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12/2/20141Good Morning

Sarangani Energy CorporationDecember 3, 2014Root Cause Failure Analysis RCFA TRAINING : DAY 1: 221014141212/2/20142You Have to Know What You're Looking for If You're Going to Find ItSarangani Energy CorporationDAY 1Using RCFA and Making it SuccessfulTrue Causes of Plant and Equipment FailureRisk Analysis, Reliability Growth and Failure EliminationApplying RCA Failure Analysis Tools and Their UseDAY 2The RCFA Team and The Role of the FacilitatorIntroducing and using RCFAPractice the RCFA MethodsPropagating Improvements Company-Wide12/2/20143Root Cause Failure Analysis CourseSarangani Energy CorporationSometimes it is very hard to spot the real cause

Sometimes it is not

12/2/20144Introduction to RCFA and Analysis ToolsSarangani Energy CorporationRoot Cause Failure Analysis answers your problems. RCFA is a step by step method that leads to the discovery of faults first or root cause. Every equipment failure happens for a number of reasons. There is a definite progression of actions and consequences that lead to a failure. RCFA investigation traces the cause and effect trail from the end failure to the root cause.4

What We SeeWhat Caused ItThe failure event is the end result of many failed processes.But the failure started long before the failure event happened.Effect - CauseCauseEffect 2 - Cause 6

Effect 1 - Cause 4Cause 5Cause 3Cause 2Cause 1FailureRoot Cause Failure Decision TreeAct together in combination to produce the effectActs alone to produce the effect??12/2/20145Root Cause Failure Analysis (RCFA)Sarangani Energy Corporation5Root Cause Failure Analysis answers your problems. RCFA is a step by step method that leads to the discovery of faults first or root cause. Every equipment failure happens for a number of reasons. There is a definite progression of actions and consequences that lead to a failure. RCFA investigation traces the cause and effect trail from the end failure to the root cause.

Root Cause AnalysisImproving existing plant performance, or reducing operating risk, requires the elimination of repeat failures or emerging failures. Root Cause Analysis (RCA) is undertaken as a search for the Root Cause of the problem. Effective RCA is really about seeking effective solutions that control the causes of problems. Like a detective we look for causes from the effects. Each cause produces the next effect. When we define a problem and begin looking for causes, we ask why of the effect, and answer with a cause. Effects become causes as we continue to ask why, and a cause and effect chain is established. The solution we select is the one that is attached to one of the causes that prevents the problem from recurring.

Understanding the cause and effect relationships of equipment and operational problems, is an essential part of an effective maintenance program. The best way to institutionalize RCA is to train all levels of an organization, so that seeking effective solutions is applied at the workplace and capturing good failure data for analysis is a normal requirement.Hundreds of activities across dozens of processes what chance have you got?Process 19R2Process 7Raw MaterialsPreparationManufactureAssemblyPackagingProductR1R3R4R5Process 1Process 4Process 3Process 2Process 5Process 8Process 6Process 9Process 12Process 11Process 10Process 12Process 15Process 14Process 13Process 16Process 18Process 17Process 14Process 20Process 21Process 22Process 23Process 24Process 25Process 26FAILUREFAILUREFAILURE12/2/20146Where is the Root Cause?Sarangani Energy CorporationAn Internet search by the Author for causes of centrifugal pump-set failures found 228 separate ways for the wet-end components to fail, 189 ways for a mechanical seal to fail, 33 ways for the shaft drive coupling to fail and 103 ways for the electric motor to fail. This totals 553 ways for one common item of plant to fail. MotorDriveCoupling12PumpFailsWet End1031233MechSeal22281218912/2/20147What Route did Failure Take in the Pump Set?Sarangani Energy CorporationIf you start with a failed item of plant which path led to failure if there are large numbers of causes of failure? A cause and effect tree for a centrifugal pump set could produce 553 different causes for a pump failure.7

2nd bearing sleeve

2nd bearing bush

1st bearing sleeve

1st bearing bush

Casing wear ringWhat1) HUMAN FACTORS,2) BUSINESS or WORK PROCESSES,3) PHYSICAL PROCESSESAFFECTING EQUIPMENT4) LATENCY FACTORScaused the failure?12/2/20148Parts Fail, Machines Stop; the Part is the EvidenceSarangani Energy CorporationMachines are systems of parts working together to deliver a function. When a machine fails we replace its parts to return t it to operating condition. In the column pump shown in the slide, the shaft support journals failed from sand ingress. They were worn away. To return the pump back to service required replacing the journals. But if that was all that was done, then the pump will fail again because the cause of the failure was not eliminated. Until the sand no longer gets into the journals this pump will always be repaired regularly.8

Getting the logic rightDevelop the Cause - Effect Tree12/2/20149RCFA Cause and Effect DiagramSarangani Energy CorporationScientific Causes / EffectsIncident ActionsLatent CausesBusiness System CausesInvestigative tools3W2HFault TreeFishbone5/7 WhyEtc...12/2/201410We Identify All Possible Cause and EffectSarangani Energy CorporationFoundation FailedRoof Material FailedColumn Material FailedStopStopStopColumn to Ground Connection FailsColumns TiltColumns TumbleRoof MovesTrailer Hits RoofScientific Event SequenceRoof Fell12/2/201411Start with Scientific Cause-Effect SequenceSarangani Energy CorporationScientific Causes / EffectsIncident ActionsLatent CausesBusiness System CausesShows an OR arrangementShows an AND arrangement12/2/201412Showing OR - AND ArrangementsSarangani Energy CorporationScientific Causes / EffectsIncident ActionsLatent CausesBusiness System Causes

BUT... The root causes are still there, and may find other ways to produce a failure12/2/201413No need to solve the root cause to prevent a problemSarangani Energy CorporationProduction RateTimeExpected NORMAL OperationPotential Maximum PerformanceMost plants would regardthis as a problem and miss this one!RCFARCFARCFARCFA12/2/201414How RCFA Contributes To ImprovementSarangani Energy Corporation14The chart highlights the presence of two problems. The chart is a visual management tool to make clear to people that normal conditions are breached. It turns numbers into pictures that people can recognize.

