Fracas - Failure Scene Investigation
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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.
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Root Cause Analysis (RCA) is a structured process that identifies the underlying causes of undesirable events. It can be used for both single and multidisciplinary cases. The RCA process involves data collection, identifying the immediate causes and basic causes of failures, and determining where lack of control contributed. Common investigation techniques include STEP, FMEA, and fault tree analysis. Laboratory analysis of failed parts is also important for identifying causes like material defects, corrosion, or overloading. Identifying root causes allows corrective actions to be implemented to prevent future recurrence.
Root Cause Analysis.pdf
Root Cause Analysis (RCA) is a structured process that identifies the underlying causes of undesirable events. It can be used for both single and multidisciplinary cases. The RCA process involves data collection, identifying the immediate causes and basic causes of failures, and determining the lack of controls that allowed the failure to occur. Conducting detailed analysis of failed parts through methods like STEP, FMEA, and FTA allows investigators to identify issues like material defects, improper operation, or inadequate maintenance as the root causes of failures. Addressing these root causes helps improve equipment reliability and availability while reducing maintenance costs and downtime.
HSE - Accident Investigation.PPT
This document provides information on accident investigation, including definitions, objectives, processes, and techniques. It begins with defining key terms like accident, near miss, first aid case, lost day case, injury, and illness. It then explains the objectives of accident investigation are to prevent reoccurrence, identify areas for improvement, and demonstrate management commitment to safety. The document outlines the general process of accident investigation including securing the area, gathering facts, identifying the root cause, and implementing corrective actions. It provides guidance on gathering facts at the scene, interviewing witnesses, and documenting evidence. Identification of root causes is discussed along with tools like the 7-step problem solving methodology.
1- Tripod Beta Analysis, Incident Reporting & Investigation Techniques.pptx
The document provides an outline for a workshop on incident reporting and investigation techniques, including Root Cause Analysis using the Tripod Beta methodology. The workshop will cover: the business case for accident investigations; accident causation mechanisms; reporting and investigation techniques; and conducting a Root Cause Analysis using the Tripod Beta method. It will include incident case studies and experience sharing. The document also provides background on the workshop presenter and an overview of the Tripod Beta methodology for structuring accident investigations and identifying underlying causes.
Problem management foundation - Lifecycle
- The Major incident process
- The importance of Time
- Detection
- Diagnosis
- Checklists
- Workarounds
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Here are some potential causes, consequences, safeguards and recommendations to consider for the "LEVEL HIGH" and "LEVEL LOW" deviations for the T-100 storage tank:
Guide Word: LEVEL HIGH
Causes:
- High flow rate into tank from Process Vessel 100
- Failure of level control valve to close fully
- Failure of level transmitter
Consequences:
- Tank overflow, release of material
- Overpressure of tank if vapor space is small
Safeguards:
- High level alarm
- Automatic shutdown of transfer pump
- Float valve to isolate tank on high level
- Dyke/bund around tank
Recommendations:
- Review calibration of level transmitter
Risk analysis
This document provides an overview of risk analysis. It defines key terms like risk, risk analysis, risk assessment, and risk management. It describes various qualitative and quantitative methods used for risk analysis, including hazard and operability studies, fault tree analysis, failure mode and effects analysis. The document discusses the importance of risk analysis for chemical processes and highlights some historical accidents to emphasize this. It also provides examples of applying different risk analysis methods.
Accident Investigation Training- Safety First!
This document outlines the steps for conducting an effective accident investigation:
1) Immediately respond to the accident and secure the site.
2) Investigate by determining the 5 Ws and collecting evidence through interviews and photos.
3) Analyze the data to determine the root causes such as equipment issues, environmental factors, human errors, or management failures.
4) Recommend corrective actions and implement solutions permanently through standard procedures and communication. The goal is to prevent future accidents.
topic7.ppt
The document outlines the process for investigating accidents and incidents at quarries. It discusses selecting the appropriate level of investigation based on severity, investigating through observation of the site, documents, and interviews, analyzing causes, determining remedial actions, recording results, and reviewing the investigation process. The primary purposes of investigations are to identify causes to improve safety and prevent future occurrences.
