What Happened?: Investigating the (literal) Nuts and Bolts
Reading Time: 4 minutes
What Happened? As many of you know, I have been encouraging my LI contacts for years to take me up on my offer to review any pictures they have of failed parts, and we would try and provide them some preliminary feedback. Well, someone finally took us op on the offer and we wanted to share what was learned (we
A Mechanic’s Story: The Human & System’s Contribution
Reading Time: 7 minutes
Shallow Cause Analysis vs. Root Cause Analysis In this original post, A Mechanic’s Story: Basic Component Fatigue, we took a detailed journey through the physical side of a shaft failure RCA. We stopped at the physical side of that failure, parallel misalignment. However, stopping at the component level of failure does not constitute a credible and thorough RCA. Actually stopping at
Grade Your RCA Effort and Print Out Your Private Report Card…
Reading Time: 10 minutes
Grade Your RCA Effort and Print Out Your Private Report Card… Abstract: If you had to give a grade to your current Root Cause Analysis (RCA) initiative, what would it be? How would you come to that conclusion (grade)? The paradox many face with such initiatives is drawing the distinction between compliance and actual effectiveness. What would our RCA grade be based on? In this
Be “Little Bit Bold & Outrageous”: The Man Who Taught Us How
Reading Time: 10 minutes
The Need to be a “Little Bit Bold & Outrageous” the man who taught us how This phrase ‘a little bit bold & outrageous’ was constantly used by my father, Charles J. Latino early in his Reliability career. Charles founded and led one of the first corporate, global Reliability Engineering R&D groups in the U.S. for a company called Allied
The Pro’s and Con’s of Using Pre-Existing Logic in Root Cause Analysis (RCA)
Reading Time: 13 minutes
The Pro’s and Con’s of Using Pre-Existing Logic in Root Cause Analysis (RCA) By Robert J. Latino, CEO, Reliability Center, Inc. Abstract: There has been an ongoing debate for decades as to whether or not the use of pre-existing logic for conducting Root Cause Analyses helps or hinders the analysis results. Does the use of such pre-existing logic expand the thinking
Is All ‘RCA’ the Same?
Reading Time: 5 minutes
In order to know if all RCA is the same, we first have to define ‘What is RCA?’ On the surface, this seems quite simple, but unfortunately, it is quite complex. When I train or present speeches around the world, I often poll my audiences about how they define ‘RCA’. The fact is I will get as many answers, as I have people
What is ‘Reliability Engineering’?
Reading Time: 3 minutes
What is ‘Reliability Engineering’? I have been very involved recently with ongoing LI discussions with respected and noted experts in the Safety community, revolving around the perceptions those in Safety have of Reliability, and vice-versa. In Safety today, there are ‘new’ approaches emerging being lead by noted Safety researchers like Sidney Dekker, Erik Hollnagel and Todd Conklin. Such ‘new’ approaches
People Forget to Be Afraid…
Reading Time: 3 minutes
“Preventing process accidents requires vigilance. The passing of time without a process accident is not necessarily an indication that all is well and may contribute to a dangerous and growing sense of complacency. When people lose an appreciation of how their safety systems were intended to work, safety systems and controls can deteriorate, lessons can be forgotten, and hazards and deviations from safe
A Different View of the Swiss Cheese Model
Reading Time: 4 minutes
Much has been written about James Reason’s original Swiss Cheese Model described in his book Managing the Risks of Organizational Accidents. Figure 1 is a basic representation of this model. Many today consider this model to be obsolete because of the evolving complexity of systems due to emerging technologies. Therefore, the linearity of failure expressed in this original model, is not as
Is System’s Thinking Critical to Root Cause Analysis’s (RCA) Success?
Reading Time: 11 minutes
Is System’s Thinking Critical to Root Cause Analysis’s (RCA) Success? Put another way, can RCA be successful without the incorporation of system’s thinking? What prompted this question was that according to Drs. Leveson and Dekker in their 2014 paper Get To The Root of Accidents, systems thinking is not currently utilized in the application of RCA. In this paper they cite:
Why Can’t Learning Teams (LT) & RCA Teams be Friends?
Reading Time: 7 minutes
Why Can’t Learning Teams (LT) and RCA Teams be Friends? A Little History About How I Came Across Learning Teams. A little over three years ago I was asked to speak at a conference that was entitled, Human Performance, Root Cause and Trending or HPRCT (great conference BTW and I encourage you to attend). This was a different world for me as I typically
What Does It Mean to Be ‘Safe’?
Reading Time: 6 minutes
So what does it mean to be ‘safe’? Is a company ‘safe’ because they have not had an OSHA recordable injury in say over a one year period? Does that mean they will continue to be ‘safe’ in the next year? Does it mean they are at a higher risk of an incident in the near term, because they weren’t