For production rate you could instead represent injury rate or serious audit findings, or another suitable performance parameter.Once a problem is identified it needs to be addressed. The key point about a Problem is that in most organizations when it is resolved the plant simply returns to the previously expected performance norm. Nothing is progressed to prevent the problem.

Clearly we cannot ignore problems. A problem is caused by a defect and unless corrected it will reoccur. We must investigate them to prevent a recurrence, especially for safety incidents. RCFA is a formal method often used to identify the cause of failures and come up with answers to fix it permanently. Another, simpler way for use on the shop floor, is the 5 Whys. This is a great tool for getting the shop floor people to solve problems and come-up with the solutions.Identifying and eliminating the problems that are responsible for creating the gap between the status quo and the potential output of the plant is how to turn problems into OPPORTUNITIES !

Raising the normal or expected performance of any organization is always worth more than recovering from a short-term problem because it pays you back 24x7.

FailureEvidenceInvestigationAnalysis Corrective ActionImplementationPermanent ImprovementPropagationBeyond RCFARCFA Process12/2/201415The Power in RCFASarangani Energy Corporation

Sourced from: Benchmarking Performance in the Mining Industry - Reliability and Maintenance as Strategy Components by Edwin K. Jones PE, and William Holmes ERV = Equipment Replacement ValueStarted RCFA

12/2/201416Successful Uses of RCFA in MaintenanceA famous example DuPont ChemicalsSarangani Energy Corporation16Ever since I first heard the DuPont Chemicals turn-around story I have been inspired by it. If you dont know the DuPont Chemicals story, here is a very quick summary.

Back in the early 1980s DuPont realized that though they were a big company, they were exposed to low-cost producers. They began investigating what opportunities they had to protect their world-wide business. What soon became clearly apparent was that they were not utilizing their capital plant and equipment well and were getting a poor return on investment. Compared to the best operators in their industry they were average performers. Their maintenance costs per unit of production were well above the top organizations and their plant availability well below. They decided that this had to change if they were to secure their future.

From the mid-1980s onward they initiated and used good asset management practices across their operations. They started challenging their business-unit managers to implement those practices that improved the utilization and availability of their plants. Figure 1 is a graph from that period that shows how DuPonts cost of maintenance as a proportion of equipment replacement value (ERV) fell during the years following the introduction of those initiatives. It represents some 30% reduction in maintenance costs. But more importantly, it implies greater plant reliability as the need for repairs fell. For DuPont that translated into higher equipment availability and plant utilisation, which gave them more production for no extra capital cost. The return on investment skyrocketed!

As a consequence DuPont Chemicals became known as innovative pacesetters and a world-leader in industrial asset management. Along the way they developed or improved many of today's commonly used asset management practices and knowledge. It is a highly inspirational story to those of us who work in the field of industrial operations and maintenance.

There were many initiatives used by DuPont during that period. One that their people today claim was amongst the most important was the use of Root Cause Failure Analysis (RCFA) (A comment made by a DuPont presenter in a 2004 seminar heard by the Writer.). They applied it to solve both sporadic failures and chronic process problems. As each RCFA improvement project was successfully completed their process plants reliability and productivity rose higher and higher.RCFA for Continuous Improvement Process12/2/201417......DESIGNPROCURECONSTRUCTSymptoms of aprocess with noimprovementcyclessAsset ProductivityImprovementCollect DataAnalyze &Prioritize Information21Root CauseAnalysis34ProjectImprovementShareBestPracticesSustain the GainNetworksPreventFutureDefects5UptimeLosses

0102030405060708090100LeverageLearningContinuous Improvement Cycle6Losses&GapsRESTOREOPERATESarangani Energy Corporation18Incident/Problem

12/2/201418Sarangani Energy CorporationThe model shows how organisations can be structured and managed to remove incidents and problems.Why Tree and/orFault TreeGet Info About the FailureDescribe the Sporadic FailurePeople, Records,Orientation, Beliefs, EquipmentFailure

Observations (Facts)

Hypotheses

VerifyPhysical CauseHuman CauseSystem RootsWork on Chronic orSporadic?SporadicChronicGather Data on all types of FailuresChoose an Area & Define What Failure Is Interview or FMEAPrioritize Data (Pareto)Choose a Failure From ParetoDescribe the Chronic FailureChoose SolutionsAudit / Follow-upImplement Solutions12/2/201419RCFA MethodSarangani Energy Corporation19Different steps are taken depending on whether you are investigating a Chronic or Sporadic failure.

The Why Tree is an ideal tool for working on either type of failure.Root Cause and EffectTeam of experts in several meetingsHigh cost and timefocus on big problems and you keep having big problemsIdentifies wider perspectivesRisk AnalysisTeam of experts with detailed FTA, failure investigation and reliability analysisProblem of catastrophic sizeNo stone left unturned; the truth comes out11030600Property DamageMinor InjuriesSerious InjuriesIncidentsSAFETY ACCIDENTS110 losses6500 repairs20,000 defectsProcess LossesMinor FailuresSerious FailureProcedural IncidentsEQUIPMENT FAILURES11030600Property DamageMinor InjuriesSerious InjuriesIncidentsEFFECT OF MODERN SAFETY INITIATIVESXXXXEscalateEscalateThe Heinrich Accident Pyramid The Failure Pyramid Source: Winston Ledet, Manufacturing GameEQUIPMENT IMPACTBUSINESS IMPACTCOMMUNITY IMPACT12/2/201420What Scale of RCFA to Apply?Creative DisassemblyIndividual persons working on-the-jobLow cost, little timePreventive focusstops the many small causes that lead to large failuresMisses multiple causesSarangani Energy Corporation20FTA = Fault Tree AnalysisRCFA comes in different sizes to suit the situation. We know from modern safety management practices that reducing safety incidents cause a reduction in more serious accidents. The same logic applies to equipment failures; reduce the procedural errors and there is a consequent reduction in production losses. It is more effective to get the trades people solving small problems and preventing failures, than to collect people together after a failure and try to prevent it in future.FTA = Fault Tree Analysis

