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SARANGANI ENERGY

CORPORATION

Good
Morning
6/4/15

RCFA TRAINING : DAY 1: 2210141412

SARANGANI ENERGY
CORPORATION

Root Cause Failure Analysis

You Have to Know What You're Looking for If You're Going to Find It

December 4, 2014

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Root Cause Failure Analysis Course

SARANGANI ENERGY
CORPORATION

DAY 1
Using RCFA and Making it Successful
True Causes of Plant and Equipment Failure
Risk Analysis, Reliability Growth and Failure
Elimination
Applying RCA Failure Analysis Tools and Their Use

DAY 2
The RCFA Team and The Role of the Facilitator
Introducing and using RCFA
Practice the RCFA Methods
Propagating Improvements Company-Wide
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Applying RCFA in the Workplace

Cross-functional

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Teams

The

Facilitator
Team Dynamics
Running RCFA Meeting
Cooperation Techniques
The Six Hats
Facilitation Techniques

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RCFA Process and Rules of Thumb

SARANGANI ENERGY
CORPORATION

PREPARATION

Keep an Open Mind what you think happened is very unlikely to be the total story

Most problems are due to human factors and poor business processes/controls

Get/keep the evidence concerning the failure from throughout the operation hard evidence from
failed items and soft evidence from interviews
IMPLEMENTATION

Appoint Facilitator and cross-functional team - involve specialists as necessary

Come to meetings prepared with the details that you can provide or are asked to provide
RESEARCH

Conduct interviews; collect site information

Fully flow chart the process (boxes and arrows), and its interconnecting activities into other
processes, and identify the location of the problem

Provide a P&ID, drawings, operator manual, maintenance procedures, operating records, maintenance
records, etc related to the problem
ANALYSIS

Fishbone Analysis for thorough coverage and understanding from range of data collection and data
analysis tools select those that are appropriate

Develop Is-Is Not Table to identify contributing factors

Develop Cause and Effect Tree of necessary cause-effect conditions, states and interactions

Test Why Tree with the 5/7 Whys start as low down Why Tree as there is certain evidence

5 Why Table with Evidence + personal beliefs, attitudes, corporate culture norms, etc. Understand
Latent issues
CORRECTION/CHANGE

Prove proposal is effective

Recommendations and report prioritise by payback and ease to implement


(Taproot/Apollo etc. software for complex problems or problems needing deep analysis)
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Cross-functional Teams

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cross-functional team consists of a group of


people with different functional expertise working
toward a common goal.
RCFA Teams:

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A Facilitator with no vested interests but


knowledgeable of the organisation, operating
systems and culture
Contain a wide range of organisational
knowledge
Include the designer or one who has designed
similar
Include Operations/Production experience
Include Maintenance experience
Include a person intimate with the incident

The Facilitator and Their Role

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CORPORATION

Is the Meeting Chairman,


Is Independent of the
Incident,
A Coach,
A Guide,
A Director of Affairs,
A Timekeeper,
A Recorder,
Is the Project Manager,
Ensures resolution of team
issues is achieved
NOT
a Participant of the
investigation and analysis

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Facilitators Plan

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CORPORATION

Define problem clearly for RCFA


Select team with proper mix of skills and knowledge.
Advise team members what to prepare for first meeting.
Develop meeting agenda and likely list of tools for
investigation and analysis.
Identify means to measure progress along RCA
process (Measure progress in 5%-10% size steps
indicate deliverables at end of each step)
Responsible to follow-up implementation until
complete.
Report progress of all RCAs monthly to superiors.
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Facilitators Problem Solving Toolbox

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Team Attitudes , Challenges and Choices

The
Powerful

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Navigator

Survivor

Victim

Proactive I am going to take the


initiative and make it happen
The
getting by
line

Some Body Should do


Something

Powerless
Reactive

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Why Bother , there is no


Point

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Team Building / Relationship / Partnership


How does RCFA
help us in
Production?

SARANGANI ENERGY
CORPORATION

Do you want
Reliability,
Availability,
Throughput, Safety,
Quality, Lower
Costs, and Less
Waste?

