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Slide 1Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Murphy’s Law BusterFMEA Improves System Reliability and Saves Costs
Presented by Ernie Borgoyne
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 2
Ernie Borgoyne - Biography
• Pine Creek Canyon DWID – Board Chairman
www.pccdwid.org• Ceptara - Engagement Manager
www.ceptara.com / [email protected]• Rim View Consulting - Consultant
[email protected] / 602-571-7983
– Lean Six Sigma Black Belt
– ASQ - Certified Quality Engineer• Motorola – Project Engineer for over 35 years• Arizona State University - BS/MSEE
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 3
Agenda
• Background• Application to an Actual System• Process Overview• Wrap-up
Slide 4Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Background
What is an FMEA and how did it originate?
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 5
FMEA is an acronym forFailure Modes and Effects Analysis
• FMEA is a systematic group of activities intended to:– Recognize and evaluate a failure and the effects that
failure has on the system– Identify actions that could:
• Eliminate the failure• Reduce the probability the failure occurs, or• Reduce the criticality of the failure on the system or its users
– Document the process
* ASQ CQE Reference Material
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 6
FMEA History
• Discipline developed by the US Military– Released in 1949 as MIL-P-1629– Failures classified according to impact on mission success
and personnel/equipment safety• ISO-9000 pushed for global industrial standardization
– Business Management Standards first released in 1988– Pushed organizations towards formal Quality Management
Systems, including such tools as:• Advanced Quality Planning• Design and Process FMEAs• Control Plans
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 7
FMEA is a “Bottom-Up” AnalysisComplements other Reliability Analysis Methods
*Failure Modes and Effects Analysis
(FMEA
FMEA for Critical Components (FMECA)
Fault Tree Analysis (FTA)
Type of Analysis
• “Bottom-up” inductive analysis
• Considers failure modes at the lowest level and works up to determine effects at the highest level
• “Bottom-up," inductive analysis
• Considers product components at the lowest level for potential causes of a failure.
• “Top-down,” deductive analysis:
• Considers failure modes at the highest level and works down to determine causes at the lowest level.
Type of use
• Typically used if there are multiple effects at the system level of comparable severity, such as with an automobile engine.
• Typically used on complex systems to evaluate new designs or improve the reliability of existing equipment and address safety or reliability issues, such as with the braking system on an automobile.
• Typically used if there is one extremely critical top-level event, such as with a nuclear meltdown.
* ASQ CQE Reference Material
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 8
Application to an Actual System
• A Failure Mode and Effect Analysis was performed on the PCCDWID system in Pine, Arizona in August 2010
• During this time several system upgrades were already in progress:– Construction of a Deep Well to augment the existing shallow well– Addition of an emergency generator for the water electrical
system– Raising the berms on the effluent pond– Creating a secondary effluent pond for maintenance purposes
• The following slides identify additional improvements resulting from the FMEA
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 9
Application to an Actual System (cont’d)
Subsystem Action
Electrical System • Check emergency generator diesel tank levels monthly• Establish maintenance procedure for emergency generator that includes
monitoring the hour meter register • Change Programmable Module backup battery every 5 years.• Install Auto‐dial alarm system for pump house
Deep Well / Shallow Well
• Water management and usage plan being developed by Highland Water Resources Consulting should include the effects of pump life and Filter Pack Media/Well Screen life.
Water Storage System • Policy for regularly inspecting the water tank internally for coating failure, deterioration, or corrosion should be defined.
• Exercise the bypass valve and check for debris yearly
Central Water Pressure Control System
• Install auto‐dial alarm to notify operators of pump failures• Periodically check for the correct settings for the multi‐stage booster
system
Water Distribution System
• Document and communicate policy for ensuring water meters are protected against freezing conditions.
• Work with HOA Road Committee to establish policy for and procedures for snow plow operators
• Perform random sample water meter checks for accuracy• Verify Fire Department performs fire hydrant checks in accordance with
National Fire Protections Association
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 10
Application to an Actual System (cont’d)
Subsystem Action
Water Distributed Pressure Control System
• Investigate and recommend maintenance policy for Pressure Reducing/Pressure sustaining valves
• Manually inspect booster pump for lots 55, 54, 53, and 52, periodically.
Wastewater Influent Collection System
• Document and communicate policy for periodic flushing of wastewater when leaving property for some period of time.
• Document and communicate policy for periodic flushing of wastewater when leaving property for some period of time.
• Consider Standardized inspection procedures for installation of grinder pumps and include inspection of Check Valve, Corporation Stops, and valve boxes.
Wastewater Treatment Plant
• Document and communicate limitations of WWTP when power is out (customers need to be aware that WWTP is not powered by an emergency generator)
• Install Auto-dialer for alarm conditions
Effluent Pond • Perform yearly exercise of pond control valves.