12/2/201421Words and DefinitionsRoot Cause(s)the factor(s) that arose to initiate an eventual failure

Failureunsatisfactory performance or outcome

Chronic Factorsingrain, habitual

Sporadic Factorsrandom, intermittent

Hidden Failurefailure that is not known until the failed the item is required

Latencythe expectations, values and beliefs that cause us to behave as we doSarangani Energy Corporation2112/2/201422Root Cause Failure Analysis Process RCFA fundamentals The RCFA process is fault-tree based Develop and implement solutions that prevent the problem everywhere

Finding the Evidence and Proof Operating and maintenance records and history analysis Interviews with persons involved Creative disassembly of failed item(s) Important to keep accurate records and history of equipment

Using RCFA in the Workplace Requires a cross-functional team brainstorming The 5 Whys method is simpler for the workforce if Why Tree is proven by evidence Needs operator and maintainer buy-in for sustained usage

Applying RCFA Recommendations Needs Change Management methods to get buy-in of proposals Implementation is 80% of the effort Prove the changes actually prevent the problemSarangani Energy Corporation22OVERVIEW OF THE RCA PROCESSThe method brings a team of 3 to 6 knowledgeable people together to investigate the failure using evidence left behind from the fault. The team brainstorms to find as many causes of the fault as possible. By using what evidence remained after the fault, and through discussions with people involved in the incident, all the non-contributing causes are removed and the contributing causes retained.

A fault tree is constructed starting with the final failure and progressively tracing each cause that led to the previous cause. This continues till the trail can be traced back no further. Each result of a cause must clearly flow from its predecessor (the one before it). If it is clear that a step is missing between causes it is added in and evidence looked for to support its presence.

Once the fault tree is completed and checked for logical flow the team then determines what changes to make to prevent the sequence of causes and consequences from again occurring.

12/2/201423Phases of an Investigation (Not the same as Phases of an RCFA)Sarangani Energy Corporation4Ps TechniqueProductPlacePricePurpose23Preserve and collect evidenceAppoint experienced facilitatorAssemble a cross-functional team of persons involved in the incident and others knowledgeable in plant/process design and operationCost the total impact of the incident to give power to the investigationInterview persons involvedInvestigate the evidence for its historyTeam brainstorms, starting at the failure, to develop a cause-and-effect fault tree of all sequential steps that may have led to the failureUse the evidence and interviews to confirm the failure pathRecord the findingsDevelop the fault treeIdentify what can be done at various stages along the path to prevent the failure and how they should operateCommunicate the findings and necessary changes company-wideAppoint a person to put the changes in place, including doing necessary training, using change management methodologyReview and monitor that progress is made towards the improvementsUse Hierarchy of ControlsNO BLAME, NO BLAME, NO BLAME... else truth disappears and fear will reign. 12/2/201424Document and Describe Your RCFA Process StepsSarangani Energy Corporation2412/2/201425Final Team task is recommendations and reportThe 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 errorsthese 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.Sarangani Energy Corporation25FlowchartFishbone DiagramTimeline PlotsDistribution HistogramsPareto ChartsFMEAFailureEvidence and ProofInvestigation and UnderstandingAnalysis and IdentificationCorrective ActionImplementationRCFA ProcessInterviewsProtect Equipment/PartsDocuments, Records, DiagramsCreative Disassembly of PartsExpert InvestigationBrainstormingBrain WritingIs-Is Not TableWhy Tree (Fault Tree Analysis)5/7 Whys (to test Why Tree)3W2HEvaluation TableAffinity DiagramsRelationship DigraphProject ManagementRCFA ToolsUnderstand the physics science key factors progressionUnderstand interactions and the human element12/2/201426Tools to Use During Equipment Failure RCFASarangani Energy Corporation

12/2/201427Overview of Basic Data Collection MethodsSarangani Energy CorporationInitial Data Collection involves:Collecting and photographing failed parts.Photographing and taking note of the physical conditions and circumstances surrounding the failure.Question persons present before, during and after the failure.Obtaining historical vibration, thickness and other pertinent data.Obtaining assembly and other pertinent drawings.Determining operating conditions, such as RPM and pressure, leading up to and at the time of failure.

Source: Latino, C. J., The Plant Managers Guide to the Reliability Approach, Allied Chemicals 1980Data CollectionData AnalysisEnough Information?Identify the Root CauseNoData Analysis usually involves:Metallurgical analysis of failed parts.Theoretical calculations of loads and stresses using design drawings and known operating conditions, if practicable.Analysis of historical condition monitoring records and other pertinent data for possible contribution to the root cause.If necessary conduct on-site monitoring, measurement and data collection of the system and components that failed.Root CauseConstruct a decision tree of the failure incident using factual information to trace back to the root cause.12/2/201428Machine Failure Data Collection and AnalysisSarangani Energy Corporation12/2/201429Data Gathering Following an IncidentCollect EvidenceGet to the scene ASAP, take a video/cameraPay extra attention to the things that will change laterColours, temperatures, smells, liquid spills, cloth, wire, rope, unstable objectsDont move anything, including paperwork, until recordedPosition, orientation, conditionCollect paperwork and documentsLogs, instructions, data, recordsIsolate the scene so you can return and look again later, if not get some else to independently record the evidence, video tape the scene

Collect Information and Record itAsk people early, before memories fade or are influenced. Watch for additions, omissions and distortions caused by fear of blame, retribution and desire to protect others.

What Happened?How did it happen?Sequence of eventsWho or what was involved? people, machines, information systems, sensors, structures, etc.Where did it happen?When did it happen?What has changed?

Sarangani Energy Corporation12/2/201430Protecting and Collecting the EvidencePeople evidence talk to people working at time of failure to record all their thoughts and ideas as to the cause.

Position of controls note position of switches, settings, dials and instruments.

Position of People find out where everyone was standing as well as what they were doing at time of failure.

