Root Cause Analysis (RCA): Root Cause Analysis (RCA) Solving compliance discrepancies via a systems approach


Root Cause Analysis (RCA): Root Cause Analysis (RCA) USES: Accident Investigations Safety Analyses TQM programs


PROBLEM: Deviation from expected resultsDEFICIENCY: Failure to meet standards or requirements: PROBLEM: Deviation from expected results DEFICIENCY: Failure to meet standards or requirements


Slide4: What is Problem Solving? The use of judgment to identify and implement permanent solutions to defined problems guided by an organized approach validated by evidence with input from interested people documented adequately backed by a commitment to follow up.


Slide5: Root Cause Analysis (RCA) - Everyone involved has their own way to solve the problem + maintenance man + engineer + supervisor + operations manager Employ the reason concept + no personal bias Think Outside the Box


Slide6: Root Cause Analysis (RCA)


Our emphasis in DoD:: Our emphasis in DoD: Identify real problems in our environmental programs Prevent recurrence Trend analysis Crossfeed lessons learned Solve findings in a new way… Prioritize our investment - emphasize pollution prevention


NEED FOR STRUCTURED PROBLEM SOLVING : NEED FOR STRUCTURED PROBLEM SOLVING Fines or penalties Release exceeds permit limits Adverse impact Repeat deficiencies Repeat compliance issue Systemic management problem


Slide9: Sources of Evidence Self Audit Accidents, Spills, and Releases Regulatory Agency Inspections Management Review EMS Review Compliance Assessment


Slide10: Structured Problem Solving Define Problem and Write Objectives Statement Analyze Contributing And Root Causes Develop Alternatives Select Action(s) Design/Develop Action(s) Compile Evidence Monitor Effectiveness Implement Actions


DoD Program...: DoD Program... Air Force: Management Action Plan Root Cause Analysis Codes Trend Analysis Army: Installation Corrective Action Plan


DoD Program...: DoD Program... Navy: Environmental Quality Assessments - Internal assessment – compliance focus - external assessment – EMS focus - EQA report developed annually by host facility + brief summary of each program/media + description of identified deficiencies + assigned root cause categories + recommended corrective actions + Plan of Action and Milestones (POA&M)


DoD Program...: DoD Program... MARINE CORPS - Annual self assessment - Benchmark ECE conducted every 3 yrs - Annual validation of POAM


Symptom verses Root Cause- An Analogy: Symptom verses Root Cause- An Analogy Symptom…..Fever Root Cause Analysis…..Flu Weeds - if not properly eliminated will reappear - spread to other areas


Symptom verses Root Cause: Symptom verses Root Cause Symptom…..Unlabeled drum Root Cause Analysis…..People not trained


Benefits: Benefits minimizing/eliminating other deficiencies improved mgnt efficiency/effectiveness help in prioritizing actions for correcting deficiencies documentation/justification for deficiency related management decisions cost reduction or avoidance


USAF Root Cause Categories...: USAF Root Cause Categories... Plans and Implementation Training and General Awareness Command Emphasis/ Oversight Resources External Factors


PROBLEM SOLVING is not:: PROBLEM SOLVING is not: Fixing deficiencies Root cause categorization


A Universal Approach...: A Universal Approach... Improving environmental performance with a systems approach… Structured problem solving and decision making tools Provokes questions Institutionalizes creative solutions


Why use a systems approach?: Why use a systems approach? Continuous improvement is the way of the future. Analysis of causes Consideration of alternative corrective actions Having a “system” gives you the tools necessary to consistently evaluate and solve problems.


The “system”… one step at at a time: The “system”… one step at at a time Understand your process Chart “cause and effects” in your processes (Root Causes) Problem solving


What are we doing?: What are we doing? The process… Identify pollution prevention opportunity Fulfill required environmental compliance mandates.


