root causes analisys


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www.armsreliabilit.com/rca

Training in RootCause Analysis

ARMS Reliabilit has beendelivering Apollo Root CauAnalsis courses throughothe world or the past 16 both at public seminars anclients sites.

Since 1997 we have trainedover 20,000 people worldwARMS Reliabilit has trainavailable to meet our traineeds in North America,South America, Europe, AsArica and Australia.Boo courses online atwww.apollorootcause.com

ROOT CAUSE ANALYSIS PRESENTEDBY ARMS RELIABILITY

Over the past 16 ears ARMS Reliabilit have been teachingRoot Cause Analsis across a wide cross section o industries.

In that time we have seen some common traps that preventcompanies realising the ull benet o adopting a root causeanalsis process.

We now the power o an eective problem solving processwhich:

9 Avoids the blame game

9 Embraces all perspectives

9

Is simple and can be used b anone9 Gives the condence to see creative and eective

solutions or an problem

9 Eliminates the usual rustration and arguments

9 Creates a common realit or a problem

9 Ensures bu-in rom all staeholders

9 Includes user-riendl sotware to create evidenced-

based cause & eect charts

But despite high acceptance and excitement ollowingattendance at a training course, we still see some pitalls thatcan be avoided. This eboo las them bare. Our intent is inline with our training, a problem recognised is a problemhalf solved.

These chapters are written b sta o ARMS Reliabilit whoare experienced in delivering Root Cause Analsis trainingand conducting investigations or companies rom a widecross section o industries.

Foreward By Michael DrewCEO, ARMS Reliability

View Public Training Schedule

Request Quote or Onsite Training
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North America | South America | Europe | Asia | Arica | Australia

Why RCA Doesnt Work

The Impact o Language on RCA Investigations 2

Tips & Hints or Creating More Eective RCA Cause-And-Eect Charts 6

Root Cause Analsis and The Blame Game 15

Listen to our Operators 21

RCA Training or ou and our Team...Value or Mone? 23

Conclusion and Additional Resources 27


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THE IMPACT OFLANGUAGE ON RCA

INVESTIGATIONS

CHAPTER 1
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By challenging the imprecise wordsconsistently, you will create CLARITY wherepreviously there was none.

How man times have ou read an incident report and been let wondering what

was being investigated, or what the causal relationships were all about? This oten

occurs when vague or nebulous descriptors are used to explain causal relationships.

Below we give some examples o non-descriptive language commonl ound in

incident reports and suggest strategies ou can use as a Root Cause Analsis

acilitator to prevent ambiguit or misinterpretation.

Three tpes o vague descriptors commonl used to explain causal relationships,

and how to address them:

Wrong | Incorrect

Poor | Inadequate | Ineective | Insucient

Time | Speed | Age | Weight

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Poor | Inadequate |Ineective | Insufcient

EXAMPLE

Poor maintenance

EFFECTS

Leads easil into the categorising o causes, such as humanerror, which can quicl move down the blame path. We willtend to end up with the same generic tpes o solutions or eachcategor. These terms are oten emotive, infammator, and canlead to confict.

SOLUTION

As a means o clarication, as something to the eect o whatis it that maes the maintenance poor? B challenging theimprecise words consistentl ou will create CLARITy wherepreviousl there was none.


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Time | Speed | Age| Weight

EXAMPLE

It was the shaft was worn because of wearing over time

The Car crashed because the person didnt see the other car and speed

The pipe corroded because it was a metal pipe and age

We couldnt stop it because it was rolling and its weight

Another example of a different context would be maintenance...i.e the machine failed because of maintenance.

EFFECTSNow whilst all o these causes probabl have some specic relevance within

the causal pathwas in which ou nd them the all create conusion as there is

no clear descriptor to explain the relationship. This will again lead to subjective

assessments. People will interpret the reerence in their own wa. Speed will

mean dierent things to dierent people, as will weight, age and time.

