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Root Cause Analysis of the Washington Monument

There was a problem with erosion of the Washington Monument. The Monuments rate of erosion had
increased. The initial cause was do to harsh chemicals used to clean off pigeon droppings. This being
an important monument for America a study was conducted to solve this problem. This is the story I
heard as recounted by Dr. Woods during her presentation at PSAM 10 in Seattle June 11,2010. I
apologize if any of the story is mis-communicated and any mistakes are mine.
As the study began the first thing that was discovered was the rate of erosion increased after harsh
cleaning chemicals began to be used. The analysts therefore concluded that the cleansers were the
problem. The cleansers were being used to combat a problem related to pigeon poop. Yup, need to
solve that problem. We cannot have one of our most powerful symbols covered in pigeon poop.
Doesnt say good things about us if we allowed that kind of mess. So, why were pigeons there? Well, it
turns out that pigeons like spiders (probably like I like hamburgers (I know I have eaten more than I
should have in the past) and spiders were now nesting in the Washington Monument? Well, Spiders
like gnats and gnats were all over the Washington Monument and only recently. It turns out that gnats
come out right at dusk and they are attracted to light. The Monument is bathed in light which were
turned on the same time each day not accounting for the seasons. So the solution to the whole
problem was to just turn the lights on later (well after dusk). No gnats therefore means no spiders and
therefore no pigeons.
Now this solutions is fantastic. You are saving electricity (very small amount) and there is no need to
use harsh cleansers. All in all an elegant solution to the problem. Of course, this is obvious after the
fact, but how could this solution be enacted by a single person. This has to be done with a few people
getting together at different levels to even see the problem. The cleaning crew isnt going to know
enough to solve this problem. The lightning person wont know- even if there is a lightning person
since the lights may have been automated.
My point is if something seems obvious after the fact- it isnt. You see this blame game going on
whenever you have an accident that seems obvious after the fact. When the details are effectively
communicated the problem can be solved and solved quickly- only once all the factors are known.
From the Titanic to now the British Petroleum oil spill- complex failures will have solutions, but only
after the fact until we can our attitudes and focus. I still refuse to believe that BP is solely to blame.
There are thousands of oil wells in the Gulf and around the world. The real problem was our human
nature to underestimate risk.

The People Side of Root Cause Analysis

By Josh Rothenberg, CMRP, Life Cycle Engineering
As appeared in the April Edition of RxToday
Has your facility started an RCA program, only to have it fall by the wayside? Or has
a RCA program failed to take hold because of a variety of factors, all challenging to
manage? This article will address some common pitfalls of RCA programs, and
recommend some strategies to establish (or reestablish) a program at your facility
that will bring lasting success.
First off, a bit on terminology. There is a distinct difference between an RCA and an
RCFA. I define RCA root cause analysis as just that, determining the root cause
of something through some sort of formal analysis. RCFA root cause failure
analysis is analysis performed to determine the root cause of a failure. It could be
an equipment failure, a failure of people, or a failure of process. Both leverage the
same tools and the analysis is often similar. Think of RCA as the umbrella under
which RCFA resides.
RCA can be done reactively (after the failure RCFA) or proactively (RCA). Many
organizations miss opportunities to further understand when and why things go well.
Was it the project team involved? The change management methodology applied
during implementation? The vendor used or the equipment selected? I would argue
that performing RCA on successes is just as, if not more, important for overall
success than performing RCFAs on failures but that is a topic for another article.
So what are the reasons RCAs fail? What culture and behaviors are necessary for
an RCA program to be successful? First and foremost, all organizations are made up
of people. When it comes down to it, we are responsible for the success and failure
of any initiative. Clients of mine are often very willing to hire outside help to perform
an RCFA on a recent equipment failure that led to days of lost production and
millions of dollars in potential revenue, but they wont put in the serious effort to
identify and understand why they havent had success in implementing their own
internal RCA program. Prosci, the leading provider of research and tools that enable
organizations to manage the people side of change, recently released their 2012
edition of Best Practices in Change Management. Their researchers found that the
top contributors to the overall success of any initiative, in order of importance, are:

Active and visible executive sponsorship

Frequent and open communication

Structured change management approach

Dedicated change management resources and funding

Employee engagement and participation

Engagement with and support from middle management.[1]

Lets address them one at a time.