DS Crisis Management Foundation - Lifecycle
Preview of Crisis Management Foundation
The lifecycle of a crisis which includes a disaster, outage or Major Incident. The process and all aspects of the process of dealing with the lifecycle of a crisis is covered.
Failure Mode & Effect Analysis
Introduction of FMEA; Definition, Activities, important terms, factors, RPN; Process of FMEA; Steps of FMEA
Types of FMEA; FMEA Application; FMEA Related Tools:
Root Cause Analysis, Pareto Chart, Cause Effect Diagram
Accident Investigation.ppt
An accident investigation aims to analyze accidents objectively to determine root causes and prevent future incidents. It involves gathering information at the accident scene, interviewing witnesses, and analyzing all contributing factors across multiple levels. The goal is to identify failures in management systems and implement corrective actions, not blame individuals. An effective investigation considers human, equipment, environmental, task and organizational factors using techniques like root cause analysis.
Operations SecurityWeek 5Incident Management, Investigatio.docx
Operations Security
Week 5
Incident Management, Investigations, and Physical Security
Incidence Response
Incident response is an organized approach to addressing and managing the aftermath of a security breach or attack (also known as an incident).
The Steps of Incidence Handling
Triage – Is it an actual incident or a false alarm? How serious is it?
Investigation – Gathering evidence
Containment – Limit the damage by isolation and mitigation
Analysis – Reconstruct the incident. Who is responsible? How did they do it? When did it occur? Why did they do it?
Tracking – Document the incident and determine the source
Recovery – Mitigate the incident and apply lessons learned to reduce risk of recurrence
Triage
The term Triage is used within the medical community. Triage is the art of rapidly assessing the severity of the incident and following the right protocols, in the right order, to reduce the consequences of the incident and doing it all in the midst of crisis, when every second counts.
Different incidents require different responses – A Denial of Service attack (DOS) has to be addressed differently than a malware infection.
Establishing baselines can help identify unusual activity. The number of indicators to potential incidents are very high, so false positives are common.
Investigation
The Incident Scene – The Environment where potential evidence may exist
Principles of criminalistics apply
Identify the scene
Protect the Environment
Identify evidence and potential sources of evidence
Collect Evidence
Minimize the degree of contamination
General Guidelines
All general forensic and procedural procedures must be applied
Seizing digital evidence must not alter the evidence
Any person accessing original digital evidence must be trained
All activity relating to seizure, access, storage, or transfer of digital evidence must be fully documented, preserved, and available for review
While an individual is in possession of digital evidence, he or she is responsible for all actions
Any agency responsible for seizing, accessing, storing, or transferring digital evidence is responsible for compliance with these principles
Roles and Responsibilities
A solid foundation of knowledge and policy
A properly trained response team
Core areas must be represented
Chain of Custody
Tracks Evidence Handling
A formal, well-documented procedure MUST be followed – NO EXCEPTIONS
Locard’s Exchange Principle
When a crime is committed, the perpetrators leave something behind and take something with them.
Digital Forensics
Be Authentic
Be Accurate
Be Complete
Be Convincing
Be Admissible
Live Evidence
Data that is dynamic and exists in processes that disappear in a relatively short time frame once the system is powered down
Short Term Containment
The short term goal is to prevent more damage from occurring and provide time for additional analysis and mitigation. Isolate the system from the production network and create a backup cop.
Accident_Investigation_2.ppt
The document discusses guidelines for conducting accident investigations. It describes preparing an investigation team, gathering at the accident scene, interviewing witnesses, examining the location and factors involved, determining causes, and developing corrective actions. The goal is to understand what happened to prevent future accidents and complete required reporting. A quiz at the end tests comprehension of proper investigation procedures.
Accident_Investigation_2.ppt
The document discusses guidelines for conducting accident investigations. It describes preparing an investigation team, gathering at the accident scene, interviewing witnesses, examining the location and factors involved, determining causes, and developing corrective actions. The goal is to understand what happened to prevent future accidents and complete required reporting. A quiz at the end tests comprehension of proper investigation procedures.
Root Cause Analysis - Omaintec 2023, Riyadh
Root Cause Analysis presentation presented during the 20th international operations & maintenance conference in the Arab countries.