SOLUTION

Tpicall what is required is to quanti each o these words. In other words:

How much time are ou taling about?, What was the speed?, How old is

it?, How heav is it? and What is it about the maintenance that was less

than adequate?


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Wrong | Incorrect

EXAMPLE

This sort o description is purel subjective, opinionated and manot be based in act. I what we are tring to do is to present theacts then these tpes o words would ail to achieve that.

SOLUTION

your tas as a acilitator is to see clarication o these words.Wh is it wrong? What maes it wrong or incorrect? When thesequestions are ased the responses to them need to be recordedand added to the RealitCharting. The original reerence has beenreplaced b something ar more actual and meaningul.

Become an effective Root Cause Analysis Facilitator.ARMS Reliabilitys Apollo RCA Facilitator Course.
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CREATING MOREEFFECTIVE RCA

CAUSE-AND-EFFECT CHARTS

CHAPTER 2


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There is tendency to see the obvious however. We seethe things that happen, the things that people do. These

are all the action type o causes. What we ail to seeas easily are all o the conditions that are there. Thebeneft o fnding the conditions is that conditions areeasier to control.

Actions or Conditions

Wh does anthing happen???...Because it can!

Too man words

Clues on nding causes

Understanding conditional causes


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Clues on fnding causes

When describing causes, ou are searching or words to adequatel describe the cause. Clues ornding the causes and or the description o these causes can be taen rom the eect

that ou are questioning.

EXAMPLE: Negative publicityWe are looing or at least two causes here (as in each eect should have at least two causes). Whilstsearching or the reason o wh we have an publicit at all, which is probabl the rst cause, we alsoneed to understand what maes that publicit negative, because not all publicit is negative. This wouldthen be the second cause (or perhaps there ma be more than one cause or the negativit so thensecond, third and/or ourth causes ma ollow).

It should be noted that whilst searching or at least two causes it is not restricted to just two causes.This is the basic requirement and et i diligentl challenged more causes ma still be ound. It is the

exhaustive search or causes that will provide the most opportunit or control o our problem, as themore causes ou nd, then the more opportunities ou will have to control change or mitigate aspects othe problem.

EXAMPLE: Hand bleedingI we tae hand bleeding as an example, we are tring to understand what has happened. What wereou doing? is a good question to as and then what happened?. But i I am reall perceptive and Iexamine the word bleeding then I should understand that I must have blood to bleed. So or the handto bleed something must have happened, ie ...ou cut our hand and ou bleed because there is blood inour hand.

EXAMPLE: Delayed shippingI a cause has the word dela in its description, as in delaed shipping, then what does this mean?Dela is a reerence to time so in the causes o the shipping dela there must be some reerence to timeotherwise we havent reall understood what we are looing or. So or shipping dela the causes couldbe something to the tune o a shipment is due (time reerence) and we didnt ship it in the time ramerequired. I ou never have a time rame then ou can never be late so ou need to establish the timerame in the causes o delaed shipping.

This basic understanding could then be applied to all causes.


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Understandingconditional causes

I ou ollow the Apollo methodolog o causal analsis, ou need to nd at least one action and onecondition or each eect, but tpicall there are more conditions. The context o man conditional causes

is that it, something, must exist. Now what does this mean? E.g. To be able to break a rule rstl theremust be a rule. The rule must exist. The same can be said o not ollowing a procedure, or not meetinga standard, not ollowing a protocol. In each case the rule, the procedure, the standard or protocol mustexist otherwise ou can never sa that ou ailed to ollow it or achieve it.

EXAMPLE: Radiator HoseTae a radiator hose or example. your problem would be that ou have lost our coolant. Wh? Becausethe radiator hose has burst. So? Wh does this mean that ou lose all o our coolant? Because thecoolant fows through the hose ..otherwise wh would ou lose an coolant at all?

For a hose to rupture there must be a hose. The hose has to exist. Without the hose there would be no

ruptured hose. So now ou have .. a hose connects motor to radiator(the hose exists), the hosetransports coolant (it has a purpose) and that hose has burst(this is what happened).