Parts condition record position of failed parts, examine the parts in detail.

Paper trails gather all manuals, procedures, design documents, operating and maintenance history.Sarangani Energy Corporation

12/2/201431RCFA InterviewsAnswer these questions using a structured formSarangani Energy CorporationCheck this on page 5 of your Course Workbook.31Data Analysis Tools to Release Information

Use Visual Analysis Tools for Patterns and Trends

Date/TimeXXXXXXXXBunchedRegular repeatTime LogRedRedBlueColourYesNoYesDriven by sonNoNoYesPetrol smell2 yr1 yr10 yrsAgeDifferencesAll CamryAll sedansSimilaritiesNoNoYesGot the problem?Relatives carNeighbours carOur carProblem:high fuel consumptionIs/ Is Not table to Compare Operation12/2/201432Sarangani Energy CorporationData may need to be interrogated for it to release its information. There are numerous techniques available to draw the information out of data. The slide show several visual management methods commonly used to investigate a situation. You can get books and go to training courses that explain in detail how each method is used.Pareto chart - named after VilfredoPareto, is a type ofchartthat contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line.

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HLHHL12/2/201433Fault Tree AnalysisSarangani Energy Corporation33

12/2/201434Fault Tree AnalysisSarangani Energy Corporation34Start with a Flowchart to Explain the Correct ProcessTank Level Falls

Y Sensor Detects LevelTank Level Refills to Set PointHLHHLWater Flows to PlantX Sensor Detects Overfill Valve B Fully OpensValve B Fully ClosesValve B Fully ClosesHigh High Level AlarmDescribe the design intent of the proper and correct operation of the equipment/plant/work instruction/etcMake required outcomes for ideal performance of each step clear e.g. fully closed, detects overfillOverfillYNStep 1) Start with descriptive flowchart12/2/201435Sarangani Energy CorporationActivity 1 Fault Tree Analysis (FTA) of a failure event12/2/201436Sarangani Energy CorporationActivity 1 Pump FailureGroup the participants into two teams.Use the post-it paper and the two white boards36Analyzing with the Fishbone Diagram

12/2/201437Sarangani Energy Corporation37Activity 2 Do Fishbone on the Valve FailureMeasurementMaterialsPeopleEnvironmentMethodMachinesFill Valve Failed Open12/2/201438Sarangani Energy CorporationPeople Gender (men, women), age (young, old), experience level (junior, senior)Machine valve stem, wheel, discMaterials cast iron, stainlessMethod - Manual, hydraulic, movMeasurement - pressure, temp., flowEnvironment - outdoor, indoor38Is Is Not Table pinpoints problem area

12/2/201439

Sarangani Energy CorporationWhy Tree for a Stalled Car12/2/201440

Sarangani Energy Corporation40RGCA = Reliability Growth Cause AnalysisA simple example of how to use a Why Tree. Use them in your personal life, around your home, to solve problems. A technique people may be using already without realizing it. In the example, the car is stalled at a light and you can't restart it. You hypothesize two possible reasons. You verify through looking at the gas gauge or putting a stick in the gas tank that you are not out of gas.

That leaves you with the engine problem being verified by the process of elimination. You haven't proven it's an engine problem yet but you've eliminated the other possibility -- being out of gas.If these two hypotheses were all inclusive then you can drive down this one with confidence after eliminating the other one. Then you ask, "How can a problem with my engine cause me to be stalled or why can an engine cause me to be stalled?" You surmise or hypothesize that either the engine is seized or there's no combustion in the cylinders. You can verify the engine is not seized by using the starter to turn it over a couple of times. That leaves you with the possibility there's no combustion in the cylinders.

When you ask how can or why is there no combustion in the cylinders, you come up with three possibilities. You can eliminate inadequate compression (compression gauge) and no spark to the cylinder (remove spark plug crank the engine and look for a spark) as possibilities. That leaves you with the air/fuel mixture as the intermediate cause, and continue onto root cause. In this case the author stopped at a human root, but there are some other likely system roots.This example points out how you can use the process of elimination to verify.

Stalled Car Engine Is / Is Not Table12/2/201441

Sarangani Energy CorporationActivity 3 Develop Is / Is Not Table (for failure event you experienced)12/2/201442

Sarangani Energy CorporationActivity 3 Motor trip42Time LinesPropositionThe simple Time Line is the most powerful data analysis tool (which is so simple it is generally overlooked).It is difficult to describe many events, collect relevant plant information, find inconsistencies in information sources, and make sound judgements without such a representation of relevant events. Review of history on a Time Line is a mandatory first step.Time between Failures - DaysXXXXX5050250New materialXX3040350Precision MaintenanceXX2004050Time Series Plot Showing Increasing Time between Failures for a Component

Maintenance Data Analysis with Trend Plots4312/2/2014Sarangani Energy CorporationfffffTimelineTime Series Plot for Tracking Changes in Frequency of FailuresfDateSeparate Failures and Problems into ModesMTTF is consistentCluster of failures indicating a second mode of failure is present. This distribution contains multiple failure causes.All FailuresMode 1 FailuresMode 2 FailuresffffffInfant MortalityRandom Failure Top line indicates dates of all incidents. Lower lines show dates of each fail mode12/2/201444Sarangani Energy Corporation44The slide shows a serial correlation, which tracks the life of parts in the same socket, or position in a machine.

We must be very wary that the distributions we chose for modelling parts/systems failures really are the correct ones for the situation. If we chose the wrong distributions we will get wrong answers that we are not even aware are wrong. There are special mathematical tests that can, and must be, conducted to confirm the fit of a distribution to the data. But a simple method we can see for ourselves is to plot the parts/machines failures on a dated timeline and observe the times between repairs and maintenance to confirm there are no unusual occurrence that will confuse the analysis.

