What RCFA is / isn’t; when to launch an RCFA (repeat failures, high risk, high cost) 

Define the problem: boundaries, “what is happening” vs “why it’s happening” 

Levels of causes: direct / contributing / root causes (avoid blame labels) 

RCFA workflow: scope → evidence → analysis → causes → actions → verification 

Build the “problem understanding pack”: timeline + flowchart of the system/process 

Workshop: create a clear problem statement + initial timeline (oil & gas case) 

Brainstorming vs brainwriting (how to capture better causes, reduce bias) 

Is–Is Not matrix (tighten the problem and eliminate weak hypotheses) 

Nominal Group Technique (NGT) for prioritizing likely causes 

Paired comparisons to rank competing cause theories 

Draft a “cause list” grouped by: people / process / equipment / materials / environment / management system 

Workshop: team session to produce a ranked shortlist of causes + evidence gaps 

Evidence planning: what data is needed for each hypothesis (and where it lives: CMMS, historian, inspection, OEM, interviews) 

Sampling basics + check sheets for repeatable field data capture 

Surveys/interviews (structured questions; facts vs opinions) 

Data analysis tools: histogram, Pareto, scatter (patterns, correlations, “vital few”) 

Visual tools: problem concentration diagram (where), relations/affinity diagrams (how causes link) 

Workshop: build a Pareto + scatter from a provided dataset; update the timeline with confirmed facts 

Cause-and-effect chart (Fishbone) with evidence tags (confirmed vs assumed) 

Matrix diagrams (link causes ↔ evidence ↔ controls ↔ consequences) 

Five Whys (done with evidence checks, not “why-spirals”) 

Fault Tree Analysis (FTA): top event → logic gates → minimal cause paths 

Workshop: complete an evidence-based causal model (Fishbone + 5 Whys + FTA) for a rotating/process equipment failure scenario 

Root cause elimination tools: Six Thinking Hats (decision quality), TRIZ / SIT (break constraints, generate stronger solutions) 

Select corrective actions: eliminate vs mitigate; engineering vs procedural; prevent recurrence 

Build implementation plan (owners, dates, resources) + tree diagram for rollout steps 

Force-field analysis: resistance vs enablers; change acceptance plan 

Verification plan: effectiveness review, monitoring window, KPIs, closure criteria 

Capstone: teams present the full RCFA (problem → evidence → logic → root causes → actions → verification)