Tuesday, August 21, 2012

Preliminary RCA Reports Promote Failures

Numerous government agencies including the FAA create preliminary failure reports however like many other things our government does preliminary failure reports are a bad idea for businesses as they drive many bad behaviors including reoccurring failures.
If you are currently providing these "educated guesses" to your organization prior to the actual root cause analysis report then the best advise I can give is to stop as soon as possible. I know it is not quite that easy but, when these preliminary reports are issued the manager and those effected are quick to review them even though they are merely guesses at the causes and may not be based on real data. The second issue is that once your complete analysis report is generated with all of the contributing factors, full causal chains, solutions and the data to support them is released then no one is really interested enough to take the time to read them after all they have already seen the prelim. It is like trying to read a book after someone spoils the ending, it is just not worth the effort. If you issue the prelim that  means that major decisions that effect the business are made based off of a quick reviews of partial sets of facts and strait conjecture. This conjecture leads to repetitive failure. In fact, many of the preliminary reports are nothing more than regurgitation of past experiences and not the facts related to this situation and real proven data.
I know many of you feel the pressure to get a report out with in 24 hours but in most cases this is just not a reasonable request and if you can not immediately change that expectation your should at least be working toward it. If you need to have a fast turn around on your RCA investigations then streamline your RCA process to limit the number of analysis required per month, request more resources for each investigation, and/ or speed up the report creation process. One way to speed up the RCA process is to use our A3 RCA reporting process where you put all of the information from the RCA on an A3 size sheet of paper that is populated as you move through the analysis process not at the end. I don't have the space here to show the full document but for an example send me an email at
The point is don't put out your reactive quesses at a cause if you can streamline your RCA process and put out a complete analysis in less than a week. Just like you can't get to excellence in reliability overnight you also can not complete an effective RCA in an overnight time frame either.

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