We really need to identify the full range of failure modes a part has been experiencing and plot each one on its own timeline.Timeline Identifies Changed EffectsLooking at this, a fair person would accept that due to the change it is likely that there will be less de-scaling downtime in future and (considering this issue only) the Facility throughput would improveThe future will not be the same as the past. Without the timeline an analyst using MTBF to predict outage would produce erroneous predictions of Facility future performance and bad recommendations

Anti-corrosive chemical changed on this date and less scale producedHours required to de-scale process. The failure definition was de-scale outage12/2/201445Sarangani Energy CorporationMean time between failures (MTBF)is the predicted elapsed time between inherent failures of a system during operation.[1]MTBF can be calculated as thearithmetic mean(average) time betweenfailuresof a system. The MTBF is typically part of a model that assumes the failed system is immediately repaired (mean time to repair, or MTTR), as a part of arenewal process. This is in contrast to the mean time to failure (MTTF), which measures average time tofailureswith the modeling assumption that the failed system is not repaired (infinite repair time).The definition of MTBF depends on the definition of what is considered a systemfailure. For complex,repairablesystems, failures are considered to be those out of design conditions which place the system out of service and into a state for repair. Failures which occur that can be left or maintained in an unrepaired condition, and do not place the system out of service, are not considered failures under this definition.[2]In addition, units that are taken down for routine scheduled maintenance or inventory control are not considered within the definition of failure.45Frequency of Failures and Problems12/2/201446

Sarangani Energy CorporationThePareto principle(also known as the8020 rule, thelaw of the vital few,and theprinciple of factor sparsity) states that, for many events, roughly 80% of the effects come from 20% of the causes.[1]Management consultantJoseph M. Juransuggested the principle and named it after ItalianeconomistVilfredo Pareto, who observed in 1906 that 80% of the land in Italy was owned by 20% of the population; Pareto developed the principle by observing that 20% of the pea pods in his garden contained 80% of the peas[citation needed].It is a commonrule of thumbin business; e.g., "80% of your sales come from 20% of your clients". Mathematically, the 8020 rule is roughly followed by apower lawdistribution (also known as aPareto distribution) for a particular set of parameters, and many natural phenomena have been shown empirically to exhibit such a distribution.[2]The Pareto principle is only tangentially related toPareto efficiency. Pareto developed both concepts in the context of thedistribution of incomeand wealth among the population.

APareto chart, named afterVilfredo Pareto, is a type of chart that contains bothbarsand aline graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line.The left vertical axis is thefrequency of occurrence, but it can alternatively represent cost or another importantunit of measure. The right vertical axis is the cumulative percentage of the total number of occurrences, total cost, or total of the particular unit of measure. Because the reasons are in decreasing order, the cumulative function is aconcave function. To take the example above, in order to lower the amount of late arrivals by 78%, it is sufficient to solve the first three issues.The purpose of the Pareto chart is to highlight the most important among a (typically large) set of factors. Inquality control, it often represents the most common sources of defects, the highest occurring type of defect, or the most frequent reasons for customer complaints, and so on. Wilkinson (2006) devised an algorithm for producing statistically based acceptance limits (similar to confidence intervals) for each bar in the Pareto chart.These charts can be generated by simple spreadsheet programs, such asOpenOffice.org CalcandMicrosoft Excel[1]and specialized statistical software tools as well as online quality charts generators.The Pareto chart is one of theseven basic tools of quality control.[2]

46Frequency Histograms

Requires more data. X (time) axis broken into time or usage intervalsFailures stacked as in a series of histograms Note X axis is km not Time The term time can be replaced by another measure of exposure to degradation processes. Note use of colours Failures have been coded according to Cause of Failure Very important as not all causes are wear related.Tyre Failures Frequency - Stack at Age of Death12/2/201447Sarangani Energy Corporation12/2/2014

The Double Pareto Chart Method

First Pareto in Order of Problem EquipmentSecond Pareto in Order of Equipment ProblemsConduct RCFA on the worst problemsPareto worst equipment48Used to Identify Equipment and Problem Priorities for RCFA Sarangani Energy Corporation48First produce a Pareto chart of the bad actors equipment in an operating plant. Equipment across an operation is charted in order of cost impact to the operation, with the worst cost plant items being clearly identified on the Pareto chart. (Defect and Failure True Costing would be a good method to apply when quantifying business-wide losses.) The second step is to make another Pareto Chart for each of the worst equipment showing the cost of each problem on the equipment. Finally RCFA is applied on the repetitive problems and their causes were either removed by redesign, or better procedures put into place to address the cause Check Assumptions and Extra Clues to Causes12/2/201449Ask People with Knowledge and ExperienceExperience of similar processes and/or productsRelevant specialist technical knowledgeExperience with solving similar problems in the pastSuppliers of equipment , materials or servicesVideo process in action and discuss with those who do the job. Review video of the process at different times.Ask customers (with care for the relationship ) of their experiences when did problems start, when does it happen, when was it noticed, etc?

Look for the Hidden Assumptions This one is and easy trap to fall into, and we all do itIs it being assumed that Only one possible way for a thing to ariseOne thing must follow another in a particular wayTwo things are the same when they are actually different? spare parts, methods of work, process plantsThe information is correct? meters are accurate, figures were written correctly, time was rightThings that are usually related/co-dependant were in step? pressure/temperature, time of day/rest breakCause is in one half of the problem when it could be in the other half? mating parts, leakage and not excess flow

Simulate the experience act out the problem as accurately as possible looking for assumptions being made

Expose Fixed Ideas Use the three steps to prove the cause Ego and ownership can make you stick to step one. When thisIt must explain the problem convincingly happens say, Yes, that sounds convincing, now lets findIt appears and disappears with the problemthe evidence coinciding with history that turns the It can switch the problem on and offproblem on and off. Invite a third party to listen to your story of what you think happened.Sarangani Energy CorporationOperating and Maintenance Records and AnalysisOperator log booksWork order history and recordsDesign and Construction records12/2/201450Enter into spreadsheetsGive logical categories to the information e.g. breakdown, preventive maintenance, operator error, corrosion, assembly error, etcLook for repetition and frequency of issues/problemsLook at the comments written about incidentsLook for preceding factorsSarangani Energy CorporationImportance of Keeping Accurate Records and HistoryKeeping Useful Engineering Records:

Develop a record numbering/sub-numbering system recognisable to allCollect information by operating area, equipment, assembly, part no., dateDecide and document the specific recorded details to be kept, suggest:Keep original equipment manufacturers data and as-built project detailKeep history of failures, investigations and modificationsKeep history of calibrations, tests, performance reports, alignments, etcKeep Preventive Maintenance historyProtect the records from loss and from destruction.

