobbs <sam.h.hobbs@...>
      Subject: RE: [rootcauseconference] SUMMARY: JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?
      To: rootcauseconference@yahoogroups.com
      Date: Thursday, September 1, 2011, 9:58 PM

       

      Joe,

       

      Thanks for asking your questions and for providing your wind up summary, and thanks to all who posted suggestions for you.

       

      Although, I would like to think that I am not a novice anymore, this has caused me to think hard about the things I thought I knew and about how to do a good job.

       

      I’m looking forward to seeing another of your questions or topics! .

       

      Sam

       

       

      From: rootcauseconference@yahoogroups.com [mailto:rootcauseconference@yahoogroups.com] On Behalf Of Joe the Novice
      Sent: Thursday, September 01, 2011 8:47 AM
      To: rootcauseconference@yahoogroups.com
      Subject: RE: [rootcauseconference] SUMMARY: JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      To all:

      This is what I learned from all of you about “how I can learn about root cause analysis.”  I have done my best to list my learning’s in the order in which I should pursue them.

      ===============================

      ASK QUESTIONS ON THIS FORUM.

      Keep a list of the questions that occur to you as you are working. Feed them to these groups as time permits.

      ATTEND EXISTING COMPANY-SPONSORED TRAINING, if any RCA-training currently exists.  Unfortunately, my company does not offer this kind of training.  The closest thing to it is some bearing failure analysis classes.  I will attend these classes to see what is being offered.

      Be aware of training offered by organizations like ANS and HPRCT.

      VISIT SOME GENERIC WEB SITES:  Some that were recommended are:  http://www.maintenanceworld.com/root-cause-analys.htm, http://www.bill-wilson.net/root-cause-analysis.

      READ ARTICLES from the Internet.  Some recommended articles were:  http://www.systems-thinking.org/rca/rootca.htm, “Getting Root Cause Analysis to work for you” by Alexander Dunn: http://www.maintenanceworld.com/Articles/plantmaintenance/root-cause-analysis.pdf, “Root Cause Analysis – Not what you might think” by C. Robert Nelms: http://www.maintenanceworld.com/Articles/nelmsc/rootcause.pdf

      Subscribe to Bill corcoran's free newsletter by sending an e-mail to

      TheFirebirdForum-subscribe@yahoogroups.com


      READ RCA REPORTS.  Get a feel for what I like and don’t like.  Strive to be better than the best.  Some links to many reports are:  http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/links/Event_Reports_and_RC_001017524478/, and

      http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Pract ice/files/Root%20Cause%20Analysis%20Reports%20/.

      BE AWARE OF REFERENCE MATERIALS:  I have been given a lot of links to a lot of comprehensive-looking resources:  http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/database


      READ BOOKS.  Several people mentioned Sidney Dekker's, The Field Guide to Understanding Human Error.

      SET-UP SOME PARAMETERS for judging different methods.  Prioritize them.  Some parameters might be:  More practical training than theory; Available tools; Instructors with practical experience; A scalable method (suitable for small and large investigations); Do you prefer on-site training or off-site? (personally I don’t like on-site because people tend to be less focused); Cost; The number of people allowed in each ! class; Instructors are able to give you examples that your line of work can recognize; What other people say about the training program; Instructors available for on-site guidance after the training program.

      WRITE A PAPER TO SUMMARIZE MY LEARNING’S:  It should be an introduction on the subject RCA, and I should write it with the management team in mind.  I should focus the paper on what the situation was on problem solving in our organization, what RCA is, and how RCA could help us.   I should also talk about what needs to be in place to get RCA to work.

      PICK AND METHOD AND USE IT.  It doesn’t really matter which one I pick, as long as I use it as intended.  If I need to change or modify methods later, I can. Be sure to obey the ten commandments as suggested above.

      DO RCA’s ON SMALL THINGS FAST, so that I’ll be e bit experience for the big ones.


      MOST DIST UBRINGLY, A LOT DEPENDS ON ME, as a person, which makes me a little nervous.  I have been told to take advantage of my own ignorance, and ask questions, and realize that they might not expect too much from me.  I am to be very, very curious.  One person said that “IF I have what it takes to be a good RCA lead person, others will be satisfied when I am satisfied.  I am not to worry, and to have fun.

      Thank you all very much for this.

      I will ask another question either later today or tomorrow.


       

       

       

       




      From: rootcauseconference@yahoogroups.com [mailto:rootcauseconference@yahoogroups.com] On Behalf Of Tore Skoglund
      Sent: Wednesday, August 31, 2011 1:15 PM
      To: rootcauseconference@yahoogroups.com
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      Joe,

       

      if you are allowed to go to 3 different training programs that would of course be the best test for your organization. I don’t think many managers would allow that, so it sounds like you hav! e a good sponsor in your organization. Another approach could be to se t up some parameters that are important for your organization and check them out before you decide what training program to go for. Also you should prioritize the parameters so you know what is most important and not so important / nice to have. Maybe we could work out a list together on the forum? I am also thinking that not only should you look for a training program that do a good training, but also available documentation/tools, a program that also focus on implementing the process, etc.

       

      Here is a list to start the brainstorming:

      ·      More practical training than theory

      ·      Available tools

      ·      Instructors with practical experience

      ·      A scalable method (suitable for small and large investigations)

      ·      Do you prefer on-site training or off-site? (personally I don’t like on-site because people tend to be less focused! )

      ·      Cost

      ·      The number of people allowed in each class

      ·      Instructors are able to give you examples that your line of work can recognize

      ·      What other people say about the training program

      ·      Instructors available for on-site guidance after the training program

      ·      Etc

       

      BTW: the paper I wrote is in Norwegian. I tried it on Google translation and lets just say that it didn’t do a good job translating it. When find the time I will translate the paper for you.