There must be a relationship between the hose and the coolant otherwise the hose rupturing will haveno impact on losing coolant. The relationship is the condition in each and ever case as is the existenceo the item in question. The happening, the event, would be the action.

EXAMPLE: Bolt ell outFor a bolt to all out or example, ou must rst have a bolt. The bolt has to exist but what does the

bolt do? It perorms a unction. It has a purpose.

Rather than saing that ou have a bolt as one cause o a bracet ailing or example, simplrecognising the act that the bolt exists as our causal description, it would be more precise to sa whatpurpose the bolt has, that the bolts secure the bracet (thereb recognising that ou have a bolt) andthat that bolt has allen out. What will happen i the bolt alls out? Will it produce the eect ou aretring to understand? I it does then ou have got it right. So i the bracet is secured b a bolt andthose particular bolt alls out wont the bracet ail to perorm its unction? Unless ou can establishthe relationship o the bolt to the bracet, then the bolt alling out will cease to have an impact on theailure o the bracet.


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EXAMPLE: Pipe droppedIn another example the pipe dropped because the scaold collapsed. For thisto mae an sense we rst need to understand the relationship between the two.So unless ou put the pipe on the scaold then the scaold collapsing would haveabsolutel no bearing on the pipe dropping. So to clari, the pipe dropped and thiswas caused b the pipe being on the scaold when the scaold collapsed. A wao testing the logic o this connection is to wor the connection rom right to let.

i.e.. i the pipe is on the scaold and the scaold collapses will the pipe drop?Now this statement is, to all intents and purposes, quite logical but there is a catchhere. It will onl all i it is unsupported b anthing else. you have just identiedanother cause. So in realit what ou are reall saing (woring rom right to let) isthat i the pipe is on the scaold and is unsupported by anything else, then whenthe scaold collapses the pipe will drop. Does this mae sense? yes it does. So ounow now that the logic o that connection is sound. you have tested the logic o theconnection.

HINTIn other words it should mae sense i ou were to read it rom let to right

which is how the caused b logic wors, but that it should also mae sense whenou read it rom right to let. Activel loo or an exceptions that mae a lie out o thisstatement. I ou nd an exception then ou have eectivel ound another cause to addto our list.

Understandingconditional causes


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Too many words

Another area that could be improved upon is in regards to the number o words thatare used to describe causes. A common pitall is to use too man words to describecauses. What is then ar more liel to happen is to combine a couple o causes intoone cause box. The impact o this will be displaed in the logic o the next connection.Because the cause is now ar more complex it is a lot harder to clearl identi speciccauses. Oten causes will be related to a part o the eect but not the other part. So thelogic starts to brea down and the chart becomes harder to understand.

EXAMPLE: Non-return valve ailedWh because it was old and not maintained. you could write this description in onebox but then when ou as the next caused b question ou will get some answersthat relate to Old valve and ou will have others that pertain to not maintained. Ithis were to be included in one connection then it would ail to mae sense. The age othe valve and the maintenance o the valve are separate concepts and the causes oreach o these need to be separated or it to mae an sense in the chart.

B being concise in the description, limiting the description to just 2 or 3 words,

then this combining o causes becomes less possible and the chart will be easier tounderstand.


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There is oten conusion with labelling causes correctl. Some people will label a causeas an action whilst others will label the same cause as a condition. Does thismatter? The answer is es it does. This is based on the understanding that it is easierto control a conditional cause. It is controllable. It tends to deal with tangibles.

The actions, the things that happen instantaneousl, are ar harder to control. Theare unpredictable otherwise we would have done something about it alread, and theare also largel centred around the people elements and thereore it is dicult to getreliable, consistent outcomes rom controls centred on these tpes o causes. So thenes it is important to tr and label causes correctl.

EXAMPLE:Shat is wornI I were to sa that the shat is worn would this be an action or a condition? It is acondition isnt it? It is the state the shat is in prior to anthing happening. I I were tosa that the shat is wearing, what would ou sa? Is this an action or a condition? Itis the action cause that leads to, or causes, a worn shat. I however it is wearing andwearing and wearing, doesnt this become a condition over time? It is the same thinghappening over and over again.

