FRACAS - Failure Secene Investigation
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FRACAS - Failure Secene Investigation



FRACAS – Failure Scene Investigation ...

FRACAS – Failure Scene Investigation
For failure analysis, much of the data needed can’t be collected from SCADA system or by other automatic means. This paper discusses ways to secure the failure scene, collect that data, and preserve it for analysis.



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  • Summary: It is important for the initial responding officer(s) to be observant when approaching, entering, and exiting a failure scene.
  • Summary: The control of physical threats will ensure the safety of officers and others present.
  • Summary: Assisting, guiding, and instructing medical personnel during the care and removal of injured persons will diminish the risk of contamination and loss of evidence.
  • Summary: Controlling the movement of persons at the failure scene and limiting the number of persons who enter the failure scene is essential to maintaining scene integrity, safeguarding evidence, and minimizing contamination.
  • Summary: Establishing boundaries is a critical aspect in controlling the integrity of evidentiary material.
  • Summary: The scene briefing is the only opportunity for the next in command to obtain initial aspects of the failure scene prior to subsequent investigation.
  • Summary: The initial responding officer(s) at the failure scene must produce clear, concise, documented information encompassing his or her observations and actions. This documentation is vital in providing information to substantiate investigative considerations.
  • Summary: Scene assessment allows for the development of a plan for the coordinated identification, collection , and preservation of physical evidence and identification of witnesses. It also allows for the exchange of information among law enforcement personnel and the development of investigative strategies.
  • Summary: Conducting a scene walk-through provides the investigator(s) in charge with an overview of the entire scene. The walk-through provides the first opportunity to identify valuable and/or fragile evidence and determine initial investigative procedures, providing for a systematic examination and documentation of the scene. Written and photographic documentation records the condition of the scene as first observed, providing a permanent record.
  • Summary: The scene(s) assessment determines the number of personnel and how responsibilities will be assigned.
  • Summary: Minimize contamination by being safe, clean, and careful to ensure the welfare of personnel and the integrity of the evidence.
  • Summary: A well-documented scene ensures the integrity of the investigation and provides a permanent record for later evaluation.
  • Summary: Prioritization provides for the timely and methodical preservation and collection of evidence.
  • Summary: Evidence at failure scenes that is in the process of documentation, collection, preservation, or packaging should be handled with attention to scene integrity and protection from contamination or deleterious change. During the processing of the scene, and following documentation, evidence should be appropriately packaged, labeled, and maintained in a secure, temporary manner until final packaging and submission to a secured evidence storage facility or the failure laboratory.
  • Summary: The failure scene debriefing is the best opportunity for law enforcement personnel and other responders to ensure that the failure scene investigation is complete.
  • Summary: Conducting a scene walk-through ensures that all evidence has been collected, that materials are not inadvertently left behind, and that any dangerous materials or conditions have been reported and addressed.
  • Summary: This will ensure that reports and other documentation pertaining to the failure scene investigation are compiled into a case file by the investigator(s) in charge of the failure scene and allow for independent review of the work conducted.

FRACAS - Failure Secene Investigation FRACAS - Failure Secene Investigation Presentation Transcript

  • FRACASFailure Scene Investigation by Jim Taylor CRE, CPE, CPMM Director of Operations, Machinery Management Solutions, Inc.
  • Key Takeaway:Effective root cause elimination can be done by the average maintenance professional michaelcardus
  • You work in a facility or plant.
  • You’re a Maintenance professional:A Crafts Person, a Planner, a Supervisor, a Maintenance Manager, or an Engineer. theakshay.
  • Low availability and repeat failures on yourequipment is affecting your production and customer service.
  • You want to find and eliminate these failures.
  • To keep track of it all, you need a system. AFailure Reporting, Analysis, andCorrective Action System (FRACAS). English106
  • First, You must FSI capture as muchinformation about Failure the Event as you Scene can. Investigation
  • You must capture the details of the Event inenough detail to do effective failure analysis. As found condition Failed components Operating parameters Sequence of events Fluid levels Signs of over temperature or pressure
  • You are the designatedFailure Scene Investigator. by West Midlands Police
  • You are not the repair person.
  • You must capture the timeline of the Event in order to reconstruct the event. T0 – time of event T1 – time of trouble report T2 – maintenance on scene T3 – trouble shooting complete, parts ordered T4 – parts on site T5 – repairs complete T6 – test complete T7 – system back on line
  • The four basic components ofthe failure scene investigation process are:
  • The accident sequence
  • Physical Evidence collection
  • Digital evidence collection
  • Narrative evidence collection
  • The nature and complexity of theaccident determines the extent to whichthese components are evaluated.
  • Arriving at the scene:Initial Response
  • 1. Initial Response/Receipt of Information
  • 2. Safety Procedures
  • 3. Emergency Care
  • 4. Secure and Control Persons at the Scene
  • 5. Boundaries: Identify, Establish, Protect, and Secure
  • 6. Turn over Control of the Scene and Brief Investigator(s) in Charge
  • 7. Document Actions and Observations
  • PreliminaryDocumentation & Evaluation
  • 1. Conduct Scene Assessment
  • 2. Conduct Scene ”Walk-Through“ and Initial Documentation
  • Processing the scene
  • 1. Determine Team Composition
  • 2. Contamination Control
  • 3. Documentation
  • 4. Prioritize Collection of Evidence
  • 5. Collect, Preserve, Inventory, Package, Transport, and Submit Evidence
  • Completing &recording scene investigation
  • 1. Establish Failure Scene Debriefing Team
  • 2. Perform Final Survey of the Failure Scene
  • 3. Documentation of the Failure Scene
  • The key to an effective failure analysis is having the right information. To do that, you must systematically collect that information. 765-366-4285