Causal Analysis & Non-Recurrence Engineering
Beyond RCA: Prysma® Methodology for root cause to organizational driver mapping
The Problem with Traditional RCA
Most root cause analysis stops at technical failure modes: "The pump seal failed due to thermal cycling." But this doesn't prevent recurrence. The real question is: Why did the operational conditions create thermal cycling? Why wasn't monitoring adequate? Why did organizational processes allow this scenario to persist?
Prysma® Methodology
Prysma® is Knar Global's proprietary framework for causal analysis that maps technical failures back through operational practices, organizational structures, and strategic drivers—identifying where systemic change is required to prevent recurrence.
Physical Layer
Equipment failure, material degradation, process upset—the immediate technical event
Operational Layer
Operating procedures, maintenance practices, monitoring systems that allowed or failed to prevent the physical event
Organizational Layer
Training gaps, communication barriers, resource constraints, competing priorities that shaped operational practices
Strategic Layer
Business model pressures, capital allocation decisions, risk tolerance policies that created organizational constraints
How It Works
Prysma® uses structured causal mapping to trace failure chains from physics to policy:
- Physical Failure Analysis: Establish technical root cause using engineering methods (metallurgy, process simulation, failure data analysis)
- Operational Context Mapping: Identify which procedures, schedules, or monitoring gaps allowed the failure scenario to occur
- Organizational Driver Identification: Trace operational gaps to underlying organizational constraints (resource allocation, communication structure, training investment)
- Strategic Root Cause: Connect organizational drivers to business model pressures or risk governance decisions
- Non-Recurrence Engineering: Design interventions at the appropriate layer—sometimes technical (add monitoring), sometimes organizational (change approval authority), sometimes strategic (revise risk policy)
Example: Protocolo de Entrega Cash3_V03
Context
A client experienced recurring unplanned shutdowns in a critical production unit despite multiple technical "fixes." Traditional RCA had identified equipment failures, but recurrence continued.
Prysma® Analysis Revealed
- Physical: Equipment operated outside design envelope during feed transitions
- Operational: Transition procedures were not updated after feed contract changes
- Organizational: Operations and procurement teams did not communicate feed variability expectations
- Strategic: Procurement decisions prioritized cost reduction over feed consistency, creating technical risk not visible to operations
Intervention
Rather than just updating procedures (operational fix), the solution required a contract governance change: procurement decisions now require operations sign-off when feed specifications shift. This strategic-layer intervention eliminated recurrence by preventing the organizational breakdown that had allowed the physical failure to occur.