It is all related to how ou see things. How causes are described b individuals willhave a direct impact on how causes are subsequentl labelled.as either actions orconditions. In other words there will be some variations.

Perhaps it is important to understand what is behind the labelling process. i.e. thelabelling o causes as either actions or conditions. It is reall about understandingwhat ou have ound but also what needs to be ound - to discover what is missing andthen to search or it. It is about ensuring that we as the next question - that we dontmiss anthing. It is about that exhaustive search or all causes. This is the real reasonbehind the labelling process.


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I ou have two conditional causes or an eect essentiall ou should automaticallbe searching or an action that made use o those conditions. The labelling processprompts ou to as the next question.

B being diligent in this pursuit ou will nd more causes. More causes are better

because ou now have more opportunities or control.

What is the dierence between actions and conditions?Well the conditions were alread there. It was lie that. The conditions pertain to theabilit o something to happen. The action maes use o the conditions to create an

eect. It tends to be instantaneous in terms o time. It is that thing which is dierent,that has changed.

EXAMPLE: FireI I were to as What are the causes o a re what would ou sa? Well there needsto be some uel. There needs to be oxgen. There needs to be an ignition source. Wellou can have paper, oxgen and matches but that doesnt mean ou have to have a re.Something needs to happen. Something needs to mae use o the conditions that arepresent, the abilit o re to happen, to actuall cause a re. This is what has changed,happened. This is the action. It is that single moment in time when the action maes

use o the available conditions to create an eect. I even one o the conditions wereeliminated the re would have no opportunit to occur.

There is tendenc to see the obvious however. We see the things that happen, thethings that people do. These are all the action tpe o causes. What we ail to see aseasil are all o the conditions that are there. The benet o nding the conditions isthat conditions are easier to control.



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Why does anythinghappen???...Because it can!

This simple statement should bring to mind what all o the conditions are that needto exist or an event to occur. When ou examine the last part o the statement ou areessentiall tring to understand the abilit o something to occur.tring to understandwhat conditions are present.

EXAMPLE: Why does an object all?For example wh does an object (anthing or that matter) all?...It alls because it

can all.

Wh can it? Because it is at height (elevated above a surace).because it is heavierthan air, because it is in the presence o gravit. Surel all o these conditions must betrue or something to all, to be able to all? Then something happens that maes useo these conditions.the action.


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THE BLAME GAME

CHAPTER 3


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Will knowing who did it, stop itrom happening again?


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How oten have ou looed at corrective actions and thought that the would have little,i an, impact in preventing the problem rom reoccurring? It wasnt just once. and itcontinues to happen.

The question is why?

Yet the answer is not a simple or straightorward one.

Do we believe that the person(s) creating these corrective actions are not tring to dotheir best? No I dont thin so. I rml believe that almost all people are tring to do theirbest. So where does that leave us?

We are caught up in a sstem where the reactive, quic xes are the goal, the wa odealing with incidents on a da to da basis. I ou were to have a downtime incident andou were to bring the power bac on quicl ater an outage, or the machine is bac inoperation ater a short space o time then the reaction rom the management group androm all o our peers is tpicall.Well done! Great job! A pat on the bac or those

who have perormed the job well. In other words we give respect and accolades to thosewho can x it quicl. Conversel there is oten little reward or acnowledgement orhours o diligent wor in the pursuit o actions that will resolve the issue once and or all.We reinorce the quic xes.

Now dont get us wrong here because the ability to do thequick fx is and always will be a valuable skill, but the realchallenge is to understand whether we have preventedthe problem rom re-occurring?

What happens ater the initial x is put into place? Where do ou go to rom there? In thecompletel reactive model, the re-ghting model, where breadown maintenance otentaes precedence over planned maintenance (which then sets ou up or the next round oailures), there is alwas a re that needs tending, so we will tpicall tend to jump to thatre, to the next problem on the list. I have dealt with that one, whats next?

