This problem solving method was later enhanced with the Kaizen concept “change for the better” and “continuous improvement”, which eventually led to what is known today as Total Productive Maintenance (TPM). The main objective of TPM is to increase the productivity of a production facility with a modest investment in maintenance. As such RCA is seen as a fundamental element of any asset performance management (APM) program or initiative.
Undesirable outcomes are the result of multiple cause and effect relationships that line up over time. Regardless of the RCA tool that is used to represent these relationships (e.g. logic tree, fault tree, causal factors tree, fishbone, et al.), we can nonetheless agree that these relationships must exist and fail for the undesirable outcome to materialize.
The concept that flawed systems adversely impact human decision making is a critical factor in both the RCA cause-and-effect relationship and the way we employ information systems. These systems are the information systems that we use to help us make better decisions. Such systems include but are not limited to our training systems, purchasing practices, procedures, and policies.
In the following example the operator in a particular area used too much lubricant which resulted in a premature bearing failure on a pump. The operator tasked with pump lubrication incorrectly decided to over-lubricate because he was not trained in proper lubrication practices. The over-lubrication decision was further impacted by recent maintenance reductions that shifted lubrication responsibility from the maintenance department to the operations department. As a result, this diagram examines the over-lubrication failure and displays the resulting cause-and-effect decision making relationship.