12/2/201451Records:

Provide evidence of changesIndicate how things were in the pastCollect trends and varianceProve things were done in certain waysSarangani Energy CorporationCase Study 1 Equipment Failure RCFA Steps1 Describe story of the actual failure.2 - Define the physical/scientific phenomena of the failure.3 - Organize details of the failure by using Cause and Effect Tree tools and testing the evidence with '3W2H questions (with what, when, where, how, how much). Team-up and trace every possible cause of the failure using post-it notes on a wall.4 - Work as a team and organise the cause event tree in logical order, respecting and applying each others expertise and knowledge, rather than individually.5 - Verify all logical causes and eliminate all illogical causes with 5/7 Why and 3W2H complete answers full of facts (with what, when, where, how, how much) tools.6 - If determined that a cause was human error, separate that cause from the physical causes (beware our natural tendency to bias and jumping-to-conclusions).7 - Look for and identify the latent causes and human factor frailties.8 Develop preferred recommendations and the RCFA report.

Note: This example is used in Activity 4 Guided RCFA12/2/201452Sarangani Energy CorporationThe Scientific Causes of Equipment Failure12/2/201453

Sarangani Energy CorporationCommon Wrongs Humans Do To Machines

12/2/201454Sarangani Energy CorporationStrength of Materials Limitations

12/2/201455Sarangani Energy Corporation55Theoretically if the strength of materials are well above the loads they carry, they should last indefinitely. In reality the load-bearing capacity of a material is probabilistic - i.e. there will be a range of stress-carrying capabilities. We can show the probabilistic nature of parts by drawing a curve from the stress level at which the first part failed to the stress required to make the last part fail. If a part with a low stress capability is used in a situation where the probability of experiencing high loads is greater, then there is a chance that a load will arise that is above the capacity of the part and it will fail.

Many materials degrade with time, or from the local environment service conditions, or from accumulated fluctuating stresses. The parts fatigue and they are no longer able to carry the original loads and stresses. In such situations the probability that the item will see stresses above its remaining capacity to sustain them increases. Eventually the part will fail.

Note that the y-axis is probability (the chance that a thing could happen). The curve is a probability density function of probability v stress/strength.

Cause of Aging Failures12/2/201456

Sarangani Energy Corporation56Wear-out failures are any failure mechanism that result from parts weakening with age and usage. Included are processes involving material fatigue, wearing between surfaces/substances in contact, corrosion, degrading insulation, and wear-out in light bulbs and fluorescent tubes. Initially the strength is adequate for the applied load, but over time the strength deceases. In every case the average strength value falls and the spread of strength distribution widens. This makes it very difficult to provide accurate predictions of operating life for such items.Know the Stress Limits of Your Parts

10,000 cycles at this stress level1,000,000 cycles at this stress levelInfinite cycles at this stress level for steelFailure

FailureLimited life at this stress level for non-ferrousWe must know what our equipment parts are made of and prevent high stress in those with infinite life but replace those of finite life before they fail.12/2/201457Sarangani Energy Corporation57Owing to the statistical nature of the failure, several specimens have to be tested at each stress level. Some materials, notably low-carbon steels, exhibit a flattening off at a particular stress level as at (A) in the figure which is referred to as the fatigue limit. As a rough guide, the fatigue limit is usually about 40% of the tensile strength. In principle, components designed so that the applied stresses do not exceed this level should not fail in service. The difficulty is a localised stress concentration may be present or introduced during service which leads to initiation, despite the design stress being normally below the 'safe' limit. Most materials, however, exhibit a continually falling curve as at (B) and the usual indicator of fatigue strength is to quote the stress below which failure will not be expected in less than a given number of cycles which is referred to as the endurance limit.

Although fatigue data may be determined for different materials it is the shape of a component and the level of applied stress which dictate whether a fatigue failure is to be expected under particular service conditions. Surface condition is also important to prevent crack initiation. Often complete components or assemblies, e.g. railway bogie frames or aircraft fuselage, will be tested by subjecting them to an accelerated loading spectrum reproducing what they are likely to experience over their entire service lifetime. Stress and Fatigue are Optional (Use Degradation Management)12/2/201458

Sarangani Energy Corporation58The stresses that parts experience are a result of the situation and circumstances they are put into. To a great extent we control those situations. Once a part is stressed the damage is done, and it stays in the part weakening it. If the local environment attacks the part, the two factors overload and weakening act together to compound the rate of failure.

It is worth pointing out that almost all failures, even to electrical and electronic parts, are ultimately mechanical or heat-related. Both factors are controllable by proper procedures and practices.Why You Need Defect Elimination and Failure Prevention

Design ErrorsFabrication ErrorsOperating ErrorsManagement ErrorsWorkmanship ErrorsInstallation ErrorsDefect CreationYour Operation is a Bucket for Collecting Defects.Business-wide Errors12/2/201459Sarangani Energy Corporation59When you look at the time spent by managers, much of it is involved in solving problems. These problems are necessary to be solved. But the important question to be asked is Why have the problems arisen? What started the chain of events that now needs management time to fix? This diagram tells us that at sometime in the past defects were created and they sit in the operation until their effect becomes so severe it must be addressed.

This is a version of the DuPont Defect and Failure Creation Model. It shows that a business collects other peoples and business errors, defects and failures. These then cause further problems to build-up in the organisation. The problems can become so numerous that they take extraordinary amounts of resources and time away from running the business.