The Blame GameFrom conversations with people who attend the courses that are presented in Root CauseAnalsis, something else becomes blatantl clear. We still seem, on man dierent levels,to be plaing the blame game. The question o who still seems to be o paramount

importance to some, perhaps man people. The question to as these people is Willnowing who did it, stop it rom happening again? Now the wa o thining b ar themost common answer to this question will be No(although there are exceptions).So wh do we eel that we need to ocus on the who? I the goal o doing Root CauseAnalsis is to prevent recurrence o the problem the challenge lies not so much in whowas involved but rather emphasising, or ocusing, on what ou can do to stop it romhappening again. This ocus will lead to gathering more actual inormation which is theessence o understanding the problem rst and oremost.


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The who side o the question is prett eas to determine, but i that is what we ocus onthen it is liel to limit thorough questioning, and leads quicl and easil down a blamepath. Sanctions are given or jobs lost, all based on the nowledge o who was at ault.But where does this lead? Wouldnt this lead to a lac o reporting mistaes or aults asthere will be unwanted consequences because o the report? Doesnt it elevate ris asthere would now be a culture o hiding or covering up mistaes? When ou as questions,what are liel to get? The truth?

Something else to consider is whether people intend to cause damage, create ailures,injure themselves or hurt others? Again the overwhelming answer is still NO. Thatpeople are oten involved in man incidents, and mae mistaes, is seemingl theconstant part o the equation. But that is the nature o the beast. People are allible, thedo mae mistaes and no matter how hard we tr to control this aspect, the humanerror side o causes, it is orever doomed to ailure. I we rel on tring to control peoplethen our solutions will have no certaint in their outcome. Going down this path is simplnot reliable.

Hierarchy o ControlThis is echoed in the concept o the Hierarch o control where corrective actionsare placed within the Hierarch, as being either a orm o Elimination, Substitution,Engineering, Administrative or P.P.E. controls.

The rst three o these are perceived to be ver strong controls, or hard controls, withalmost guaranteed, reliable, consistent results. The are however more time consumingand tpicall involve spending mone to achieve our desired outcome.

Administrative controls or the use o PPE as a orm o control are perceived to be sotcontrols. The are relativel quic to implement and dont cost too much and et i ou

were to as the question will the prevent recurrence, almost universall the responsewill be NO!

The ma however satis the need to report. I have ticed the box and created aperception o having done something about the incident.

To tae this a step urther, these sot options now get signed o b managementwho are ull cognisant o the Hierarch o control. I we eep taing the sot optionshowever is it an wonder that we are still re-ghting. I we dont undamentall changeor control causes that create the problem then the problem still has an abilit to happenagain, regardless o the who, the person involved. This could be anone.


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Creating another ProcedureHow oten have ou heard or seen, as a response to a problem .create anotherprocedure? Would ou be certain that this will prevent recurrence o the problem? Itcould be said that ou have tried to control the problem. you can certainl show that ouhave done something. Would it however be deensible in a court o law i someone wereto subsequentl get hurt? I ou expect someone to remember ever single procedure, oever single tas, o the man tass that the need to perorm in ever single da, is thiseasible? And we all now it is a sot control!! An administrative one. So do the courts.

The Argument about SanctionsWho learns the most rom the mistaes that are made? Isnt it the personor the people involved? This was put into perspective or me b anotherinstructor at a conerence in Indianapolis in 2010. He said to me isomeone maes a mistae or instance and the cost o that mistae mightbe, sa, $500,000, and ou are so angered b this that ou then sac theperson who made the mistae (quite possible, even probable)it is liesending someone on a $500,000 training course and then sacing them thenext da. Does this mae an sense?


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LISTEN TO YOUROPERATORS

CHAPTER 4


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The downtime lost on this insignifcantproblem was quantifed to be worth over

$1million in losses to the business. Thesolution identifed during the Root CauseAnalysis equalled $34,000!


