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Root Cause Analysis (RCA)

Root Cause Analysis (RCA) is an investigation into a problem to determine the root cause or root failure.  If the problem is identified by the investigator, he or she may then be able to establish the solution to the dilemma.  The problem or the procedure used that caused the problem is made right.
If your car is sliding sideways in a snow storm it could be your tires.  An investigation may find that the tires didn't have sufficient tread for snowy roads.  Many people look at situations in this manner, but DJA also offers Route Cause Analysis which differs in the approach and answer.

Route Cause Analysis may look at the same situation and come to a different analysis.  The car sliding on the snowy roads is the problem.  What route was taken to get to this situation?  Was there a weather warning? Was the driver trained for driving on slick highways? Was the trip necessary? Were there other road conditions involved? What was the condition of the vehicle?  When an analysis of the situation is made with the route cause in mind, all of the above need to be considered.

As an example of the RCA: a floating roof rolling ladder failure occurred.  The failure occurred when a rag froze to the rolling ladder rail and the wheel caught on the rag and as the roof raised the ladder buckled.  Root cause was the rag.  If a Route Cause analysis was made the ultimate failure mechanism would be the same, however the recommendations for future operation would be different.

The route to the failure was more than the rag.  The rag got in that position because the gauger left it there.  The gauger used the rag to clean his gauging tape.  There were no procedures given to the gauger for this operation since the gauger was to simply gauge the tank and record readings on the gauger's chart.

The analysis in this case found that the gauger was never trained in the operation or in the hazards of debris left on the tank.  The failure was a buckled rolling ladder however it could have been a fire due to old oily rags accumulated on the roof and the gauger's platform.  There was no disposal receptacle for oily rags.  There were no rules for disposal of oily rags.

The route cause of the failure

  1. No training for the gauger in how to gauge tanks properly
  2. No training in the dangers of spontaneous combustion
  3. No company procedures for the disposal of oily rags
  4. No system to check employee compliance to rules and procedures.

Not following this route brings us the failure.  The root cause is important but the route to the failure gives the operator of the tank facility the opportunity to implement procedures to eliminate the root and other conditions that actually may be more dangerous.

Who should make the analysis?

It is never recommended that one person make an investigation by him or herself.  It is ever so important for the investigators to keep their eyes on the route to the failure and not the root cause.  The root may be obvious or seem to be obvious and thus can hinder a single investigator in finding the route to the problem.  We recommend the team approach with a representative from the owner and one from DJA.  Two heads are better than one and two people are not as likely to go down the wrong path or route

What can DJA Inspection Services, Inc. do for you when a problem in your storage tank or other equipment occurs?  With the thousands of hours of experience our investigators have in the petrochemical industry and equipment we are uniquely qualified to perform both Failure Investigation and Route Cause Analysis.

Contact Andrew Boley; President DJA Inspection Services, Inc. for consultation (andrewb@djainspection.com  866-221-6951)  DJA has been in business since March 1990.