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 11
FMEA Process Overview
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 12
Develop System DescriptionIdentify Major System Components
• Goal is to break the system down to a manageable list of components with identifiable failure modes
• Example– Water System
• Electrical System
– Electrical Panel
– Backup Generator
• Storage Tank
• …
– Wastewater System• …
Could go further but then the list of components to
analyze becomes unmanageable
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 13
Develop System DescriptionIdentify Potential Failure Modes,Triggers and Effects• Goal is to identify
– What can fail and the manner of failure
– Cause(s) of the failure
– Effect(s) on the Customer due to the failure
• Source of Information
– Brainstorming among Subject Matter Experts
– Vendor specifications
– System Designers/Operators
– Customers
Remember Murphy’s Law: If it CAN go wrong, it WILL go
wrong
Failure Mode Trigger Effects
Catastrophic Transformer Failure Overheat or overvoltage Complete loss of water pressure, impacting fire suppression in the community
Pressure reducing valve fails OPEN Internal diaphragm failure Full downstream Pressure
Effluent pond overflows into streams
25+ year flood conditions ADEQ illegal discharge violation
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 14
Develop System DescriptionIdentify Current Controls
• Goal is to identify the existing controls and procedures that are in place for each of the potential failure modes
• Example:– Transformer catastrophic failure – None– Pressure reducing valve – Drive through community
and look for leaks – Effluent pond overflows into streams – Go to Home
Depot and buy lots of sand and burlap bags.• Source of Information
– Operations Policy Manual (if one exists)– System Operators
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 15
Perform Risk AnalysisRate the Severity of the Effect on theCustomer
• Goal is to quantify the effect using a rating scale• Source of Information
– Industry Standards– Custom Defined Standards (see below)
Rating Severity of Effect10 Result in Injury9 May be Illegal8 Render product or service unfit for use7 Cause extreme customer dissatisfaction6 Result in partial malfunction5 Cause a loss of performance which is likely to result in a complaint4 Cause minor performance loss3 Cause a minor nuisance but can be overcome with no performance loss2 Be unnoticed and have only minor effect on performance1 Be unnoticed and not affect the performance
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 16
Perform Risk AnalysisIdentify Probability of Occurrencefor each Cause
• Goal is to assign a Probability Rating to thefailure occurrence
• Source of Information– Historical failure data (Best Source)– Estimates from Industry Experts– Simulated failure rates from reliability models– Best guesses by those preparing FMEA (Least Desirable)
Rating Occurrence Probability10 More than once per day > 30%9 Once every 3-4 days 30%8 Once every week 5%7 Once per month 1%6 Once every 3 months 0.03%5 Once every 6 months 1 per 10,0004 Once per year 6 per 100,0003 Once every 1-3 years 6 per million2 Once every 3-6 years 3 per 10 million1 Once every 6-9 years 2 per billion
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 17
Perform Risk AnalysisIdentify Probability of Detection
• Goal is to assign a Probability Rating of the failure detectability
• Source of Information– Operations Policy Manual (if one exists)– System Operators– System Design
Rating Detectability
10 Defect caused by failure is not detectable
9 Partial system shutdown required to reveal defect
8 Units are systematically sampled and inspected to reveal defect
7 Cursory inspection of system reveals defect
6 Process is monitored and manually inspected at the site
5 Defect is obvious when operator arrives at the site
4 Defect is auto detected and recorded but not alarmed
3 Defect can be detected by casual observer who calls operator
2 Defect is auto detected and audibly or visibly alarmed
1 Defect is auto detected and alarm is sent to operator
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 18
Perform Risk AnalysisCalculate Risk Priority Number (RPN)
• Goal is to quantify and prioritize the relative risk of each of the failures
• Calculation
– Severity x Probability of Occurrence x Probability of Detection
– Results in a RPN value between:• 1 = (1 x 1 x 1) = Lowest priority
• 1000 = (10 x 10 x 10) = Highest priority
• Key Points about RPN values
– It is a Relative rating for the system under consideration and values should not be absolutely compared with another system
– There is no ideal target value to achieve
Hint: Calculate the average of all the values as a baseline. Then Focus only on those RPNs that are
above the average
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 19
• Assigning wrong SEVERITY scores• Missing Failure modes during brainstorming• Estimating probabilities incorrectly for OCCURRENCE• Scoring easily detectable failure modes as high
DETECTABILITY instead of low
• Assigning wrong SEVERITY scores• Missing Failure modes during brainstorming• Estimating probabilities incorrectly for OCCURRENCE• Scoring easily detectable failure modes as high
DETECTABILITY instead of low
Quiz: What is the most commonsource of error in generating FMEAs?