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When it comes to looking for failures during a Reliability Study or for causes during a

Root Cause Analysis investigation, Listen to your operators.

The are the ees and ears o our production acilit. it doesnt matter i ou are runninga chocolate actor, bottling beer, or drilling or oil, the all have one thing in common -operators on the ront line.

These valuable members o our team are oten the rst to notice problems occurring;these problems ma onl stop the machine once a shit or a ew minutes while the goand hit the reset button. These high requenc short duration issues oten get reportedbut are not seen or considered as critical because we have not et witnessed a majorstoppage. Ater all, we hit the reset button and the machine starts again.

A ew things start to naturally happen at this stage.

Operators stop reporting aults because nobod does anthing about them operators start to change the operating practice o the machine to allow or these

issues during their shit. This then becomes normal operating practice, without anorm o ris assessment having been perormed. These changes are usuall onlidentied ollowing a major incident investigation. When it is oten too late.

Reliabilit is lie Saet - Ignore the little things and beore long it could be something major.

Typical comments used by operators during Reliability Studies and RCA investigations

are:

Weve been doing it that way for years

We kept reporting it to management

I used to do that task but we removed it from our check list because we never foundanything

Great examples exist lie the operator who used to carr out torque checs on a rotatingpiece o equipment at the end o shit, onl to be told it was no longer required. Two earslater the Reliabilit investigation into downtime on the machine revealed sheared bolts asthe number one ailure mode on the machine. We re-introduce the torque checs and theproblem disappears.

Or the Root Cause Analsis perormed on a light curtain trip that stopped the machineonce a shit or ve minutes. The downtime lost on this insignicant problem was

quantied to be worth over $1million in losses to the business. The solution identiedduring the Root Cause Analsis equalled $34,000! The problem solved.

So during Reliabilit Studies and Root Cause Analsis, listen to our plant engineers,equipment specialists and OEMs, but, whatever ou do, dont orget to Listen to ouroperators.


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ROOT CAUSEANALYSIS

TRAINING - VALUEFOR MONEY!

CHAPTER 5


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Change will only occur when the pain rom

changing becomes less than the pain ostaying the same.

Important questions to ask as you embarkon a training course:

Whoreinforcesthislearningormonitorsthe

standard o acilitation and the reports that aregenerated?

Whoprovidesanyfeedbackorconrmsandendorsesthe process or endorses the outcomes that aregenerated rom it?

Isthereamentororexperttoprovidethe

appropriate eedbac? Isthereacompulsiontouseordemonstrate

competenc in the use o the training material thehave learned?


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Q. Do companies get the most out o the training dollarthat they increase or their employees?

Answer. No!

Whilst training per seis perceived to be important, as evidenced b the volume o training thatoccurs throughout industr, I eel that companies are still not getting the biggest bang or theirbuc rom the training that the provide their emploees.

Training is provided regularl or emploees to attend or the benet o the compan and also o theemploees and in completing the course the emploee(s) will leave with some new nowledge andsills or perhaps with prior nowledge being challenged, changed, reinorced or enhanced.

What then happens though when these people get back into the workorce? Do they apply this new

learning or do they go back into their comort zones continuing to do what they did beore?

I there is no compulsion to utilise their training, then it is quite possible that those people who

have received the training ma not use it, as tring anthing new or dierent oten requires moreinitial eort and it is possible, even probable, that the ma get it wrong to start with and becomedisillusioned b the experience. Practice taes time and we are tpicall, across industries,time poor.

Unless people are given the time and opportunity to practise, using and perecting these new

skills, then there is the chance that they wont use it o their own volition.

Is this the outcome that we desire?

Change will onl occur when the pain rom changing becomes less than the paino staing the same.

Change will occur when there is enough motivation or that change.

People who have attended training are oten perceived to be experts ollowing their return to theworplace. Sometimes this results in being thrown into the deep end o the o the next big incidentthat occurs.

youve had the training!

Oten there is a perception that there is little time available to investigate the root cause

A ew hours or das o training and practice however maes no-one an expert in anthing.It is the constant application or use o this training that will create competence.


