Reliability Maintenance Engineering 3 - 2 Root Cause Analysis
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Reliability Maintenance Engineering Day 3 session 2 Root Cause Analysis Three day live course focused on reliability engineering for maintenance programs. Introductory material and discussion ranging from basic tools and techniques for data analysis to considerations when building or improving a program.
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Reliability Maintenance Engineering 3 - 2 Root Cause Analysis
- 2. ROOT CAUSE ANALYSIS Day 3 Session 2
- 3. Objectives • Examining different root cause techniques • Conducting incident investigations • Evaluating corrective actions • Advancing equipment troubleshooting • Failure reporting, analysis and corrective action system (FRACAS)
- 5. 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
- 6. Root Cause Techniques • Causation • Forensic engineering • Proximate & ultimate causation • Root Cause Analysis
- 7. 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
- 8. 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. Plan D1. Use a team D2. Define and describe the problem D3. Develop Interim Containment Plan (implement and verify) D4. Determine, Identify and Verify root causes D5. Choose and verify permanent corrections D6. Implement and validate corrective actions D7. Take preventative measures D8. Congratulate the Team
- 11. Incidents • An unplanned or undesired event that adversely affects operations • Work related injuries • Occupational illnesses • Property damage • Spills • Fires • Near misses
- 12. Investigation • Get the facts – Reporting – Data collection – No blaming… • Determine root cause • Recommend corrective actions
- 13. 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
- 14. 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
- 17. Corrective Actions • Action in response or reaction to a failure • Use root cause techniques • Incident analysis
- 18. Predictive Action • Proactive or prediction of problem and taking steps to avoid the failure • Root cause analysis • Risk analysis techniques
- 19. Examples • Error proofing • Visible or audible alarms • Product or process redesign • Process control improvements • Condition monitoring
- 20. Tactical & Strategic • Tactical • Immediate effects • Local processes • Physical causal chain interruption • Strategic • Cumulative effects • Overall process • Information causal chain improvements
- 23. Troubleshooting • Problem solving applied after a failure • Logical • Systematic • Determine the cause(s) of the observed symptoms
- 24. Troubleshooting Guidance • Critical vs magical thinking • Correlation vs causation • Understanding what is supposed to happen • Reproducible? • Intermittent causes • Multiple problems
- 25. Diagnostics • The identification of the nature and cause of a failure. • Focus on cause and effect
- 26. Diagnostic Guidance • Black box recordings • Condition monitoring information • Sources of variation • Theory of operation support
- 29. FRACAS • Failure Reporting Analysis and Corrective Action System • Corrective and Preventive Action (CAPA) system
- 30. 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
- 31. Poor examples • Multiple systems • No periodization – first reported first resolved • Rewarding entries and completions
- 33. 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
Editor's Notes
- Examining different root cause techniques
- Balance between investment and value
- Conducting incident investigations
- Balance between investment and value
- Evaluating corrective actions
- Balance between investment and value
- Advancing equipment troubleshooting
- Balance between investment and value
- Failure reporting, analysis and corrective action system (FRACAS)
- Balance between investment and value