       

      -Tore-

       


      To: rootcaus! econference@yahoogroups.com
      From: joethenovice@...
      Date: Tue , 30 Aug 2011 15:29:04 -0400
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      Tore,

      Now I really like this idea a lot.  Write a paper!  That’s how I think best, by writing, so this fits me to a tee.

      I also like each of the three articles.  I’ve already read them, and can see a thread developing.

      And those web sites are perfect.

      I am saving all these messages in a special folder so that I can refer to them later.

      What do you think of my idea to pick 3 or so training programs to audit?

      After all this reading, I’ll be in a better position to judge them.

      PS:  Can you share the paper that you wrote to your management?

      Joe the Novice

      (seeking help with root cause analysis)

       

      From: rootcauseconference@yahoogroups.com [mailto:rootcauseconference@yahoogroups.com] On Behalf Of Tore Skoglund
      Sent: Tuesday, August 30, 2011 2:38 PM
      To: rootcauseconference@yahoogroups.com
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      Joe,

      < div>

       

      When I implemented RCA in the organization I worked for one of the first things I did was to write a paper. This was an introduction on the subject RCA and I wrote it with the management team in mind. I focused on what the situation was on problem solving in our organization, what RCA is, and how RCA could help us. Also I said something about what needs to be in place to get RCA to work. Below are links to three articles I read in the beginning that inspired the paper I wrote.

       

      The first thing you could do is to read this article:

      http://www.systems-thinking.org/rca/rootca.htm

      Even if I today don’t agree with everything the author is saying you have to love scenario #2 about the Plant Manager.

       

      Next I would read: “Getting Root Cause Analysis to work for you” by Alexander Dunn:

      http://www.maintenanceworld.com/Articles/plantmaintenance/root-cause-analysis.pdf

       

      There was one quote from the article I remember today, and I am still using it: “If you haven’t got time to stop these failures from recurring, how are you going to find the ! time to keep fixing them?”

       

      Then I would read “Root Cause Analysis – Not what you might think” by C. Robert Nelms: http://www.maintenanceworld.com/Articles/nelmsc/rootcause.pdf

       

      These are the articles that started my interest for RCA. Not only did they give me an idea about what RCA is, but also the problems you encounter getting people to accept that we need to spend time understanding our problems.

       

      A couple of web sites I use to find articles:

      http://www.maintenanceworld.com/root-cause-analys.htm

      http://www.bill-wilson.net/root-cause-analysis


      -Tore-

       


      To: rootcauseconference@yahoogroups.com
      From: bob@...
      Date: Mon, 29 Aug 2011 16:49:05 -0400
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      Tore,
      !
      Thank you for replying.

      My company is just starting with RC A, and they have asked me to “make it happen” here at my site.  I have searched the internet and am overwhelmed with different approaches, ideas, suggestions, vocabulary, etc.

      I am so glad to hear from a person that might have been in my shoes a while ago.

      Can you suggest any favorite articles, books, web sites?

       

      Thanks again,

       

      Joe the Novice

       

       

      From: rootcauseconference@yahoogroups.com [mailto:rootcauseconference@yahoogroups.com] On Behalf Of Tore Skoglund
      Sent: Monday, August 29, 2011 2:49 PM
      To: rootcauseconference@yahoogroups.com
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      Joe,

       

      I don’t have any definitive answer to you, but I can tell you how I learned about RCA. The first thing I did was to read articles I found on the Internet. That gave me an idea about the! principle and philosophy behind RCA. It also taught me that there are may different methods around. For me it was a great help to be able to go on a 2-day training course introducing the method my work place had chosen. That also gave me a book describing the RCA method. Last, but not least, talking to people with experience has given me the most help. So you are on the right track joining this forum.

       

      -Tore-

       


      To: rootcauseconference@yahoogroups.com
      From: bob@...
      Date: Mon, 29 Aug 2011 12:58:17 -0400
      Subject: RE: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      To all,

       

      How can I learn more about Root Cause Analysis?

       

      Joe the Novice

       

       

      From: rootcauseconference@yahoogroups.com [mailto! :rootcauseconference@yahoogroups.com] On Behalf Of C. Robert Ne lms
      Sent: Monday, August 29, 2011 9:56 AM
      To: rootcauseconference@yahoogroups.com
      Subject: [rootcauseconference] JOE THE NOVICE WANTS TO KNOW: How Can I Learn about Root Cause Analysis?

       

       

      To all:

      It has been suggested that I start a series of threads where we do our best to answer as if we were talking to a novice.

      The novice’s name will be “Joe.”

      Please address all your comments to “Joe.”

      I will try my best to strongly moderate these threads.

      By this, I mean that I will discourage discussion amongst the various members of this forum. 

      Please address all of your comments to “Joe.”

      I will pla! y the role of “Joe” by asking follow-up questions.

      Please try to work with me on this.  If it does not work, I’ll change the rules.

      Thanks, ahead of time, for your cooperation.

      PS:  These “rules” only apply to the “Joe the novice wants to know……” threads.

      PPS:  Remember:  Keep it simple!

       

      C. Robert (Bob) Nelms

      bob@...

      Forum Moderator

      Root Cause Live

      www.rootcauselive.com

       

       

       

       

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