Identify RCFA value add for people and company


Bring groups together in a cooperative,
professionally run meeting
Request others ideas/input and discuss/do them
Continual communication: changes and assistance

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The RCFA Meeting

Identify purpose of the meeting, set priorities, fix


times, resource management and allocate
responsibilities

Right mix of people Production decision


makers, Maintenance decision makers, plus
electrical, mechanical, engineering, OHSW reps

Professional meeting practices Room booked,


Agenda, Meeting Timeline, Action minutes listing
responsible persons and due dates

Report back on decisions and actions performed


and their success

A face-to-face, people process (trust, belief,


honesty, laughter)

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SARANGANI ENERGY
CORPORATION

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Tell-Tale RCFA Meeting Success Factors

SARANGANI ENERGY
CORPORATION

Team work of equal partners.


Honesty in communication, trusting that
each has the
best interest of the business, its people and
its future at Heart.
Credibility through commitment to
agreements and the
continual improvement of the operation and
its people.
Consistency of intent by attending regular
meetings, providing participants, actioning
decisions and delivering results.

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SARANGANI ENERGY
Facilitator Ensures Solutions are
CORPORATION
Implemented
You want permanent improvement throughout the organisation, rather than
in one operation or department

Management is responsible to provide the resources to make the


improvements

Making change needs change


management.
THE CHANGE 1.Plan
MANAGEMEN 2.Prepare - document, tool-up,
train
T PROCESS
3.Authorised by all concerned
4.Implement
5.Monitor and Encourage
6.Confirm adoption
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If Its Not Written, Its Not Real

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CORPORATION

Unless something positive and concrete comes out


of a bad situation there has been no learning, and
the problem will reoccur.

Act

Planners

Workforce

Improve the
Planning,
Procedures
and Forms
Do

Learn from
Managers
the
experience
Plan
act to
Cost
correct
Quality
Time
your
business
Check
systems
Supervisors
and
processes
so it
doesn't
Until the
new ways are
happen
again.and people are
documented,

Improve the
Job
Procedures
and Checks
Improve the
Training and
Competence

trained to do them right, they


will not happen in the
workplace.
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The Facilitator Monitors Progress and Schedule

SARANGANI ENERGY
CORPORATION

The
Facilitators'
responsibility
may not
include
making the
changes
recommende
d by the RCA
team. It does
include
reminding
management
Continually Improve that until the
changes are
introduced
and are in
use,
the risk
Is the agreed work being completed, at the right time, with the right
resources?
remains in
the business.
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Using the Six Hats to Help Teams Work

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Anger: listens to their emotions

Creative: cultivates,
encourages new
ideas

ptimistic: helps make ideas work

Pessimistic: looking for problem

Objective: systematic and care

Visionary: sees things from a higher perspective


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Six Hats in RCFA Meetings

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SARANGANI ENERGY
CORPORATION

1. Assign hats to people on the discussion team,


ideally one colour per person. When each person
speaks they must identify with the colour and speak
accordingly
2. The team discusses the problem (every member
can contribute to the discussion) with the following
main responsibilities
1. White hat presents the facts of the problem
2. Green hat presents the ideas on how the
problem can be solved
3. Possible solutions are discussed with yellow hat
focusing on benefits and black hat focussing on
drawbacks
4. Red hat encourages all team members to
express their gut feelings about the situation
5. Blue hat summarises the discussion and closes

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Evaluate and Select the Solution(s)

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List the Objectives satisfying to all stakeholder, meet legal


requirements

Rate the Objectives most important (10) down to least (1)


important

Rate the Options best outcome (10) to least desirable (1)


Review Risks select the highest rated option that meets risk

control requirements and is practical to implement

Test the Choice get independent expert opinion, do a small


scale experiment and adjust as necessary

Cause to
Address

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Proposed
Solution

Solution
Objective

Risks with
Implementatio
n

Rating
for
Objective
1, 2, 3

Rate for
Option
1, 2, 3

Overall
Rating
(Obj x Opt)

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Prioritise the Recommendations

Make sure there


are low cost
solutions as well

High
Do
these
first

Impact

Develop multiple
recommendations

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Gets
Management
Support

Low
Hard

High Payback

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Ease to
Implement

Easy

Easy to Do
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The final task of the Team is the report

SARANGANI ENERGY
CORPORATION

The effort expended during an RCFA is justifiable only because it leads


to recommendations which, if implemented, will eliminate or minimise
repeat occurrences in the future.

