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To demonstrate this point, consider the analogy of assembling a puzzle. You would start with a box of puzzle pieces and then proceed with placing the pieces together until complete. An experienced puzzle builder can develop many tricks and techniques to complete the puzzle efficiently, but someone who has never built a puzzle will likely struggle. However, even the most skilled puzzle builders cannot complete the puzzle if pieces are missing or the facilities don’t accommodate this activity. The same holds true for a root cause analysis (RCA). The team cannot complete the analysis if critical evidence is missing, key team members are absent, or the facilitator is unable to follow the agenda because of inadequate equipment or other resources in the meeting facilities. This article will discuss practical ways to anticipate these problems and provide ways to contain their negative impact on RCA effectiveness.

Collecting Evidence - Strike While the Fire Is Hot

Although every investigation is unique, there is critical evidence that must be collected, some with a sense of urgency. You need to strike while the fire is hot, so to speak. Unplanned events sometimes occur on weekends and at night when most support staff are off-site. You must make yourself available for callouts or train operators and maintenance craft to collect time-sensitive evidence. Eyewitness testimonies, failed parts, process data stored in short-term memory and environmental conditions at the time of the incident may be lost forever if they’re not gathered in a timely manner.

These actions will help you collect the necessary evidence:

  • Take pictures of the asset before, during and after repairs are complete.
  • Evaluate failed components and send them to applicable subject matter experts (SMEs)for analysis.
  • Mine your computerized maintenance management system (CMMS) for equipment history of repair, and preventive and predictive maintenance.
  • Search the equipment library for installation documentation, operational and maintenance manuals, drawings and records of the asset's lifecycle.
  • Review operational logbooks, either electronic or hard copy, for additional details of long-term and short-term history.
  • Include standard operating procedures for the asset and ancillary equipment in the evidence package.
  • Record a snapshot of process control screens that reveal the failure through key parameters.This will be the basis for developing the timeline of events, a prerequisite for the subsequent analysis.

The RCA Team - Identifying Key Players

The effectiveness of the RCA in mitigating or eliminating unplanned events also depends on having the right roles present at the analysis. Too many people at the RCA may pose a problem, but the absence of key players will likely result in a stalled or ineffective analysis. The RCA team should consist of a trained and unbiased facilitator, those directly involved in the incident, equipment and process specialists, operators and maintenance craft, a maintenance reliability engineer and, possibly, an environmental and safety specialist. Additional team members may be named based on the data and evidence collected. The process owner should be included as an ad hoc member to gain support in the solutions and implementation phases. The process owner will likely possess expertise, historic perspective, or knowledge of the specific event. The report generated from experts analyzing failed components also requires interpretation. This may be done by the author of the report or local SMEs. Communicate the importance of attending team meetings to each team member. Building an RCA team consisting of the right people is critical to the outcome of the analysis.

RCA Meeting Logistics - Prepare for the Unexpected

It would be unfortunate, to say the least, to invest precious time and resources preparing a thorough preliminary investigation and forming an RCA team only to have the analysis fail because of poor planning of meeting logistics. As reminded by Murphy’s law, anything that can go wrong, will go wrong.

Here are some tips to ensure RCA team attendance and effective use of meeting time:

  • Develop and stick to an agenda that doesn't last more than two hours.
  • Reserve a centrally located meeting room with sufficient seating and IT equipment. Team members and ad hoc resources off-site may need to attend the meeting remotely, so provide conference call numbers and online meeting information.
  • Schedule the RCA at a time when attendees are free or flexible. Team members on shift may need to come in on overtime to accommodate the majority of schedules and others may need to reschedule lower priority meetings.
  • Send an e-mail one or two days prior to the RCA, emphasizing the importance of attending the meeting.
  • If a follow-up meeting is required, schedule it at the end of this meeting.

Taking the time to develop contingencies for what could go wrong at the analysis meeting will help ensure efficient use of everyone’s time and create an environment for success.


Reliable organizations make it a part of their daily work to prepare for the unexpected. The same holds true for root cause investigations. The analysis is unlikely to produce solutions capable of preventing event recurrence if preparation isn’t given due diligence. Thorough preparation for the unexpected will set the stage for a successful analysis phase.

The practices detailed in this article cover basic problems based on personal experiences. You will need to assess your own investigation to ensure you collect sufficient evidence, form the right team, and properly plan meeting logistics and format.

Michael W. Blanchard, CRE, PE, is a reliability engineering subject matter expert with Life Cycle Engineering (LCE). He has more than 25 years of experience as a reliability leader in a variety of industries. Mike is a licensed Professional Engineer, a Certified Reliability Engineer and a Certified Lean Six Sigma Master Black Belt.

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