Problems Waste Time, Money and Resources

Design ErrorsFabrication ErrorsOperating ErrorsManagement ErrorsWorkmanship ErrorsInstallation ErrorsDefect ManagementBusiness Systems and Maintenance Help You Handle Failures, and the Problems They Bring.MaintenanceBusiness SystemsBusiness-wide Errors12/2/201460Sarangani Energy Corporation60In response to the many problems, a business installs systems to handle them. These become the way we do things around here and are seen as normal behaviour. In reality the business systems are correcting errors, defects and failures that should never have happened.

Managers typically set-up new systems and procedures to handle complexities created by problems. One such system is maintenance. When new equipment arrives the maintenance budget is increased to allow for additional repairs and maintenance. These being accepted as normal, and so the maintenance costs multiply. Little do people query the defects from the manufacturer that unwittingly entered their business.

Eliminate Defects to Prevent Problems

Design ErrorsFabrication ErrorsOperating ErrorsManagement ErrorsWorkmanship ErrorsInstallation ErrorsDefect EliminationThe Best Answer is to REDUCE the Numbers of Defects and so REDUCE the Need for Managing Failures and Problems!MaintenanceBusiness SystemsBusiness-wide Errors12/2/201461Sarangani Energy Corporation61The right approach is to stop all defects entering your business. This is known as defect elimination and failure prevention. The result for your business is far fewer problems to handle, with much smaller business systems. Once you have a failure busters organization there will be more time and money to spend improving the business, and not lost solving problems that should never have happened.

Would it not be better to stop the problems from entering the business in the first place? This is what defect elimination and failure prevention is all about. It becomes necessary to develop dozens of procedures, guidelines and best practices to control the creation of defects and train people in the right way to prevent problems. Some of the documents needing to be developed are:1.Technology & Facilities Safety Systems: Process Hazards Analysis Standards and Guidelines Process Safety Management Implementation Assistance Continuous Improvement Process Management Commitment and Responsibility Facility Placement Studies Inherently Safer Processes Emergency response Planning Integrated SHE Organization2.Electrical: Electrical Safety Training and Consultation Incident Investigations Audits Using DuPont Protocols Electrical Safety Standards/ Guidelines Short Circuit Studies Time/Current Coordination Arc Flash Hazards Fire and Explosion: Fire and Explosion Incident Investigation Fire and Explosion Modeling, Detection, and Suppression Fire Safety Audits Fire Safety Training Life Safety Occupant Notification and Egress Emergency Preparedness and Response Fire Safety Management Systems4.Environmental: Environmental Permitting Environmental Solutions Environmental Management System Assessment Air Dispersion Modeling Exposure/Risk Assessments Water Quality Treatment Ground Contamination Remediation Planning Solid Waste ManagementProduct Stewardship: Senior Management Support Internal Communications Product Review Systems Risk Characterizations and Risk Management Systems for Training and Refreshing R&D Systems Sustainable Growth Initiatives Standards and Guidelines6.Distribution: Regulatory Training Standards and Guidelines Risk Assessments Carrier Safety Emergency Preparedness7.Occupational Health and Industrial Hygiene: OH Injury and Illness Reporting, Classification, Investigation, and Documentation OH Roles, Responsibilities, and Accountabilities Metrics of OH Management OH Audit Protocols Medical Programs for Fitness Duty, Surveillance, and Emergency Care OH Records and Communications Effective Wellness ProgramsASSET PRODUCTIVITY1.Maintenance and Reliability Systems Work Managing Processes Managing Storeroom (MRO) Supplies Effectively Reliability-Focused Maintenance Uptime Measurement Software Preventive/Predictive Maintenance Strategies2.Manufacturing Capacity Material and Product Flow Analysis Continuous Flow Manufacturing and LEAN Manufacture Industrial Ergonomics Warehouse/Distribution Analysis Manufacturing Systems Simulation/Visualization3.Energy Optimization Steam Generation Electrical Power Distribution Refrigeration Cooling Towers Heating, Ventilating, & Air Conditioning (HVAC)4.Facilities Infrastructure Groundwater Protection: trenches/sumps/dikes; tank foundations; sewers Structural Integrity and Architectural Components Transportation Systems: roads/pavements; railroads Power/General Services: PG&S equipment & systems; electrical power equip & systems; HVAC equipment & systems; service piping Materials: coatings & linings; plastics & elastomers; insulation; fireproofing Life Safety Systems5.Mechanical Integrity Materials of Construction Selection, Specification, and Fabrication Equipment and Piping Nondestructive Testing and Condition Assessment Maintenance and Reliability Predictive/Preventive Maintenance Process Safety Management6.Product Quality and Process Control : Dynamic Simulation Product Performance Lab Feedback Proportional Integral Controllers Process Operability Analysis Statistical Process Estimation and Control tools Six Sigma and Applied Statistics Quality ManagementCAPITAL EFFECTIVENESS1.Business Planning Business Objectives 2.Facility Planning Project Objectives Project Capital Budget3.Project Planning Production Design Basis Authorization Estimate4.Project Implementation Production Design Procurement Construction5.Start-up and Initial Operations Plant Commissioning, Operations, and Maintenance6. Value Improving Guidelines Technology Selection Process Simplification Classes of Facility Quality Waste Minimization Constructability Reviews Process Reliability Modeling Minimum Standards and Specifications Predictive Maintenance Design-to-capacity Energy Optimization 3D CAD Value EngineeringContractor Effectiveness 8. Shutdown/Turnaround PracticesVariability and Risk Across the Life CycleDesignBuyStoreInstall

Start-upOperate

Maintain

Product

Higher Unit Cost, Poor Quality and Delayed Delivery

Plant Uptime and Throughput

SpecifyIntroduceddefectsVariability in each process causes defects which sometimes progress to failure.Management

Engineering

Supply

Contractor

Operations

Maintenance

110650020,000The Failure PyramidRepairsLossesSerious FailureDefect ModesDefect and Failure Cost SurgePath to DisasterEvery process across the life cycle will create many defects if the 3Ts are not used. 12/2/201462Sarangani Energy Corporation62Making and delivering a product/service is the output of many processes and numerous actions and decisions. We know that in every process, act and decision there is an opportunity for variation to arise. Extreme variations lead to the creation of defects and eventually failures. This was supported by the Failure Pyramid evidence where disaster will arise given enough chances.