Incident Investigation and Analysis by HF&C
The document discusses guidelines for investigating incidents in an organization. It covers:
1. The importance of investigating all incidents, including near misses, to identify root causes and prevent recurrences.
2. Organizational preparation for incidents, including communication plans, training employees, and determining investigation procedures.
3. Guidelines for investigations, including involving multiple perspectives, collecting data through interviews and documentation, and focusing on system-level causes rather than individual blame.
Accident Investigation & reporting traning.ppt
Accident incident training slide is one of the best slide to to understand and make proper investigation report and reporting system.
ITD BSides PDX Slides
Methodology for combining Incident Response, Threat Intelligence, and Red Teaming into one holistic program to become more efficient.
Root Cause Analysis | RCA | Gaurav Singh Rajput
This document outlines the steps of the Why-Why root cause analysis (RCA) process used in total productive maintenance (TPM). It begins by explaining that RCA identifies the underlying causes of losses by asking successive "why" questions to determine root causes. The 6 steps are: 1) identify the problem, 2) understand the ideal situation, 3) identify the phenomenon using 5Ws and 1H, 4) develop a cause tree by asking "why" for each factor, 5) implement countermeasures for the root causes, and 6) standardize the improvements. Examples are provided for each step to illustrate how to apply the Why-Why analysis to identify root causes of equipment failures or process issues.
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Genetic libraries
Genetic libraries allow researchers to study genes and proteins from organisms. There are two main types of genetic libraries: genomic libraries and cDNA libraries. To build a genomic library, genomic DNA is extracted from an organism and cleaved into fragments using restriction enzymes. These fragments are then inserted into plasmids which are introduced into bacteria, allowing amplification of the complete genome. A cDNA library focuses only on expressed genes. mRNA is extracted and converted to cDNA, then inserted into lambda phages which infect bacteria for replication. The library can then be screened using probes to isolate specific DNA fragments of interest.
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Hepatitis A is caused by the hepatitis A virus (HAV), which has a single-stranded RNA genome surrounded by an icosahedral capsid. The virus is primarily spread when an uninfected person ingests food or water contaminated with the feces of an infected person. There is no specific treatment for hepatitis A, but improved sanitation, food safety, and immunization are effective ways to prevent the disease.
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1) The document discusses developing a machine-centered preventative maintenance program that optimizes machine health rather than focusing on individual technologies or minimizing costs.
2) It recommends taking a systematic approach of first identifying possible machine failures, determining which are most significant, trying to avoid failures, getting early warnings of failures that can't be avoided, tailoring tests to detect those warnings, and collecting all machine health data at key decision points.
3) This machine-centered approach aims to better assess overall machine health, catch issues earlier, defer unnecessary overhauls, and improve failure management compared to traditional technology-centered programs.
Six steps to motor management webcast
The document outlines a 6 step motor management plan to minimize costs, maintain reliability, and receive early warnings of failures. The steps include: 1) creating a motor inventory and tracking program, 2) developing repair/replace guidelines, 3) preparing a spares inventory, 4) establishing purchasing specifications, 5) developing repair specifications, and 6) implementing planned maintenance. The overall goals are to reduce energy costs through proper sizing and efficiencies, maintain uptime, and detect potential issues before failures occur.
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This document outlines a six step process to take a machine-centered approach to machinery healthcare:
1. Identify possible failure modes of the machine.
2. Determine which failures are most significant based on frequency and consequences.
3. Figure out ways to avoid failures through adjustments, lubrication, or preventative replacements.
4. For failures that can't be avoided, identify ways to get early warnings through process parameters, inspections, or technology.
5. Tailor a suite of tests to monitor for early warnings of significant failures.
6. Collect all monitoring information at a single decision point to determine if maintenance is needed.
Taking this approach optimizes the health of each machine
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Fracas - Failure Scene Investigation
- 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 michaelcardus
- 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. theakshay.
- 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). English106
- 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:
- 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
- 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
- 28. 1. Conduct Scene Assessment
- 29. 2. Conduct Scene ”Walk-Through“ and Initial Documentation
- 31. 1. Determine Team Composition
- 33. 3. Documentation
- 34. 4. Prioritize Collection of Evidence
- 35. 5. Collect, Preserve, Inventory, Package, Transport, and Submit Evidence
- 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