Publication Details (including relevant citation information):
Presented in 2014 at ADIPEC, Abu Dhabi, UAE.
Effective corrective action has always depending on the correct and accurate identification of the real problem to be fixed. Investigation of system deficiencies and development of corrective action processes have evolved over the decades from “experience-based” expert teams (internal or external) to formalized methodologies than can be applied with a basis of training and moderate field experience. All formal Quality Management Systems (ISO-9001, ISO/TS 16949, AS 9100, Six Sigma) outline requirements for both correct investigation and documented corrective action. However, the best methodologies are not defined, leaving the success of these processes subject to significant variation. A plethora of Root Cause Analysis (RCA) methods are available, all based on the principles defined as early as 1905 in the Lancet article "The Present State of Medical Practice in the Rhondda Valley"1, and expanded in "Definition of a Root Cause" by Mark Paradies in October 20052. In the culmination of its development from 1985 in the development of the TapRoot® RCA method. As stated in the American Society for Quality (ASQ) book, “Some root cause analysis approaches are geared more toward identifying true root causes than others; some are more general problem-solving techniques, while others simply offer support for the core activity of root cause analysis.”3
After years of experience with different levels and definitions of investigation procedures and corrective and preventive action (CAPA) activities, the Company recognized the need for a more objective and precise identification of systemic problems that were manifest in the continuing failure of individual action plans. A formal Root Cause Analysis (RCA) procedure and training were implemented to improve the investigation phase, but the systemic root causes remained elusive. Further research into behavioral safety led to the seminal work “The Human Factors
Analysis and Classification System–HFACS” by Scott A. Shappell of the FAA Civil Aeromedical Institute, February 2000.4 The HFACS was developed to address faults in highly-critical industries such as aerospace and military readiness, and has been adopted successfully by many other organizations. The company has modified its Root Cause Analysis process to incorporate the HFACS at the “contributory cause” level. This change from the more simplistic assignment of “operator errors” has removed the assumption of blame to an improved understanding of the actions that can be taken by the company to prevent errors. The significance of the formal linkage from operator actions to corporate policies and structure cannot be overstated. A description of the HFACS and how it has been applied to improving asset Integrity and Reliability in the company will be presented.
1"The Present State of Medical Practice in the Rhondda Valley". The Lancet166 (4290): 1507. 18 November 1905.
2Mark Paradies, "Definition of a Root Cause", 17 October 2005.
3Bjørn Andersen and Tom Fagerhaug Root Cause Analysis: Simplified Tools and Techniques, Pp. 5 & 13, ASQ Quality Press, March 24, 2006.
4Shappell, S.A. and Wiegmann, D.A., The Human Factors Analysis and Classification System–HFACS, FAA Civil Aeromedical Institute, Oklahoma City, OK; University of Illinois at Urbana-Champaign, Institute of Aviation, Savoy, IL, February 2000.