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Root Cause Analysis

Improving Performance for Bottom-line result

Oleh : Halomoan Sianipar
• Root Cause Analysis is a method that is used to address a
problem or non-conformance, in order to get to the “root
cause” of the problem. It is used so we can correct or
eliminate the cause, and prevent the problem from
• Root Cause is the fundamental breakdown or failure of a
process which, when resolved, prevents a recurrence of the
• Or, in other words
• For a particular product problem, Root Cause is the factor
that, when you fix it, the problem goes away and doesn’t
come back.
• Root Cause Analysis is a systematic approach to get to the
true root causes of our process problems.

Problem versus Opportunities
• Problem -> Reactive
– a negative deviation from a performance form.
– Problem -> action to fix it – never improve /progress
– We work on problem, we are working to maintain the
status quo and we never be able to progress

• Opportunities -> Proactive
a chance to achieve a goal or an ideal state. We are going
to make some change to increase our performance Norms
or status quo

Opportunity graph
A chance to achieve a goal
or an ideal state
A negative deviation from a
performance norm
Sporadic versus Chronic Events
• Sporadic
– A dramatic event has occured
– Tend a lot of attention, urgent and immediate action
– Only one time and one mode ussualy
– Do cost a lot of money when they occur
• Chronic
– Not very dramatic, happend over and over again
– Accepted as part of routine -> become a cost doing
– Ussualy no very costly
How to handle chronic items
• We tend to elliminate the chronic or repetitive
event . Then elimination would actually cause
the status quo to improve , this improvement
is the equivalent of realizing an opportunity ,
we work on opportunity , the organization
• We have to look at significance of chronic
RCA as an approach
RCA as an approach
• I don’t have time to do RCA -- oxymoron
• They are so bussy fighting fires, the do not
have time to analyze why the event occurred
in the first place
----- Is this your maintenance strategy? The
organization will never progress, because
no level of dedication is being put towards
getting rid of need to do the reactive work
RCA as an Approach
• RCA is certainly applicable to both chronic and
sporadic events
• Focusing RCA only for sporadic item is not
optimizing its potential for corporation, just
reactive situation
• To solve the chronic events down to their roots
causes and pass the knowledge on to others in
corporation who may accepting them AS A COST
FMEA Modified
Failure Mode and effect Analysis (FMEA).
The modified Approach
• Traditional FMEA is probabilistic
– What might happen tomorrow as we are in what
did happend yesterday
• Modified FMEA process to help us to uncover
the problem and failures that currently
occurring. This allow us to see what the real
cost of these problem is and how they are
really affecting our operation

Traditional FMEA
Modified FMEA
Modified FMEA
Seven basic steps
1. Perform preparatory Work
2. Collect the data
3. Summarize & encode results
4. Calculate loss
5. Determining the “ Significant” view
6. Validate result
7. Issue a report
1. Perform preparatory work
• Define the system to analyze
• Define undesirable event (an desirable event is anything
that causes downtime an injury, an environmental excursion or
a quality defect)
• Draw block diagram Describe the function of
each block
• Calculate the “gap” (Gap analysis will Vissualy show where
we currently are vs. Where we could be)
• Develop preliminary interview sheets and
Develop Preliminary Interview and schedule
• To design an interview sheet to collect data consistent
with undesirable event definition and set up schedule
of people to interview:
– Subsystem -> correlates to the block in block diagram
– Event -> the actual undesirable event that matches the
definition we created earlier
– Mode -> the apparent reason that undesirable event
– Frequency per year -> The number of times the mode
actually occurs in a year’s time
– Impact per occurence -> actual cost of mode when it
– Total loss per year -> it is calculated by simply multiplying
the frequency per year by the impact per occurance
2. Collect data
• All Data can be retrieved from CMMS (some
time data from computer is suspect at best
• Collecting data from people through the use
• Structure interview will use event definition
and a block diagram of proses flow
• Interview across dicipline (maintenance.
Operation, PE, etc)

3. Summarize and Encode Data
• Be careful, not have redundant events and are
essentially “double dipping”

4. Calculate Loss
• Total Loss = Frequency x Impact
5. Determine The Significant View
To determine which event out of all the ones we listed are significant
The Proact RCA Method
• RCA Tool can be used in a reactive fashion and
/or a proactive fashion
• The greatest benefit from performing RCA will
come from chronic event, using RCA in a
proactive manner
The Proact RCA Method
Preserving Event Data The 5-P’s

5-P’s Concept
1. Part (fisik & tampak
Contoh Industri Proses:
- Bearing, Seal & Flanges
- Coupling, Mur & Baut
- Peralatan Proses
- Dll
2. Position (fisik & waktu)
- Posisi tampak lingkungan
- Posisi Kejadian
- Posisi detail bagian yang
mengalami kejadian
- Dll

3. People (orang yang memiliki info ttg kejadian)
- Saksi Kejadian
- Personel maintenance
- Personel teknik
- Dll
4. Paper (cetak & electronik)
- Laporan data laboratorium
- Spesifikasi teknik
- Prosedur/kebijakan
- Dll

