Resources

Reading Time: 5 minutes

Traditionally RCA is only utilized after an event has occurred, so how can one call it proactive? This perception is explored through trying to understand the current paradigms that exist about RCA, what it is and when it is used. Do we really have to wait for an undesirable outcome to occur in order to use RCA?

Reading Time: 4 minutes

I recently presented a webinar for SMRP and Empowering Pumps, on the title above. There were several questions, post-presentation, that I felt were worthy of expanding on in the form of a blog. Question #2  How do you manage a situation where people just decide not to use simple tools like RCFA, just comfortable doing things same way? Even when you keep

Reading Time: 3 minutes

I recently presented a webinar for SMRP and Empowering Pumps, on the title above. There were several questions, post-presentation, that I felt were worthy of expanding on in the form of a Q&A style blog…

Reading Time: 6 minutes

Trick question, it’s neither! When we hear people use the term ‘error’ it is normally associated with being the cause of some type of bad outcome. We hear it all the time with airline accidents where they conclude ‘pilot error’. ‘Error’ is neither the cause nor the undesirable outcome! Let’s see why.

Reading Time: 2 minutes

We might be doing a Shallow Cause Analysis (SCA) if … 1. We blame and discipline the violator and that concludes the investigation. There is no attempt to try and understand the intent of the decision.

Reading Time: 9 minutes

Note: Everyone has their own way to use cause-and-effect logic trees and we use the PROACT RCA Methodology that we teach in our root cause analysis training courses. Sign up for our free RCA 101 course. What is a Logic Tree? A logic tree, in a general sense, is a graphical representation or structure used to systematically organize and display

Reading Time: 10 minutes

There has been an ongoing debate for decades as to whether the use of pre-existing logic for conducting Root Cause Analyses (i.e. RCA templates and/or libraries) – helps or hinders the analysis results. Does the use of such pre-existing logic expand the thinking of the team members or does it lead the team to pre-determined conclusions, and away from other

Reading Time: 13 minutes

This article contrasts the application of preventive and predictive technologies in industry to those in healthcare. For years, risk managers have been discussing the rationing of care. This article presents the perspective of an engineering professional from the manufacturing industry who now consults with healthcare risk managers. The human being is often referred to as an “asset” in our society.

Reading Time: 8 minutes

Has your organization adopted Six Sigma? Lean manufacturing?  What about Lean Six Sigma?  If you already have any of these business process improvements in place, where will you go next? In this article we will focus on transforming your organization beyond Lean Six Sigma to the next level of performance. 

Reading Time: 4 minutes

  Can you identify and name this fracture pattern? How can you tell it is that fracture pattern? Where are the origin(s) of the failure on the fractured surface? How can you tell where the origin(s) are?

Reading Time: 3 minutes

This failure occurred on a turbine driven boiler feedwater pump (TDBFP) at a fossil fuel power plant. The pump in question is an outboard boiler feed pump. Plant is operating normally when unexpectedly pump shuts down and causes a forced outage. Here is a basic process flow diagram for this process…

Reading Time: 8 minutes

This is a failed shaft that came out of a pump in a paper mill. The pump was only in service for about a month before it failed unexpectedly…