Source: Motorola Black Belt Certification Exam
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 20
• Potential failures are detectible through detailed inspections
• Failure modes are identified only after failures actually occur
• Failure modes are not detectable before failure and are often misdiagnosed after occurrence
• The failure has never been detected because it has never occurred
Quiz: Which of the following would resultin the HIGHEST value of DETECTABILTY for FMEA?
• Potential failures are detectible through detailed inspections
• Failure modes are identified only after failures actually occur
• Failure modes are not detectable before failure and are often misdiagnosed after occurrence
• The failure has never been detected because it has never occurred
Source: Motorola Black Belt Certification Exam
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 21
Develop Risk Mitigation and Control PlanIdentify system upgrades and/orcontrols for high risk areas
• Goal is to mitigate operational risks
– Refer to risk analysis for the existing Electrical System• Excel spreadsheet tool calculates and colors higher than average RPN values
– Options for reducing risks:• Increase Probability of Detection
• Reduce Probability of Occurrence
• Reduce Severity of the Customer Impact
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 22
Develop Risk Mitigation and Control PlanPerform Risk Analysis on Proposed Controls
• After brainstorming solutions, team determined:– Changing battery every 2 years reduces probability from 2 to 1 for backup battery– Addition of Back-up Generator reduces probability of Transformer catastrophic
failure causing complete loss of water pressure from 1 to 2– Addition of status auto dialer improves probability of detection for most failures– No solutions identifies for reducing customer impact
• Overall risk reduction is deemed acceptable
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 23
Develop Risk Mitigation and Control PlanDeploy Risk Mitigations and Controls
• System Design changes are implemented and deployed following typical project management practices
• Control plan is implemented and deployed to ensure system is operated according to the changes:
– According to the Glossary and Tables for Statistical Quality Control, ASQ Statistics Division a Control Plan is:
• “a document describing the system elements to be applied to control variation of processes, products and services in order to minimize deviation from their preferred values.”
• a living document that summarizes the necessary information used to explain, monitor and control a product or process and should be updated as control methods are evaluated and improved
– It can take different forms based on the particular organization:• A formal policy statement given to system operators
• A set of procedures to be followed by individuals
Slide 24Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Wrap-up
A Failure Modes and Effects Analysis is only one tool in an organization’s comprehensive Quality Management System
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 25
ISO-9000 Global IndustrialStandardization (1988)
• Emphasis on Quality Management Systems (QMS)
– Planning includes:• Determining customer needs and requirements• Establishing quality policy• Determining the quality processes• Ensuring adequate resources and• Establishing process effectiveness measures.
– Control is the oversight to ensure the processes are implemented and effective
– Measurement includes:• Implementing systems to determine conformance• Preventing nonconformance, and• Ensuring continual system improvement.
A highly overlapping
and Continuous
Process
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 26
ISO-14000 Global EnvironmentalManagement Standardization (1996)
• Emphasis on Environmental Management Systems (EMS)
– Modeled after ISO-9000
– A comprehensive approach to environmental management.
– “(ISO-14000 is an) attempt to control and rationalize some complex and cumbersome environmental processes”*
• Covers
– Materials and Energy Usage and Control
– Materials Storage and Handling
– Wastewater Management
– Air Emission Management
– Chemical Waste Management
– Solid Waste Management
– Noise and Other Waste Management
How will ISO-14000 affect
your business going forward?
* ISO-14000 - Standardizing environmental management beyond ASTM” Howard N. Apsan, Environmental Quality Management, Volume 4, Issue 4, pages 115–118, Summer 1995
Motorola Confidential RestrictedMOTOROLA and the Stylized M Logo are registered in the US Patent & Trademark Office. All other product or service names are the property of their respective owners. © Motorola, Inc. 2005.
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Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
Slide 27
Ceptara Can Help YourOrganization Bring Excellence into Focus
• CONSULTING– Quality Management Systems and Tools (including FMEA)– ISO Registration Preparation & Compliance Coaching– Lean Six Sigma Project Facilitation, Leadership & Training– Supply Chain Assessment & Improvement Planning– ITIL Assessment & Improvement Planning– Strategy Maps, Hoshin Planning, Performance Scorecards
• TRAINING– Lean Six Sigma Belt Preparation– Process Mgmt, Kaizen, RCA, 5S, Facilitation, et. al.– Custom Training
• PRODUCTS– Personal Excellence Outlook Add-in– Supply Chain Management Models– Process Simulation Models
Slide 28Rim View ConsultingErnie BorgoyneSix Sigma Black Belt - ASQ CQE
If you would like a copy of the complete FMEA report for PCCDWID please complete your opinion survey
and give to me along with your business card
Questions?