5. Paradigms (paradigma)
Pernyataan -pernyataan yang mempengaruhi
rekomendasi dan pengambilan keputusan
- Kami tak punya waktu untuk RCA
- Kami sadar bahwa keselamatan adalah
faktor utama , tapi biaya tinggi
- Alat ini memang sdh tua, pantas saja
gampang rusak
• People,
– Who we need to talk to initially in order to
obtain information about an event (be physical
observer or witness to the event)
• People must feel comfortable around an interviewer
and not intimidated
• Experts estimate: app. 55 to 60% of all
communication between people is through Body
language, app 30% by tonal voice, 10-15% is through
the spoken word
• Paper,
– Paper data is probably the most understood form
of data.
– Avoid no collecting paper data for the sake of
developing a big file. Data must relevant to the
analysis at hand.
– Typical paper data: Chemistry lab/metallurgical report,
specification, procedures, policies, financial report, training
records, maintenance/production hsitories, DCS strips

• Paradigms
– Paradigms are recognizable because repetitive
themes ar expressed in these interview from
various individual.
– When a certain population share the mindset it
become population
– Common paradigms: this is imposible to solve, we
do not have time to perform RCA, it is old
equipment, it is supposed to fail, we know because
we have been here for 25 years, etc
Data Type:_________ Responsible:___________
Completion date:___/___/___
Person to interview/item to be collected: _____
Data Collection Strategy: __________________
Ordering The Analysis Team
Having too many people in a team can force the
goals to be prolonged due to the dragging on of too
many opinions.
• The member of RCA:
– The Principal Analyst (PA)
– The associate analyst (optional)  inputing data
– The experts  “Nut and Bolt” expert
– Vendor  an excellent source of information about their product
– Critics  They will force the team to see the other side of tracks and
find holes in logic by asking persistent question
Principal Analysis (PA)
• Technical Expert should Not lead the RCA team
• Unbiased
– The Leader of an RCA should have nothing to lose and nothing
to gain by outcome of the RCA
• Tenacious/Persistent
Individual who are successful as PA’s are those who do notgive up
in times of adversity, They do not retreat at the firist sign of
resistence, they painstakingly persistent and tenacious (gigih dan
• Diplomatic
– A great PA. Will know how to handle a such situation with
diplomacy, tatcfulness, and candidness
• Facilitator NOT Participator
Analyzing Event Data
Logic Tree
Logic Tree Architecture
• A Logic Tree is combination Logic diagram
(typically a decision flow chart that will ask
question, and depending on the answer, will
direct the user to a predetermined path of
logic) and Fault Tree (probabilistic tool that
uses a graphical concept that start with a
hypothetical event)
• The Event
– Undesireable outcome that is being analyzed
– Must be a fact verified
– Equipment, loss of function of a piece of
equipment and/ or process
– Production: The Reason we care (we could have
sold the product for a profit.
• The Failure Mode
– How the event has occured
– Must be a fact verified
The Hypotheses
- Hypotheses are responses to the “How Can”
- How could the preceding event have occurred
- Hypotheses that are accepted without validation are
merely assumtion.
- All hypotheses must be supported with hard data.
The initial data was collected in 5-P’s
- The 5-P’s data will ultimately be used to validate
hypotheses on the logic tree
– Data verified will be maintained on” Verification Log”
– Hypotheses are proven to be true and become facts

• Physical Root Causes
– The first root level causes that are ecountered through the
reterative process
– Tangible roots or component level roots
– All physical roots causes must also endure validation to
prove them as facts
• Human root Causes
– Always trigger a physical root to cause
– HR roots are decision error that result in errors of
ommission or commision (not to do something we should
have done)
– Switch “How can” to Why (why they made decision thay
they did)

• Laten Root Causes
– LT roots causes are organizational system that
people use to make decision
– Defined as “... Whose adverse consequences may
lie dormant within the system for a long time, only
becoming evident when they combine with other
factor to breach the system’s defenses
– Rules, operating procedures, maintenance
procedures, etc
Communicating Findings and
• An RCA should not be deemed succsesfull unless
something has improved as a result of implementing
recommendations from the RCA
• The Recomendation Acceptance Criteria:
– Eliminate or reduce the impact of the cause (MTTR,MTBF)
– Provide a _____% ROI (20%, 50%)
– Not conflict with capital project already scheduled
– List all the resources and cost justifications (cost-benefit
– Have a synergistic effect on the entire system/process (one
area look good at the sacrifice of other up and
• Developing Recomendation
• Developing The Reports
• The Final Presentation
• Developing Report:
1. The Executive Summary
a. The Event Summary
b. The Event Mechanism
c. The root Action Matrix
1. The Technical Section
a. The identified Root Cause
b. The type root cause
c. The responsbility of executing Recomendation
d. The detailed Plan to execute Recomendation
1. Appendices
a. Recognation of All Participan
b. The 5-P’s Data Collection Strategies
c. The Team Charter
d. The Team Critical Success Factor
e. The Logic Tree
f. The Verification Log
g. The recomendation Acceptance Criteria (if applicable)

PRIDE to be Excellent