Reliability Maintenance Engineering 3 - 2 Root Cause Analysis
-
Upload
fms-reliability -
Category
Technology
-
view
928 -
download
2
description
Transcript of Reliability Maintenance Engineering 3 - 2 Root Cause Analysis
Reliability Engineering
Fred [email protected]
ROOT CAUSE ANALYSISDay 3 Session 2
Objectives
• Examining different root cause techniques• Conducting incident investigations • Evaluating corrective actions• Advancing equipment troubleshooting• Failure reporting, analysis and corrective
action system (FRACAS)
Root Cause
• Initiating cause in a causal chain which leads to failure
• Depth of causal chain where an intervention is possible that changes performance or avoids failure
• Physical or Decision point
Root Cause Techniques
• Causation
• Forensic engineering
• Proximate & ultimate causation
• Root Cause Analysis
Technique Overviews
Causation
• Understanding of the system inputs as related to the output.
• Dependence – output values directly predictable by inputs to system.
Forensic engineering
• The investigation of materials, products, structures or components that fail or do not operate as intended
• The recreation of timeline of events leading to failure
Technique Overviews
Proximate and Ultimate Causation
• Proximate cause is the event which is closest to or immediately responsible for causing the failure.
• Ultimate cause is the real reason something occurred.
Root Cause Analysis, 8D
D0. PlanD1. Use a teamD2. Define and describe the problemD3. Develop Interim Containment Plan (implement and verify)D4. Determine, Identify and Verify root causesD5. Choose and verify permanent correctionsD6. Implement and validate corrective actionsD7. Take preventative measuresD8. Congratulate the Team
Discussion & Questions
Incidents
• An unplanned or undesired event that adversely affects operations
• Work related injuries• Occupational illnesses• Property damage• Spills• Fires• Near misses
Investigation
• Get the facts– Reporting– Data collection– No blaming…
• Determine root cause
• Recommend corrective actions
Poor examples
• It was Bill’s fault
• Insufficient budget
• No root cause – so must be deliberate error
• I was ordered to by pass safety equipment
Incident investigation process
• All incidents are investigated
• Corrective action determined to avert root cause
• Corrective action tracked till completed
• Trends reviewed, gaps identified and improvement plans implmented
Discussion & Questions
Corrective Actions
• Action in response or reaction to a failure
• Use root cause techniques
• Incident analysis
Predictive Action
• Proactive or prediction of problem and taking steps to avoid the failure
• Root cause analysis
• Risk analysis techniques
Examples
• Error proofing• Visible or audible
alarms• Product or process
redesign• Process control
improvements• Condition monitoring
Tactical & Strategic
• Tactical
• Immediate effects
• Local processes
• Physical causal chain interruption
• Strategic
• Cumulative effects
• Overall process
• Information causal chain improvements
Discussion & Questions
Troubleshooting
• Problem solving applied after a failure
• Logical• Systematic
• Determine the cause(s) of the observed symptoms
Troubleshooting Guidance
• Critical vs magical thinking
• Correlation vs causation
• Understanding what is supposed to happen
• Reproducible?• Intermittent causes• Multiple problems
Diagnostics
• The identification of the nature and cause of a failure.
• Focus on cause and effect
Diagnostic Guidance
• Black box recordings
• Condition monitoring information
• Sources of variation
• Theory of operation support
Discussion & Questions
FRACAS
• Failure Reporting Analysis and Corrective Action System
• Corrective and Preventive Action (CAPA) system
Purpose
• Provide closed loop failure reporting system
• procedures for analysis of failures to determine root cause
• documentation for recording corrective action
• Basic project management and prioritization
Poor examples
• Multiple systems
• No periodization – first reported first resolved
• Rewarding entries and completions
Discussion & Questions
Summary
• Examining different root cause techniques
• Conducting incident investigations
• Evaluating corrective actions
• Advancing equipment troubleshooting
• Failure reporting, analysis and corrective action system (FRACAS)
Root Cause Analysis