Rothstein Associates Inc. Business Survival ™ Weblog

In the nuclear power industry, the primary mission of a root-cause investigation is to understand how and why a failure or a condition adverse to quality has occurred so that it can be prevented from recurring. This is a good practice for many reasons—and a lawful requirement mandated by 10CFR50, Appendix B, Criterion XVI.

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“Lately, I’ve been asked to provide root-cause analysis training more than ever before in my 14 years as an independent quality/lean consultant. This is interesting in the age of Six Sigma, especially because “analyze” is the heart of DMAIC (define, measure, analyze, improve, control).” Read the rest of this entry »

Root Cause Analysis (RCA) is a valuable tool for reliability improvement in manufacturing and production operations. Yet, most efforts to implement an RCA program fail to achieve meaningful results despite significant investments in employee training. What needs to be done to assure that RCA becomes a functional work process in organizations?

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The ultimate goal of Root Cause Analysis (RCA) is to eliminate the actual cause of the problem. If a corrective action, or a series of actions, is implemented and eliminates the cause – thereby eliminating the possibility of recurrence – then that would satisfy the criteria for effective root cause analysis and corrective action.

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In order to support today’s fast-paced business operations, data centers must minimize downtime. This white paper discusses the need to detect system disruptions quickly and explores the challenges of diagnosing system failures.

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CSB Releases New Safety Video, “Inferno: Dust Explosion at Imperial Sugar”

The U.S. Chemical Safety Board (CSB) has released a new nine-minute safety video on the combustible dust explosion at the Imperial Sugar refinery in Port Wentworth, Georgia, which claimed the lives of 14 workers, injured 36, and caused extensive property damage on February 7, 2008.
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“What Went Wrong? Case Histories of Process Plant Disasters and How They Could Have Been Avoided?” has revolutionized the way industry views safety.

The new edition by Trevor Kletz  continues and extends the wisdom, innovations and strategies of previous editions, by introducing new material on recent incidents, and adding an extensive new section that shows how many accidents occur through simple miscommunications within the organization, and how straightforward changes in design can often remove or reduce opportunities for human errors.

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A common problem that Root Cause Analysis teams face when performing a root cause analysis is deciding when to stop pursuing deeper for root causes. The team should work on identifying deeper root causes, because when deeper, underlying causes are identified and addressed, more fundamental, broadly applicable solutions can be developed and implemented.

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The Buncefield Major Incident Investigation Board has published its final report and announced the conclusion of its work.

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The Basics of Root Cause Analysis

Introduction

Root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of incidents with safety, health, environmental, quality, reliability and production impacts.

Simply stated, RCA is a tool designed to help identify not only what and how an incident occurred, but also why it happened. Only when investigators are able to determine why an incident or failure occurred will they be able to specify workable corrective measures that prevent future incidents of the type observed.

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