In preparing the report there may be some unpalatable truths but these
must be appropriately stated.
adverse events are usually the result of human errors
these errors must be accepted as system flaws, not character flaws

The report will contain all the documents produced during the
investigation and a summary Executive Report at the front. This will
enable senior, and possibly non-technical management, to read the
recommendations and appreciate the value of the RCFA procedures.

The report format needs to be standardised and formatted to a company


specification. (In Toyota, investigations and recommendations have to fit on an A3
page)

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Building Failure Elimination into Your


Business

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CORPORATION

22

Dont change people, change their


practices!

SARANGANI ENERGY
CORPORATION

Changing collective values of adult people in an intended


direction is extremely difficult, if not impossible. Values do
change, but not according to someones master plan. Collective
practices, however, depend on organisational characteristics like
structures and systems, and can be influenced in more or less
predictable ways by changing these.
Hofstede, 1997

You cannot change peoples internal values, but what you can change is
the practices they must follow so that their cognitive dissonance brings
about change in their values.

For example, if you want people to always practice creative disassembly, provide a
procedure and report sheet they must complete and hand-up at the end of every stripdown so you can encourage and train them. In this way, the organisation's practices
brings about the necessary change in the value that people put-on careful observation
and recording.
THE GROUP LEADER WILL NEED TO SUPPORT AND ENFORCE THE NEW
PERFORMANCE, ELSE PEOPLE WILL RETURN TO THEIR OLD WAYS (The really important
people are the Supervisors/Team Leaders)

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Understanding what it means to be in


control and capable

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In control
and capable
In control
but not
capable

Out of control

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Getting high task reliability needs quality

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Number of
Events

Only accept this range of


outcomes because they give very
low risk

Very Bad
Outcome

Very Bad
Outcome

Acceptable
Outcome

Value of a Critical
Parameter

In the end... reliability is a quality control


issue.
Because all our machines are a series of parts, and all our work are a series of activities,
there are endless opportunities for variation many of which will cause failures. Hence,
we must set the correct standards of performance for every step in a series so that we
deliver only those results that give us the right outcomes. This is quality. The more
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precisely we approach the standards; the better the quality; the more certain and

Quality Management = Continual Business


Improvement

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Standard to
Meet

In business you need to drive a continuous improvement culture.

Requirements,
Needs,
Expectations

Degree to
which
inherent
quality
characteristi
cs meet
Effect of Using a Quality
stated or
Performance
System
implied
Levelneeds.

Time
The Meaning of Quality

Quality
Improvement
Tools

Plan

Do

Measure

Improve
Measure means
to check you
have statistical
control

We want to do all work with certainty that it will improve reliability. To do


that we need a business system that promotes and continually improves
the accuracy and quality of our workmanship and our operating and
maintenance processes. Such system is called a Quality Management
System.
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Reliability Improvement Teams

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Steering
Steering Committee
Committee
e.g.,
e.g., Eng,Tech,and
Eng,Tech,and Ops
Ops
Managers
Managers

Plant 1

Plant 2

Plant 3

Plant 4

Improvement Teams

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Reliability Framework

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Reliability
Reliability Management
Management
Focal
Focal Point
Point

Steering
Steering Committee
Committee
e.g.,Eng,
e.g.,Eng, Tech,
Tech, Ops
Ops
Managers
Managers
Reliability
Reliability
Improvement
Improvement
Plans
Plans

Approved
Approved
Action
Action Plans
Plans

Simplified
Simplified
RCM,
RCM, RBI,
RBI,
RCFA,
FMEA
RCFA, FMEA

Implement
Implement

Multi
Discipline
Teams

Publicity
Publicity

Feedback
Feedback

Monitor
Monitor

RCM Reliability Centred Maintenance


RBI Risk Based Inspections

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Create A Business Process to Produce


