August 28, 2007 | Mark Paradies

Applying Lean to Root Cause Analysis and Corrective Action Programs

I presented my paper at the IEEE/HPRCT Human Factors and Power Plants Conference. The paper for today is titled:

Improving and Existing Root Cause Analysis and Corrective Action Program

I had two attendee participation sections of the talk. These mini-Kaizen events required small teams to develop ideas based on Lean thinking to improve root cause analysis.

The first session looked at problems that cause waste in root cause analysis. The teams identified a waste type and develop a possible solution.

Heres what the teams said:

1. Waste: In an investigation, do things (interviews, evidence collection, …) over and over and waste time and effort because we didn’t plan enough before starting the investigation.

Solution: Better training for people so that they will be more efficient in performing the investigation, especially the pre-investigation planning.

2. Waste: People (including the facilitator/team leader) change in the middle of an investigation or multi-tasking (trying to get their regular work done) plus doing investigations just for political reasons.

Solution: Management needs to value investigations so that they assign adequate resources. Also, management need to stop requiring political investigations. How to get this accomplished? ????

3. Waste: Can’t get buy-in to corrective actions and waste time responding to push-back to effective corrective actions.

Solution: Involve management in corrective action development.

4. Waste: Takes to long to assign an investigator (evidence disappears, people’s memory isn’t fresh).

Solution: Pre-select and designate investigators and assignment is automatic.

5. Waste: CARB (Corrective Action Review Board) review and approval of an investigation is a waste of time (doesn’t add value).

Solution: Get good scope and charter from senior manager up-front. Give charter to CARB before review. May avoid the “You brought me the wrong rock” syndrome. Also, have a standard design for reports. May also eliminate CARB review of report (it is the team’s report) and only allow CARB to select corrective actions to implement.

6. Waste: Can’t get qualified people assigned OR not enough people assigned OR assign a single investigator when a team was needed. Insufficient or incorrect resources cause delays and waste.

Solution: Get adequate pool of people (cross functional) trained and assigned to investigations from a full-time investigator pool.

7. Waste: Interviewing does not get “fresh” information – all the stories are too much the same. Waste time collecting the decided upon story.

Solution: Develop a standardized list of questions focusing on the “What” on-line to be completed by the supervisor before the crew goes home.

8. Waste: Time wasted trying to gather information at the scene.

Solution: Provide supervisor with evidence collection form and training on evidence preservation/collection.

9. Waste: Waiting to decide to investigate an incident while management decides if the investigation is worth investigating.

Solution: Assign a single person to decide if an investigation is required.

The second attendee exercise was to look at there root cause analysis system and Corrective Action Program and make it more efficient by applying lean thinking. They could choose one of three topics to attack:

1. What does the customer want (Customer Focus)?
2. Process improvements (making your root cause process more efficient).
3. Apply 5S (Sort, Set Order, Standardize, Shine, & Sustain)) to improve your root cause analysis.

Here is what the teams reported were their ideas:

1. Customer Focus: Educate the customer. Head CAP guy ASKS senior management sponsor what they want and then discuss what root cause analysis can produce.

2. Apply 5-S:

Sort – Sort incidents into equipment or human performance

Set Order – Develop a checklist for the investigator.

Standardize – Adopt a standard report format.

Shine – Provide training to have proficient investigators/teams.

Sustain – Do evaluations of investigations an improve as required.

3. Process Improvement: Instead of department head assigning an investigator and the “letting go” of the investigation, the department manager should assign the investigator/team and then get daily/weekly feedback (updates) from the team.

4. 5-S:

Sort – Sort out tools required for investigation.

Set Order/Standardize – Organize tools into a standard toolbox and a standard list of questions to be asked. .

Shine/Sustain – Continue to use tools.

5. Customer Focus: Develop a written charter and scope and provide it to the CARB and (if applicable) get the DOE (Department of Energy) rep involved early. Provide training for managers and management sponsor so that they understand the process and the value added. Must determine what the customer wants.

6. Customer Focus: CARB  should want (and focus on) preventing incident recurrence. How do you sell root cause analysis is designed to prevent incident recurrence/prevention? Need to understand CARB’s mental model. Need high level by-in to CARB reviews to prevent CARB membership from becoming a revolving door.

7. 5-S of Prep for Investigation:

Sort – Sort out what is needed to perform investigation. Tools, projector/computer, interview sheets, measurement devices…

Set Order – Get a box or room and put all the “stuff” needed there. Pre-set-up..

Standardize – Checklist for replentishing supplies so that the room stays properly stocked. .

Shine/Sustain – Keep the room/box stocked so that it is always ready.

8. 5-S:

Sort – Develop a list of info requirements for an investigation including extent of condition and extent of cause. Also list should include who should be on a team for types of investigations.

Set Order – Develop a standard investigation order that includes checking operating experience.

Standardize – Develop a standard procedure for performing an investigation … a checklist!.

Shine – Continue to look at  priorty/order of steps in an investigation. .

Sustain – Conducting assessments of investigations to improve.

9. Process Improvement: Why do people not want to do investigations? Look at investigation requirements and plan/look at time required/what is required. Make investigation their primary duty. Give people the time needed to do a proper investigation. Have a senior level manager champion to make sure resources are available.

– – –

One more idea. After the presentation someone suggested:

Have “in-process peer reviews” rather than post-investigation peer reviews. Designate the reviewer when the team is assigned and have them perform continuous reviews as the investigation progresses. MUCH MORE effective than post investigation review. Also, people must perform investigations frequently enough so they don’t forget lessons learned about performing better investigations.

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