DE100: Defect Elimination & Root Cause Analysis

We start with why defect elimination and RCA matter. We look at the real cost of repeat failures and how most organisations end up living with them, why moving from reactive to proactive work depends on effective root cause analysis, and why defect elimination is what sets world-class plants apart. You’ll also see how DE builds a reliability culture by engaging a large part of the organisation, not just a specialist few.

This module draws the line between defect elimination and root cause analysis, and shows how they fit together — using RCA to tackle your bad actors first, then progressively eliminating the minor defects most organisations ignore. We cover where defects come from, why so many RCAs fail (shallow analysis, chasing a single “root cause”, and stopping before anything is implemented), and the 7 Rules of an effective DE process. You’ll also look at the hierarchy of controls, a fit-for-purpose “MoC-Lite” approach to change, and why a learning culture rather than a blame culture is what makes DE stick.

Human error is inevitable — even skilled, experienced people make mistakes, and the best people can make the worst ones. This module reframes “human error” as the start of an investigation rather than its conclusion: errors are consequences of the conditions people work under, not root causes in themselves. We look at the common preconditions that make errors more likely — the “Dirty Dozen” of fatigue, time pressure, poor communication and the rest — and at how you manage error by improving work conditions instead of blaming individuals. It closes with the idea of a Just Culture for handling deliberate rule violations.

Good RCA is an investigation backed by evidence, not opinion. This module covers how to write effective problem statements, how far an analysis needs to go, and the mind traps — confirmation bias, complexity bias, the engineer’s shortcut — that lead teams to the wrong answer. We spend time on preserving and collecting evidence like a crime scene, using a simple Parts, Position, People, Paper checklist so nothing is overlooked, and on interviewing people in a way that gets accurate accounts rather than leading them.

Components should last far longer than they often do — bearing life is measured in years, not hours, when load, alignment and contamination are under control. This module sets out what “good” looks like for common components and then works through the physics of how they actually fail: erosion and wear, corrosion, fatigue and overload. Underneath those failure modes we trace the chain the ABCs of defect elimination describe — physical defects caused by human errors, which are in turn caused by weaknesses in organisational systems.

Here everything comes together into one repeatable process that works for a single RCA and scales up to run defect elimination across a site. We walk the process end to end — Identify, Prioritise, Analyse, Implement, Monitor and Close Out — including how to build and maintain a defect register, prioritise your top bad actors, and take a solution all the way through to verified close-out. We also weigh up when a site-based approach works better than a centralised one.

No single technique fits every problem, so this module helps you pick the right tool for the job. We look at ways to lay out and present evidence — timelines, control charts, fault and logic trees — and then work through the main RCA methodologies: 5-Why, Fishbone (Ishikawa), Apollo RCA, Tripod Beta and Kepner-Tregoe. We also cover structured problem-solving formats like A3 and 8D.

A good process still fails without the right conditions around it. This module covers what it takes to stand up DE and RCA for real — committed leadership providing funding, resourcing and a long-term view, a documented process and a trained DE Coordinator in place, and a tracking system you deliberately keep simple to start. We look at running a pilot before a wider roll-out, and the facility readiness that has to exist first: working planning & scheduling, a reasonably stable environment, and a reliability engineer able to act as coordinator.

The course closes with real-world defect elimination and RCA case studies that put the whole process into context.