When a failure happens, you want to find out why and take action to prevent future occurrence. To do this you must capture as much evidence - verbal, physics, digital - as possible. This presentation discusses that.

1. by
Jim Taylor
CRE, CPE, CPMM
Director of Operations,
Machinery Management Solutions, Inc.
www.machineryhealthcare.com
http://blog.machineryhealthcare.com
FRACAS
Failure Scene Investigation

2. Key Takeaway:
Effective root cause elimination can be done by
the average maintenance professional
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3. You work in a facility or plant.

4. You’re a Maintenance professional:
A Crafts Person, a Planner, a Supervisor, a
Maintenance Manager, or an Engineer.
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5. Low availability and repeat failures on your
equipment is affecting your production and
customer service.

6. You want to find and eliminate these
failures.

7. To keep track of it
all, you need a
system.
A
Failure Reporting,
Analysis, and
Corrective Action
System
(FRACAS).
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8. First, You must
capture as much
information about
the Event as you
can.
FSI
Failure
Scene
Investigation

9. You must capture the details of the Event in
enough detail to do effective failure analysis.
As found condition
Failed components
Operating parameters
Sequence of events
Fluid levels
Signs of over temperature or pressure

10. You are the
designated
Failure Scene
Investigator.
by West Midlands Police

11. You are not the repair person.

12. 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

13. The four basic
components of the
failure scene
investigation
process are:

14. The accident sequence

15. Physical Evidence collection

16. Digital evidence collection

17. Narrative evidence collection

18. The nature and complexity of the accident
determines the extent to which these
components are evaluated.

19. Arriving at the
scene:
Initial Response

20. 1. Initial Response/Receipt of Information

21. 2. Safety Procedures

22. 3. Emergency Care

23. 4. Secure and Control Persons at the
Scene

24. 5. Boundaries: Identify, Establish, Protect,
and Secure

25. 6. Turn over Control of the Scene and
Brief Investigator(s) in Charge

26. 7. Document Actions and Observations

27. Preliminary
Documentation &
Evaluation

28. 1. Conduct Scene Assessment

29. 2. Conduct Scene ”Walk-Through“ and
Initial Documentation

30. Processing the
scene

31. 1. Determine Team Composition

32. 2. Contamination Control

33. 3. Documentation

34. 4. Prioritize Collection of Evidence

35. 5. Collect, Preserve, Inventory, Package,
Transport, and Submit Evidence

36. Completing &
recording scene
investigation

37. 1. Establish Failure Scene Debriefing
Team

38. 2. Perform Final Survey of the Failure
Scene

39. 3. Documentation of the Failure Scene

40. The key to an effective failure
analysis is having the right
information.
To do that, you must
systematically collect that
information.
765-366-4285
Jim.taylor@machineryhealthcare.com
www.machineryhealthcare.com
http://blog.machineryhealthcare.com