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All o this boils down to the question about what structures exist within the company to support

the training (any type o training) that is being provided?

The training itsel starts people along a learning curve and progresses them to a point along thatcurve with as man variations as there are people attending the training as to where the sit alongthat curve, at the completion o the training program.

Important questions to ask as you embark on a training course:

Who reinorces this learning or monitors the standard o acilitation and the reports that aregenerated?

Who provides an eedbac or conrms and endorses the process or endorses the outcomesthat are generated rom it?

Is there a mentor or expert to provide the appropriate eedbac? Is there a compulsion to use or demonstrate competenc in the use o the training material the

have learned?

I there is no strateg in place to address the questions above then do we move training attendeesrom where the sit along that learning curve to application o excellence in the subject matter thatthe were trained in? Surel this is the end goal.

Unless organisational structures exist to support the training then much o it is predestined to ailand not live up to the expected outcomes that generated the initial interest or the training in therst place.

I 6, 12 or even 18 months down the trac the training received is not being used then what will theperception be? The perception at that time ma be that the training was poor, o little value,too hard or didnt wor and so on. The training is then perceived as being inadequate andconsequentl that particular training pacage is not sourced again or ma be sourced rom analternative supplier suppling a similar product to attempt to provide what was initiall sought.

I this ccle were to continue, (which it inevitabl does) without maing changes to how training is

presented and managed, in a ew ears the client compan will be bac to square one and lining upor another go at a training pacage that was presented at some time previousl.

Does this ring any bells with anybody??

It is my opinion that it is not necessarily the training that is at ault here, but perhaps the lack

o eective support or the training. Support should move people sstematicall rom their earllearnings into the application o excellence in its practice and use. I the training is seen to beimportant enough to conduct, then surel this support is where the client compan ensures thebiggest bang or the training buc!

What is the purpose o the training? Is it to bring about some change in the people being trained? Isit to cover/correct perceived weanesses in learning? Upsilling? For whatever reason the trainingis being conducted, the training must be have been considered to have value. Then wh is it thatthere is limited or non-existent support or much o the training ater the course??

Click to learn more about creating an eective problemsolving culture in your organisation
http://www.armsreliability.com/rcahttp://www.apollorootcause.com/psculture.aspxhttp://www.apollorootcause.com/psculture.aspxhttp://www.apollorootcause.com/psculture.aspxhttp://www.armsreliability.com/rca


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CONCLUSION& ADDITIONAL

RESOURCES


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In this eBook we discussed some o the common

challenges our clients ace when acilitating orparticipating in an RCA investigation.

B reading this boo we hope ou have acquired a newperspective on the language used in investigation reports,cause-and-eect relationships, escaping a corrective actionmindset, avoiding the blame game, and where to loo orvaluable acts about ailures.

Its important to have the correct perormance measures toensure the process is adding value to our organisation. ARMSReliabilit is able to assist in improving our RCA program on anumber o levels.Clic to learn more about Continuous Improvement.

I ou are interested in learning more about the Apollo RootCause Analsis method, visit our website or more inormationwww.apollorootcause.com.
http://www.armsreliability.com/rcahttps://secure2.dzign.com.au/apollorootcause/continuousimprovement.aspxhttp://www.apollorootcause.com./http://www.apollorootcause.com./https://secure2.dzign.com.au/apollorootcause/continuousimprovement.aspxhttp://www.armsreliability.com/rca


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Acknowledgements

Apollo RCA: Apollonian Publications, LLC is the owner oApollo Root Cause Analsis and RealitCharting sotware. Apollo

RCA is a powerul methodolog to help ou become one o the best

problem-solver on the ace o the planet.

RealityCharting: Version 6.0 has been released. I ouhave been trained in the past on Apollo RCA methodolog and have

received or currentl own an older version o RealitCharting,you areentitled to a free upgrade to Version 6.0. Contact us to ensure ou get

our ree cop.

root causes analisys

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