Drilling Company - front line staff

REASON root cause analysis in the hands of employees at the coal face

In one REASON testing company, the Maintenance and Engineering Director placed the fledgling REASON Root Cause Analysis troubleshooting method in the hands of maintenance men and tool pushers on the company’s drilling rigs. Every time something threatened to stop the drilling bit, on any one of their drilling rigs across the nation, an analysis of the threat was created with REASON and sent to their corporate offices. Literally hundreds of operations improvements were quickly achieved throughout the inventory of rigs through this means.

We found out that these maintenance professionals and tool pushers on the rigs liked the REASON Root Cause Analysis no nonsense, straightforward approach. They liked not being required to go out on a limb with guesses, when they didn't have an answer. They liked being able to check their information for accuracy at each step . . . on their own. When we asked them for ideas for improving the REASON Root Cause Analysis Software, we found out right away that what they liked most about REASON was that it provided strong guidance, that it tapped into their experience, but did not rely upon them to have special insights and perceptions, or to make assumptions that might generate expensive projects based upon their assumptions. These professionals were interested in an efficient and effective maintenance root cause analysis troubleshooting system.

As the method has been developed to provide additional reporting and analysing capabilities over the years, those early comments have guided us to assure that REASON Root Cause Analysis Software has remained a practical tool for maintenance troubleshooting and root cause analysis. Later the maintenance and engineering director brought the company’s maintenance crews and tool pushers to their corporate training center for training in REASON Root Cause Analysis Maintenance Troubleshooting. He commented that REASON had transformed his maintenance crews into "diagnosticians".

Systemic Causes: The Primary REASON we Conduct Root Cause Analyses

Root cause analysis should find all of the systemic causes of a problem. The point of relating the circumstances of these early tests is to emphasise to you the importance of adopting a root cause analysis method that identifies all root causes when analysing your problems. REASON Root Cause Analysis data provides decision-makers with an understanding of the entire system. It details all options, and provides the opportunity to analyse for causes that are shared in common between systems, as illustrated in this early test example. The REASON Root Cause Analysis methodology provides an objective, standard operating procedure that teaches you how to ask the right questions at the right time, to get the right answers.

All other root cause approaches rely upon someone’s assumptions of what should be done. These other approaches use gimmicks like checklists and cause lists to focus upon only a small portion of the causal system.

The costly reality check comes when root causes and key prevention options go undetected and unreported, when prevention opportunities are lost, and when managers discover that their analysis system has induced them to make an unsound decision by filtering key data away from their view.

Without the opportunity to view the entire problem with all root causes identified, the likelihood of a manager finding shared causal factors existing in common among multiple events, as described above, is remote. It should be noted that these shared causal factors are the "systemic" root causes that are the primary target and goal of professional root cause analyses.

Links to MORE REASON Root Cause Analysis …

Case Study – Air Safety Investigators Conference Investigation Paper

Case Study - Hanford Plutonium Production Complex (includes slides and presentation PDF)

Detailed Case Study - Maintenance and OHS

Criteria for evaluating root cause analysis systems

NB: Many national organisations participated in the REASON® Beta testing, including Texas Instruments, Brown and Root, Delta USA, and Marathon LeTourneau. The testing environments ranged from the manufacture of computer chips to the pouring of molten steel.