Solving and Preventing Problems

1. Solving and Preventing Problems Root Cause Analysis Failure Mode and Effect Analysis

2. Goals for Workshop Introduce you to the concepts of RCA and FMEA Review examples of where RCA tools are applied Immerse you in some problem solving activities Direct you to resources for further study (Note: We do not expect to make you RCA and FMEA experts)

3. A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it

4. March 23rd, 2005Texas City, TX BP refinery Isomerization unit startup Liquid hydrocarbons released from blowdown drum Subsequent vapor cloud explodes 15 killed, 180 injured

5. BP Isom Unit VideoRefinery investigation animation Use link to show BP Isom Investigation and have small groups take notes to do a rapid root cause analysis. Results from their discussions can be compared to the actual Root Causes listed on slide 8. Without “tools” for doing RCA, the perceived root causes often differ from the actual root causesUse link to show BP Isom Investigation and have small groups take notes to do a rapid root cause analysis. Results from their discussions can be compared to the actual Root Causes listed on slide 8. Without “tools” for doing RCA, the perceived root causes often differ from the actual root causes

6. Putting you to work(without “tools”) Define the Problem Identify Cause(s) Which causes are at the ROOT (ultimate causes) Suggest Potential Solutions for BP

7. BP’s RCA of the Texas City Event

8. Root Causes Senior executives: inadequately addressed controlling major hazard risk. did not provide effective safety culture leadership did not provide resources to prevent major accidents BP Texas City Managers did not: create an effective reporting and learning culture ensure supervisors enforced plant policies and procedures. incorporate good practice design in the operation of the ISOM unit. ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup effectively incorporate human factor considerations in its training, staffing, and work schedule for operations personnel.

9. The Anatomy of a Problem and the Problem Solving Process in Industry

10. Problem Solving ISProcess Thinking In industry, assigned to teams of stakeholders

11. Solutions are the focus, NOT BLAME

12. Let’s Start SimpleWhat happened? What caused it? What is the solution?

13. Language and story-telling are linear, Cause and Effect is Non-linear Pain CB Injury CB Fall CB Slipped CB Wet surface CB Leaky Valve Solution = fix valve and clean up floor

14. Always at least TWO causes Action Causes = Triggers Conditional Causes = Pre-existing conditions

15. It is too easy to focus on action causes CONDITIONAL Oxygen in the atmosphere Oily rags not confined and properly disposed Lack of no smoking signs in area Lack of mandatory employee safety training Lack of mandatory safety inspections ACTION Match strike: employee sneaks a smoke and burns down warehouse WHAT IS THE SOLUTION ?

16. Lack of Focus on Solutions

17. Root Cause Analysis (RCA) Example Why are CCs not implementing recommended biology curriculum reform recommendations? Solutions require an analysis of root causes. Many reports are solution driven and not focused on root causes. RCA: Identify conditions (causes) and then keep asking WHY? Every recommended reform effort should connect to a root cause, and presented with a solution that can be implemented…ie. HOW?

18. Simple Example Conditional Cause: My administration is not supportive of implementing the reform recommendations at my institution. Action Cause: I asked for release time to develop a project and my administration said: “No” Published Solution: Community Colleges must get institutional “buy in” and administrative support for reform of science curricula. Great . . . . . . . . . HOW? Focus: WHY is the administration not supportive?

20. Root Cause Analysis Tools The Five Whys Fish Bone Diagrams Matrix Diagrams Fault Tree Analysis

21. Five Whys or Why-Why As always, define the problem Identify a starting point (a causal level) Ask Why (generates a new causal level) Continue rounds of WHY Look for “points of ignorance” these are launching points for collecting more information or……. ROOT CAUSES for developing solutions.

22. WHY- WHY Contamination in Bioreactor – WHY? Filter Failed – WHY? Accidentally shipped as part of a bad lot – WHY? Employee mixed numbers on released lots – WHY? Inadequate lot tracking system – WHY? We have reached a Point of ignorance

23. Fishbone Diagram Assembling the Fish At the head of the Fishbone is the defect or effect The major bones are the capstones, or main groupings of causes. The minor bones are detailed items under each capstone. Common capstones: People Equipment Material Information Methods/Procedures Measurement Environment Test logic of bones: top-down OR bottom-up like: this happens because of g; g happens because of f; f happens because of e; e happens because of d ….. Etc.

25. Combining ToolsUse “5 Whys” to analyze bones

26. Matrix Diagrams A graphical display of connections A multivariate analysis tool Uses weight measures to identify root causes Variety of shapes L-shaped most widely used and described here

27. Constructing the matrix Identify problem characteristics and possible causes Problem characteristics on one axis and possible causes on the other Symbols used at intersections to weight impact Sums presented to evaluate root causes

28. October 14th, 1908Cubs over Tigers 4 games to 1

29. Fault Tree Analysis

30. Invasive BP monitoring case The BP monitoring case is a handout. Have small groups use one of the RCA tools to analyze the case. The case, and an answer key, is available online.The BP monitoring case is a handout. Have small groups use one of the RCA tools to analyze the case. The case, and an answer key, is available online.