Understand your process...: Understand your process... Process Mapping… Schematic depiction of a process Identify all crucial elements and their sequence Varying levels of detail


Key Process Factors: Key Process Factors Sequence Cost Pollution


Why look at this so closely?: Why look at this so closely? Link the various steps to process impact Helps you to remember all steps, not just mainstream ones Expense, pollution impact, time expenditure, relationship of one step with another is not always evident. Identify any problems/ disproportionately expensive steps


Example Process Map...: Example Process Map... Sequence Process: “Paint Aircraft Engine Component”


Example Process Map...: Example Process Map... Preparation Application Completion Detail Level 1


Slide28: Example Process Map... Detail Level 1 Preparation Application Completion Clean Component Spray Paint Air Dry, Final Insp. Detail Level 2


Slide29: Preparation Example Process Map... Detail Level 1 Application Completion Detail Level 2 Prep: Clean component Appl: Spray paint Comp: Air dry, final insp. Air dry/Inspect: Air dry via ventilation fan, surface testing Detail Level 3 Clean component: Use cold solvent parts cleaning unit, wipe solvent off part Spray Paint: Fill and use paint gun


Identify and Clearly State Your Problem...: Identify and Clearly State Your Problem... This is where the “root cause analysis” of an environmental compliance deficiency comes in...


Clearly State the Problem…whether P2 or environmental compliance driven...: Clearly State the Problem…whether P2 or environmental compliance driven... Labor, material, disposal costs associated with filling, using, and cleaning paint guns is by far the most expensive step in painting aircraft engine parts. Inappropriate paint used in paint guns results in unauthorized air emissions from the paint booth and violation of the installation air emission permit.


Note:: Note: This compliance “problem” could be the direct result of an audit write-up… Inappropriate paint used in paint guns results in unauthorized air emissions from the paint booth and violation of the installation air emissions permit.


Chart “Causes and Effects” of problem...: Chart “Causes and Effects” of problem... “Fishbone” diagram allows close-up analysis of root cause. Various possible root causes are considered - materials, methods, equipment, personnel This approach expands the scope of possible “causes” considered by management, and helps planners to accurately select what is causing the problem.


Fishbone Diagram...: Fishbone Diagram... People Methods Equipment Materials


Slide35: Fishbone Diagram... People Not careful Not trained Methods Env. Management not consulted prior to selection of paint Equipment The installation is using a paint gun that only allows a certain type of paint to be used Materials Shop experience shows this Paint is much more durable than compliant paints; this is the only paint allowed by the new Technical Order


Identify and Clearly State the problem cause...: Identify and Clearly State the problem cause... “Installation is using a paint gun which only allows a certain paint be used. This paint contains chemical constituents not allowed to be emitted under our current air emissions permit. We are not aware of alternative paints that could be used in the gun.”


Generating Alternative Solutions...: Generating Alternative Solutions... Brainstorm - encourage lots of ideas Narrow down which ideas are feasible Experience Criteria Create action plan


Brainstorm - Example Problem...: Brainstorm - Example Problem... Modify paint gun to allow acceptable paint Replace nozzle, air compressor, lines, etc. Modify current procedures to allow acceptable paint Air pressure settings Thin down paint Replace paint gun Modify air emissions permit Discontinue paint operations


Your Action Plan: Your Action Plan Clearly describe your chosen solution in writing Specify all details… Person responsible for action Performance standard Monitoring implementation Target completion date Resources needed to implement the action


Replace Paint Gun: Replace Paint Gun Action: Base AFB will purchase paint gun (XXX Model, YYY Manufacturer) via AF Form 9 for $3,488. Fund Source: Environ Compliance $$. Item will be purchased from Smith Distributors, Inc. and is to be delivered and installed NLT 9 January 1998. 60 gallons paint, meeting specification 492, will be purchased via Base Supply and delivered NLT 15 January 1998.


Replace Paint Gun: Replace Paint Gun Action, Continued: A training class for all employees projected to use the equipment will be conducted on 20 January 1998. State regulatory agency to be notified of past noncompliance. Point of Contact: Tsgt Joe Duella, 89 MSS, 577-2558


Obtaining Resources: Obtaining Resources Securing adequate resources needs to be part of your action plan. Is the $3,488 already set aside for this piece of equipment? Programming documents needed? Re-prioritization of environmental requirements?