Reliability

FMEA

DAFT Costs

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Equipment
Criticality

Life Cycle Operating Risk


Reduction Strategies
MAINTENANCE

Planned Preventive
Maintenance
Planned Condition
Monitoring
Planned Reliability
Improvements
Precision Maintenance skills
and equipment
Precision Breakdown Repair
Standardise best practices

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OPERATIONS

Operate within design


envelope
Precision Operation stress
removal
Operating Performance
Monitoring
Operator listen, look, feel
monitoring and report
problems
Operator tighten, lubricate,
clean
Reliability
Standardise best
practices
Growth

ENGINEERING

Specifications for reliability


manufacturing, materials,
installation, commissioning
Select for life-cycle profit
maximising
Design-in reliability,
maintainability
Standardise best practices

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Sumitomo Chemicals Maintenance


Management Cycle

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Sumitomo Chemicals Failure Prevention


Cycle

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Project MANAGEMENT Approach to


CHANGES

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Project
Managementc
Project
Management

Perform the range of tasks necessary to organize people, plan


activities, measure progress and communicate results over the life
of the project
Communications
Communications
- Publicity
Define the key messages to build support, identify effective
delivery methods and use to create and maintain momentum for
the change effort

Do I need to change?

Putting the Plan into Action


Create the plan for
Create a view of a
change
Implement
future state
Planning
Visioning

Assessing
Renew & Sustain

To secure and sustain the benefits of


change reward people for good role
modeling
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Reminder: Identify All Possible Cause and


Effect

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(Because we do not yet know the real cause)

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Reminder: Use 5/7 Whys to Confirm Real Failure Path

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Case Study 1 Guided Application of RCFA

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A real failure of a process chemical reactor.

Defect and Failure True Cost


Php24,000,000.00

Apply the RCFA process under guidance

Trace through to the latent root cause

Feedback and discussion

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Activity 6 Do 5 Why RCA of the Roof


Collapse

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CORPORATION

1) Flow chart the perfect process to safely drive into


the filling bay
2) Do Is-Is Not Table of the process
3) 5/7 Why the incident
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Reminder: Start with Scientific Cause


Sequence

Roof
Fell

Foundation
Failed

Stop

Roof
Material
Failed

Stop

Column
Material
Failed

Columns
Tumble

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Scientific Event
Sequence

Stop

Column to
Ground
Connection
Fails

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Columns
Tilt

Roof Moves

Trailer Hits
Roof

37

What Level of RCFA to Apply?

What do your

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business procedures say?

Creative

Disassembly

Root Cause and Effect

Individual persons working


on-the-job
Escalate
Low cost, little time
Preventive focus
stops the many small causes
that lead to large failures
Misses multiple causes

Catastrophe Analysis

Team of experts in
several meetings
Escalate
High cost and time
focus on big problems
and you keep having big
problems
Identifies wider
perspectives

Team of experts with


detailed FTA, failure
investigation and
reliability analysis
Problem of catastrophic
size
No stone left unturned;
the truth comes out

EFFECT OF MODERNSAFETY
SAFETYACCIDENTS
INITIATIVES
1

Serious Injuries

10

Minor Injuries

30

Property Damage

600

Incidents

The Heinrich Accident Pyramid


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EQUIPMENT FAILURES
1

Serious Failure

10 losses

Minor Failures

6500 repairs
20,000 defects

Process Losses
Procedural Incidents
Source: Winston Ledet,
Manufacturing Game

The Failure Pyramid


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Precision Maintenance to Investigate


Equipment Failure
Equipment in Service
Maintenance need identified

Creative Disassembly

CM
QA

Precision Reassembly

Precision Installation

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CM
PM
OPS

CM = Condition Monitoring
PM = Preventive Maintenance
QA = Quality Assurance
OPS = Operator Sensing
(Watch Keeping)
ACE = Accuracy Controlled
Enterprise
3T = Target - Tolerance - Test