Active and visible executive sponsorship

For an RCA program to increase its probability for success, it has to be driven from
the top. Senior management must have the education and awareness to understand
why the need for creating a culture of waste identification and failure elimination is
important. Then, they must support the program with resources everything from
training operators and mechanics in methods like 5-WHY analysis and proper
incident reporting, to potential head count increases for reliability engineers to lead
RCA analyses. Sponsorship, however, doesnt stop there. For it to be active and
visible, senior management must spend their own time as well reinforcing their
shared vision of a facility that will identify and eliminate repetitive failures (and work
to understand and celebrate successes) on the factory or plant floor with employees
at all levels in the organization.

Frequent and open communication / structured approach

What gets measured gets improved. Even more so, what gets measured and
communicated gets understood. Program owners must work to define a process for
when and how an RCA is to be performed. Ive found that the DMAIC process works
best for developing an RCA program. For those not familiar with it, DMAIC is a Six
Sigma approach to problem solving:

Define the problem

Measure the current state and collect data

Analyze available data and utilize RCA tools and methods

Improve the situation after determining root cause and most viable solution

Control the outcome by ensuring actions were effective and results are lasting

Triggers should also be established at the appropriate levels of loss. (For a link to a
Single Point Lesson for determining RCFA Triggers, click here.) Baseline metrics
need to be established and RCA findings need to be openly and frequently shared
with area owners and plant personnel. Use target condition metrics to provide the
business case to implement results. Quarterly metric reporting to senior
management is an excellent way to keep them engaged, giving them the tools they
need to be active and visible sponsors. For individual RCA reporting, I recommend
the A3 methodology, as shown below:

Figure 1: Sample A3 Template for RCA Reporting

To successfully initiate an RCA program at your facility, a structured change
management approach is also key. Communication plans with a clearly articulated
vision should be developed and disseminated by senior and middle management.
One of the key findings in the PROSCI study is that, as employees, we want to hear
about shifts in the way we do business from:

An executive sponsor (defines the why and how) and


our immediate boss (defines the how and the what).[1]

Dedicated resources and funding

It should go without saying that for project success, management needs to provide
the necessary resources and funding for training, program installation, software
development and troubleshooting tools. This applies for both change management
professionals (especially at program inception) and for the reliability group that will
be facilitating the majority of RCAs. This makes the metric reporting and program
ROI justification all the more critical. Build a business case for program
implementation. Work to make the decision to continue the RCA program work a nobrainer for your boss. Even just one major failure elimination activity can result in
millions of dollars to your companys bottom line. Document and publish findings.

Employee engagement and participation

Without employee engagement, an RCA program will not get off of the ground.
Equipment operators are the best suited to identify when the onset of failure occurs,
and can help the RCA facilitator understand what happened when. Maintenance
personnel must be on board to ensure that physical evidence like that frozen
bearing or damaged impeller doesnt get thrown away. Even cleaning the oil

residue off of a failure inner race can destroy potential evidence. To instill ownership
and understanding, employees must be involved in creating the RCA process..

Engagement with and support from middle management.

No corrective action will last long if employees are not held to account. The role of
middle management is key to any initiative and is often overlooked. These
individuals must address the day-to-day issues in the facility or plant, and push
senior managements goals and objectives out to the organization. Ensuring that
middle management is effective is critical to the success of any RCA program.
Whether youve worked at developing an RCA program at your facility with little
success, or if you have never had the wherewithal to start one, these tips will get you
thinking about the right things and moving in the right direction. Its never too late to
start. When was the best time to plant a tree? Twenty years ago. When is the next
best time? Right now.
1. Prosci's Best Practices in Change Management. 2012 Edition. Prosci Inc. All
rights reserved.

Josh Rothenberg is a Life Cycle Engineering reliability subject matter expert (SME)
and a skilled Six Sigma Black Belt. Josh utilizes the tools learned in the tire
manufacturing, specialty chemical, and semi-conductor industries to help facilitate
change. With experience in CMMS, fixed/rotating equipment, logistics,
planning/scheduling, and a talent for fostering interpersonal relationships, Josh
brings a unique perspective to reliability centered maintenance that fosters the
growth and development of cross-functional teams. Josh can be reached
2012 Life Cycle Engineering