Manufacturing Reliability Improvement Analysis Approach

Introduction
The Shell Oil manufacturing location reliability analyses are based on the rigorous application of a structured problem solving approach. The intent of this structured approach is to make an often confusing and intuitive problem solving effort, a conscious focussed analytical process. None of the techniques utilized are "new"; some of the tools are covered in Shell's quality improvement training; several tools date back fIfty years or more. But rigorous application of these techniques are not commonly practiced. The problem solving techniques utilized by the analysis teams are made up of several discrete thinking steps. Each process step has a uniquely focused approach aimed at a particular purpose (see figure 1). These steps provide a formalized approach to resolving very complex problems when used in the appropriate sequence and with sufficient rigor. This process facilitates the discovery of multi-causal, chain (domino theory), error prone, and systemic generative (pattern) causes. The approach is partially based on the problem solving method originally developed by Kepner - Tregoe1 This analytical approach was originally designed to improve management problem solving and decision making, but it is now widely utilized a basis for failure analysis (root cause analysis) and solution development.

W.NUFACTU~ I p..(; AND TECI-f'll GAL

Problem Solving Techniques

PROCESS STEPS

TOOLS

ANALcx;y

PROBLEM
IDENTIFICATION

I NVENTQRY
SEPAAATION

GROUP I IGI PRIORI T I ZE PROBLEM STATEMENT PROBLEM DESCRIPTION I Sf IS ..oT PARETO T IMEL I NEt FLOWCHART CHAIGE MJOEL FISHBONING STAI RSTEPPING D I FFERENCEt CHANGE

THE CRIM E

THE EVIDENCE

POSSIBLE CAUSES

SUSFECT S

TESTIIGI VERI F I CAT I ON

DESTRUCT IVE TESTI i'G DA.TA COLLECTION

AUTOPSY CONFESSION PROSECUT ION TRIAL

SOLUT IONS

BRA I NSTOR.! I NG SELECT ION Gl<1 D

PREVENT I ON PLANN I
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PUNIS~ENT REHABILITATION

Figure 1
1

From The New Rational Manager by Charles H. Kepner & Benjamin B. Tregoe This book is used as a reference by all field analysis teams.

4 The teams initially develop hypotheses (potential cause-and-effect paths) that could (if true) explain the undesired effects (based on the problem descriptions). Cause and effect analysis, the "fish-bone", is the predominant analysis tool used to establish this structure. This is followed by focussed and specific data collection efforts (documentation, observation, and interviews) to either support the cause hypotheses or to discredit them. The analysis teams further narrow the possible causes by "screening" them against the problem description (ie. differentiation). The "real" cause(s) must be able to explain all four of the distinctions in the differentiation model (see figure 2). There are very few possible causes that pass these filters to become most probable causes.
THE NATURE OF CAUSE

COMv1ON CAUSES

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Testing and verification

This is the final step of the cause Figure 3 identification process. It is in this step that the analysis team attempts to specifically confirm that the most probable cause actually does (or did) occur. Absolute cause verification however, can not always be accomplished. Equipment shut down and inspection or unit performance testing (replicating the events) is rarely feasible during the analysis phase. In such cases, this step is either skipped (no viable alternative) or additional data is collected to add (or refute) further verification. Much of the additional verification of cause takes place after the analysis teams have left. The task of documenting literally thousands of findings and structuring them in a logical cause and effect structure, creates many opportunities to further validate information (compare with other information not collected before) and to conduct some additional unit tests.

Solution Development
This step represents the most naturally enticing segment of the analysis process. This is where the opportunity to develop "the answer" to the problem exists. The reliability analyses intentionally do not involve this part of the process to avoid the natural tendency to "jump" to one of the many possible solutions without a comprehensive understanding of the causes. This solution development process is normally applied by a follow-up group to eliminate the causes identified.

Common Causes
Since the reliability analysis teams have the opportunity to analyze several problems and problem areas simultaneously, they take the occasion to view all of the sub-team findings for commonality (patterns). Common causes (causes types found to generate most or all of the problems studied) represent strategic findings for the unit area and the manufacturing location. These cause types often characterize cause systems (or consistent patterns of performance) signifying that either; 1) systems to produce desired performance are missing, or 2) systems to produce desired performance are defective (not working as we would like). These patterns represent strategic significance because they may represent the causes of many problems (in addition to those found directly through a specific analysis) that could be resolved (if corrected) without additional analysis effort.

...,FACT'" rIG A~

TEe,"" r CAL

DATA

QUAL I TY

FACTS

PRECISE ACCURATE

Common causes identified in these analyses represent some of the most important findings from the analysis process. Many other seemingly unrelated problems may be generated by the same or similar common causes identified during a study.

VERIFIABLE MEASURABLE

INFERENCE

LOGICAL DEDUCTION BASED ON FACTS LOGICAL HYPOTHESIS THAT COULD EXPLAIN THE FACTS GUT FEEL & EXPERIENCE OTHERS OPINIONS 2ND, 3RD, 4TH-HAND INFORMATION EDUCATED, WILD, SWAG NO BASIS - DISTORTION

ASSUMPTION

OPINION BELIEF

Special areas of emphasis

HEARSAY

In addition to understanding the basic cause GUESS identification process, the analysis teams have to FANTASY master additional analytical skills to insure that the causes of these complicated problems are rigorously and comprehensively defined. This requires specific attention to the quality of Figure 4

the data collected and to the rigor of analysis when dealing with human/systems issues. Data Quality In addition to following the problem solving process rigorously, the analysis teams also have to ascertain the quality of the data that is being utilized in the analyses. N early all initial data is considered suspect or cross validated through other data sources. Much of this "fact basing" is undertaken during the analysis process, but a significant amount of data validation is also conducted during the write-up. Human/System Reliability Human/system reliability involves the predictability (or un-predictability) of the human elements within the context of a large and complex performance system. Sometimes known as human factors, human/systems theory is based upon two concurrent foundations; 1) an """""CTU"''' TEc..,rCOL understanding that unpredictable, irrational, unexplainable, unstable, HUMAN / SYSTEM umeliable response or activities within a RELIABILITY performance system, will inevitably lead ASSUMES THAT HUMANS 00 I'-OT to performance failure, and 2) that INTENTIONAllY COMMIT individuals or organizations rarely STUPID (IRRATIONAL) ACTS. intentionally behave irrationally. When CHARACTERISTICS confronted with apparent irrational UNRELIABLE RELIABLE evidence, the analyst must conclude that he does not have all of the data, does not lrrat. ana 1 Unbe Ii evab I e Rationol Unexpected Pred i ctab I understand the environment at the time, e Cons istent. I ncons i stent or does not understand the reasoning Stable-Sust~ining Unpredictable used.

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.AKJ

Explainable

Unstable

When the analysis teams find evidence Flexible, Adaptable (Except by FAULT) of "irrationality", their analysis becomes Reactive Unresponsive focused on two major potential contributors; 1) lack of knowledge or skill (internal stressors? or, 2) execution blockages (external stressors). The Figure 5 teams remain focussed on "why" the individuals or organizations acted as they did assuming that in the environment at the time, the responses were probably rationally based.
2 Terminology used from A Manager's Guide to Reducing Human Errors published by the Chemical Manufacturer's Association July 1990 This book is used as a reference by all analysis teams.

AntiCipatory, Proactive Unexplainable