Precision
Maintenanc
e
Activities
to ACE 3T
Procedures

These
techniques
deliver
Machinery
Improvement

Good is not good enough excellence is required and


expected.
Most machinery problems are preventable.
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Parts Fail then Machines Stop

2nd bearing
sleeve

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CORPORATION

2nd bearing bush

What
1) HUMAN
FACTORS,

1st bearing
sleeve

1st bearing
bush

2) BUSINESS or
WORK
PROCESSES,
3) PHYSICAL
PROCESSES
AFFECTING
EQUIPMENT

Casing wear ring

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4) LATENCY
FACTORS
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Tell-tale Bearing Failure Signs

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CORPORATION

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Creative Disassembly Pre-shutdown of


Equipment

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CORPORATION

Gather historical and background data whilst still in service

vibration, bearing, thermography, oil data for


diagnostic purposes. Look at this for varied
process conditions
check for running soft-foot (machine distortion when at
operating under load)

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look for resonance in machine, structure, pipe


work, other attachments
look at the equipments maintenance history
for tell-tale evidence

Thanks to Peter Brown of Industrial Training Associates for the slide

42

Creative Disassembly At Shutdown

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CORPORATION

Before Strip-down

where thermal growth is important for


alignment, obtain hot alignment readings
while still at operating temperature

look for witness marks, evidence of shifts


or relative movement

check for static soft foot (machine distortion when at


stand-still)

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sample lubricants and other fluids

Thanks to Peter Brown of Industrial Training Associates for the slide

43

Creative Disassembly At Strip-down

Look for witness marks,


evidence of fretting etc.

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CORPORATION

Inspection of bearings

Disassemble in clean and well lit


when removed, prior to cutting
areas
Photograph damage if
applicable

cut the cage/retainer rather than


springing it

Avoid damaging during removal

cut outer race from top centre to


bottom centre

Mark the relative locations of


bearings in housings, top and
side, inboard and outboard

re-inspect prior to cleaning

Gearing wear patterns eccentricity, backlash,


misalignment etc.

analyse bearing and ball path


patterns

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filter solvents to see what is in


the bearing

spalling patterns revealing poor


fitting
fitted surfaces revealing fretting,
44
out of roundness etc.

In a Bearing Failure, Dont Destroy any


Evidence
EVIDENCE
1.
2.
3.
4.
5.

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CORPORATION

Sample lubricant prior to removal


Mark relative locations of bearing in housing, top and side, inboard & outboard
Disassemble in well lit areas
Photograph damage, and on parts in contact
Avoid further damaging during removal
What chance has this bearing?

INSPECTION
6.
7.
8.
9.

Inspect bearing when removed prior to cutting


Cut cage/retainer rather than springing them
Cut outer ring from top center to bottom center
Re-inspect prior to cleaning

ANALYSIS
10.
11.
12.
13.
14.

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Filter wash-down solvents to see what is in bearing


Spalling patterns revealing poor fitting, high contact stress
Test lubricant hot plate test for water; colour; contamination
Fitted surfaces revealing fretting, out of roundness etc.
Root cause analyze bearing and ball path tracks
45

Ball Path Patterns - Normal

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CORPORATION

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Ball Pattern - Normal with outer race rotation.

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CORPORATION

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Abnormal Patterns

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CORPORATION

Thrusted
Double
loading
potential
cause is
Soft Foot

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Abnormal Patterns

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CORPORATION

Overloade
d
Misalignm
ent

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Abnormal Patterns

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CORPORATION

Unbalanc
e
Pinched
Outer Race
Bearing

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Change Habits: Creative Disassembly

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CORPORATION

51

Activity 7 Do a Creative Disassembly

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CORPORATION

Read the Creative Disassembly Explained article in the workbook and


then do the activity.
What caused the track in the
race? How do you fix it?

Why is one side of belt


glazed? How do you fix it?

What caused this marking?


How do you fix it?

Why is there corrosion?


How do you fix it?
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How do You get Full Marks?

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How do You know You


have got full marks?
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What do we mean by.