Slide43: Practical Exercise Phase II – Root Cause Analysis Scenario: In a secondary containment area beneath a 750 gallon above ground storage tank of diesel fuel. You notice 2 inches of collected rainwater and the surrounding area is darkened, smells of POL,and does not have any vegetation growing on it. Observation of the tank reveals that the discharge nozzle extends outside the realm of the secondary containment wall and has a slow drip.


Slide44: NOTE The better we initially analyze the process involved, the more aware we will be of the real problem, and be aware to recognize appropriate site priorities and suggest practical solutions.


Slide45: SYMPTOMS? Process: Maintain Above Ground Storage Tank


Slide46: Operate Tanks Inspect Tanks Maintain Tanks PROCESS MAP Detail Level 1


Slide47: PROCESS MAP Detail Level 1 Inspect Tanks Operate Tanks Maintain Tanks Fill vehicles, fill tank Clean, dry, service, maintain signs, drain containment area, document actions Check nozzle, hoses, leaks, records, etc. Detail Level 2


Slide48: Operate Tanks Inspect Tanks Maintain Tanks Fill vehicles, fill tank Check nozzle, hoses, leaks, records, etc. Clean, dry, service, maintain signs, drain containment area, document actions Fill vehicles, fill tank, train personnel, record keeping IAW shop SOP, drain containment area periodically Comprehensive check IAW checklist, preventive maintenance, area surveillance Detail Level 1 Detail Level 2 Detail Level 3 PROCESS MAP


Slide49: Identify and Clearly State Your Problem…. Although inspections are being done in the area, they are not catching problems that exist. The nozzle has been allowed to leak and there is evidence of petroleum product leakage and stressed vegetation.


Slide50: Fishbone Diagram PEOPLE METHODS EQUIPMENT MATERIALS


Slide51: PEOPLE METHODS MATERIALS EQUIPMENT Not careful Not trained Inspections not done frequently enough. Inspections are done so poorly, they don’t catch problems at the site. Proper tank and/or nozzle not available in a timely manner and mission must continue. Lack of funds to fix problem


Slide52: Identify and Clearly State the problem cause…. Facility manager walks thru the area and performs a thorough inspection. He has noted the leaking nozzle and the spilled petroleum product on the inspection sheet. When he returns to the shop the sheet is turned into the NCOIC who quickly looks it over and files it. No follow up Is done as the NCOIC is not aware of how serious the problem can be. Root Cause:


Slide53: Brainstorm: Environmental Flight initiates necessary training to ensure people are aware of environmental requirements - Unit commander’s calls, safety briefings - Base paper articles Publish new SOP holding UECs accountable. Develop acceptable inspection procedures Remove all ASTs. Use alternative site for fueling Repair nozzle Modify secondary containment to include nozzle Clean up contaminated soil DO nothing


Slide54: Choose your solution….. Environmental Flight initiates necessary training. - Unit commander’s calls, safety briefings - Base paper articles AST will be removed from this location Contaminated soil will be removed


Slide55: Your Action Plan…… NLT 23 Jan, Base AFB will hold a one-hour training session for all UECs responsible for ASTs - training will cover applicable CWA reqmts - specific detail will be given on how to manage ASTs POC: Mr. Bob Johnson, 7 – 5522 UECs will oversee requirement, train their people as they see fit Environmental Flight will inspect all ASTs at least once per month to ensure stds are being met Effort to be done in-house. No additional resources needed.


As we have seen…Documenting the Plan: As we have seen… Documenting the Plan Auditors suggest solutions Air Force: Management Action Plan Root Cause Codes Trend Analysis Army: Installation Correction Action Plan


Documenting the Plan...: Documenting the Plan... Navy: External Assessments – EMS focus Internal Assessments – Compliance * EQA report yearly * includes POAMs Marine Corps: POA&M validated annually


Continuous Improvement: Continuous Improvement “Institutionalize” a systematic process Generate “buy-in” and pride among installation personnel Get key people involved Build upon your program