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Quality, Precision, Repeatability, Variability


Quality

Precision

High
Quality

Frequency of Outcomes

Frequency of Outcomes

Accuracy

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Accurate
Precision

Repeatability

X X

Specification

Specification

Variability =
Range of Outcomes

Range of Outcomes =
Variability

Repeatability is low
in this process

Unwanted
Variability
= Unwanted
Outcomes

54

Reliability Creating 3T Error Proof


Procedures

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CORPORATION

Build Mistake Proofing into SOPs


Set a target for each task.
Specify the acceptable tolerance.
Do a test to prove accuracy.

3Ts of Failure
Prevention . Target
. Tolerance
. Test

Frequency of Outcome

et
g
r
Tarecision
P

Bands of Lesser
Quality

Quality
improvement
occurs when
variation is
reduced

(Decreasing
Accuracy)

Good, Better,
Best
Bronze, Silver,
Gold

Tolera
nce

Pro for Quality


of
for
Re Tes
liab
ilit t

Output
Specification

Range of Possible
Outcomes

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How 3Ts guide workmanship quality

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CORPORATION

As GOOD as it needs to be
BEST

BETTER

As BAD as allowed
GOOD
PASS /
ACCEPT

Perfect
Result

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World Class
Target

FAIL /
REJECT

Tolerance
Limit

Certain
Failure

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The Purpose of Accuracy Controlled


Enterprise SOPs

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CORPORATION

Instead of doing the task and measuring at completion to see if it is


accurate, the 3Ts require measuring during the task so nothing
proceeds until it is accurate.

Time

Time

Output

People in Processes Produce Variable Outcomes

Output

3Ts in SOPs Remove Volatility from Processes

The 3T method - Target, Tolerance, Test - introduces quality control into


human-dependent processes. It keeps a procedure in-control and
capable. It greatly increases repeatability and reliability of work results.

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Standardize Human Dependent Processes

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Mistake Proofed SOPs to Prevent Variation

Specify the 3Ts (Target, Tolerance, Test) for


precision, accuracy and error proofing

No.

Better

Best

Good

Range tolerance good, better, best


Make best the world-class performance
Specification

Make a SOP with a table of successive


activities in each row
Provide columns for good, better, best
tolerance range
Give all tasks a proof test
Advise what to do when out of tolerance
Get a signature when 3T is done to tolerance

Range of Outcomes
0.9

0.9

0.9

Warning This is a series system!

* It is this test that makes


an activity error proof!
0.9

0.9

0.99

0.99

3T SOPs give feed forward control


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Why Quality Control in Procedures

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NOTE:
None of these task will
prevent the pump and
piping from failing.
These tasks find future
repairs and you want a
healthy, reliable pump
set...

prevention is
easier than cure
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Accuracy Controlled Enterprise 3T


Procedure

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CORPORATION

An organisation that applies 3T accuracy


controlled procedures at every level of operation.
Te
st

Re
b
lia ring
bili
s
ty

Task
Step
No.

Task
Step
Owner

Task
Step
Name
(Max 3
4 words)

Record
Actual
Result

Full Description of Task

Test for Correctness

(Include all tables, diagrams and pictures here)

Describe the test and below specify the


target as BEST and range of acceptable
results that are Good enough.
Good

Better

Actionsif Out
ofriTolerance
ng

t b on
e
rg isi
Ta Prec

Sign-off After
Complete

Best

Toler
ance
bring
Q
uality

One Layout for an Accuracy Controlled Procedure


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Continuous Improvement = Accuracy


Controlled Procedures

SARANGANI ENERGY
CORPORATION

Now you know what good enough is!


Pro
o
f
for
Re Tes
liab
ilit t
y

Task
Step
No.

Task
Step
Owner

Task
Step
Name
(Max 3
4 words)

Tools &
Condition

Full Description of
Task

Test for
Correctness

Tolera
nc

(Include all tables, for Qua


lity
diagrams and pictures
here)

Record
Actual
Result

Tolerance Range

Good

Better

Best

Action if
Out of
Tolerance

Sign-off
After
Complete

Targ
et

Prec
ision

Drive Improvement
Accuracy Controlled 3T Procedure Layout
Continuous improvement: Make better good, make best better and set a
new standard for best. In this way, you will drive quality improvement and
innovation in your company. Good enough never is!

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Activity 8 Standardised Accuracy


Controlled Procedure

SARANGANI ENERGY
CORPORATION

In the workbook complete the pump set inspection


procedure with quality standards to meet and checks to
prove they have been met or bettered.

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Activity 9 RCA Cable Reel Near-Miss

6/4/15

SARANGANI ENERGY
CORPORATION

63

Activity 10 Group do Motor Failure RCFA

SARANGANI ENERGY
CORPORATION

An electric motor bearing failed on a piece of critical


plant.

Team-up to make a group

Appoint a Facilitator who controls team situations

Develop the cause and effect tree

Using the evidence, identify the root cause

Use any tools you wish for analysis

Develop a secure prevention against future failures

Rate the proposed solutions and prioritise

Feedback and discussion

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The Power of RCFA comes from


Propagation

SARANGANI ENERGY
CORPORATION

Propagation
Permanent
Improvement
Implementati
on
Corrective
Action

Be

nd
o
y

FA
C
R

Analysis
Investigation
Evidence
Failure

FA
C
R

Pr

ss
e
oc

Each failure is a symptom of a


business system problem.
Take what is learned in each RCA
across the whole business so the
systems are improved.
Train relevant people in the new
ways so everyone does them well

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Management Make the RCFA Process Work


for the Business

SARANGANI ENERGY
CORPORATION

Set expectations for RCFA in a corporate policy/vision on the purpose, usage,


outcomes and business improvement required of RCFA
Establish a core group of people passionate for failure elimination and teach
them the tools and methods of root cause analysis and business process auditing
Develop RCFA processes at three levels 1) defect removal, 2) problem
prevention, 3) disaster eradication
Train people in the methodologies everyone on defect removal, team leaders
and above on problem prevention, supervisors and above on disaster eradication
Establish internal auditing half-yearly (by people from outside the department)
of samples in each RCFA level and adjust processes and training accordingly
Report on RCFA completion at monthly management meetings all
uncompleted RCFAs findings, and monitoring pace of action on required
resolutions

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Document and Describe Your RCFA Process


Steps

SARANGANI ENERGY
CORPORATION

Preserve and collect evidence


NO BLAME... else truth disappears and fear reigns
2. Appoint experienced facilitator
3. Assemble a cross-functional team of persons involved in the incident and others
knowledgeable in plant/process design and operation
Total business
4. Cost total impact of the incident to give power to the investigation
losses impact
5. Interview for what persons involved were doing
6. Investigate the physical evidence for its history
7. Team brainstorm, starting at failure, to develop a cause-and-effect tree of
sequential steps that may have led to failure (only grow the real branches)
8. Use the evidence and interviews to confirm the failure path
9. Develop a 5-Why Table using the evidence
10. Record the findings
11. Identify what can be done at stages along the path to prevent the failure and how
they should operate
Use Hierarchy of Controls
12. Communicate the findings and necessary changes company-wide
13. Appoint a person to put the changes in place, including doing necessary training,
using change management methodology
14. Review and monitor that progress is made towards the improvements
1.

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Some final closing thoughts for you

SARANGANI ENERGY
CORPORATION

Many have said that RCA is more art than science. (It is if there is no RCFA process.)
Indeed, it seems to draw from a range of skills, talents, experience and
knowledge. Some investigators seem to have a special knack for it while
others toil through the process. (A diverse mix of team members makes for more success.)
Even if an RCA is unsuccessful at uncovering the root cause, the process
usually brings forth new knowledge and greater awareness of reliability risk
factors to the team. This new knowledge can then be rolled into criticality
studies, such as FMEA, leading to an overall improvement in machine
reliability. (Only if newly discovered knowledge is written into the corporate memory for all to find and
use.)

The greatest successes come when you take the learning from every RCA
across the entire business. (This is lateral development and it brings companies much success.)
Its always wise to ask, Why was this allowed to happen? What latent
thoughts, values and beliefs in the organisation and its people that let
the situation arise?

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