Throughout the life cycle of a facility and its plant there will be times when chance, variability and opportunity for disaster align and a calamity happens. If we want to reduce the possibility of a calamity it is necessary to prevent the presence of defects which under the right circumstances will progress to failure and in a few cases disaster.

The more defects present, the greater the number of problems they become. Problems show up as lost time, reduced production rates, poor quality product, workplace accidents and many other wastes and losses. These require removal and correction, which absorbs our time, resources and money. We see the end result as poor operating performance and poor profitability.Only one way to disassemble

40,000+ ways to incorrectly reassemble!The Odds are Against Doing it Right!12/2/201463

Sarangani Energy Corporation63There are plenty of opportunities to make mistakes in aviation maintenance. Look at this easy example of one bolt with many nuts. This nut and bolt assembly can only be disassembled one way. However, there are over 40,000 combinations for reassembly, of which only one is correct! This is a good example of the complexity, and chance of error, in aviation maintenance environments.

Physical Size Gender Age Strength The five sensesPhysiological Health Nutrition Lifestyle Alertness/fatigue Chemical dependencyPsychological Experience Knowledge Training Attitude Emotional state Psychosocial Interpersonal relations Ability to communicate Empathy Leadership12/2/201464Human Factors the limitations of PeopleSarangani Energy Corporation64Merely select a few of them and talk about it. There are level 3 details for: Fatigue, anthropometrics, and sensing, and perception examples.

Eliminate these causes and you have conquered most human errors

Talk about each of these with your people

What are the causes in your company?

What are the corrective actions?12/2/20146512 Most Common Causes for Human ErrorsSarangani Energy Corporation65You can just talk about the dirty dozen. We all make the same kind of errors and we are all human. "To err is human." Throughout the human factors training you may hear the words "Dirty Dozen. The dirty dozen is a listing of the 12 most common causes of human error in maintenance. The concept was developed by Mr. Gordon Dupont at Transport Canada. If we could eliminate or control these 12 causes of error we would eliminate a very high percentage of maintenance-related events. We will look at each factor that contributes to an error, and offer possible corrective actions to prevent such error. The following is a listing of the Dirty Dozen: Lack of Communication; Lack of Teamwork; Norms; Pressure; Complacency; Lack of Knowledge; Lack of Awareness; Lack of Resources; Distraction; Lack of Assertiveness; Fatigue; Stress. By the end of your human factors training, you should remember many of these errors, and also know the best methods for preventing them.

Human Factors are A Prime Focus

12/2/201466Sarangani Energy CorporationSee page 2 of your work book66Reliability of Human Dependant Processes

12/2/201467Sarangani Energy Corporation67See page 3 of your workbook.This table is an extract from the 7th edition of Reliability, Maintainability and Risk by Dr David Smith. It lists the typical error rates for a variety of tasks that equipment operators and maintainers do. You can see that some errors always occur, that is the nature of human beings we are not perfect and we make mistakes. The table also shows that the frequency of making errors increases as tasks get more complicated and/or non-routine.

The big concern for business and industry is when we start grouping individual tasks into procedures that belong to a job. The error rates for each task in the procedure multiply together and the risk to the achievement of the right outcome compounds.Fundamentally Finding the Cause Behind the Cause

"Every defect is a treasure, if the company can uncover its cause and work to prevent it across the corporation."- Kiichiro Toyoda, founder of ToyotaPerhaps not so much why did it happen?But, more Why was it able to happen??????This information is publically available from C. Robert Nelms, Failsafe Network, Inc. www.failsafe-network.com This is NOT the real Cause, it is an effect!12/2/201468Sarangani Energy CorporationWhen an incident is investigated you see the effects and use the effects to trace back to the causes. When you arrive at the causes you can chose to stop there an say the investigation is completed, or you can recognise that they are in-fact also effects of other causes and go and look for the truth.68Cause Behind the Cause - Latent Thoughts

Psychology definition of LATENT:

Present and accessible in the unconscious mind but not consciously expressed.What thoughts did people have at the time that contributed to the incident?12/2/201469Sarangani Energy CorporationWhen you go deeper into the causes of the causes of an incident, you encounter the issue of latency. Latency in psychology is a hidden, inactive, or dormant trait. When applied to failure incidents it helps us to identify what thoughts people had at the time that contributed to the incident.69The Real Cause?... Latent Values

What allowed people to think like that?Two very basic truths1. Adverse industrial events tend to be the result of human errors that queue up in a particular sequence.2. Error must be accepted as a system flaw, not a character flaw. Ask, Why did the system let me fail?

What caused people to think like that?Focus on LATENCY

The Organizational attitudes, beliefs, andassumptions accepted by all.12/2/201470Sarangani Energy CorporationWe do what we do because we hold certain beliefs, attitudes and values. These tailor our actions and behaviours. If we want to permanently change outcomes we must first change the latent issues affecting the situation. We cannot change peoples inner beliefs, but we can introduce systems to change the actions they do. If they see that the new actions produce better results, they will change their attitudes because the evidence is clear that the new ways are better.70What is a High Potential Incident?

ESCALATION BARRIERSTHREAT BARRIERSTHREATSCONSEQUENCES Eventhigh potential incident means an incident not causing loss or damage but, under different circumstances would result in an accident.HAZARD

ACTUALCONSEQUENCES12/2/201471Sarangani Energy Corporation71It takes a lot of things to go wrong before there is a real catastrophe. A threat has to be present at the specific time the natural barriers have to be breached. Even after the event, it requires a lot of things to happen before the consequences become huge. Take a fire for example: there needs to be sufficient heat, burnable fuel and oxygen together; there must be a heat source and fuel present to catch alight. Once the fire starts there needs to be more fuel to sustain it. That is why many fires are blamed on arsonists, because for them to start without help would have been near impossible.Hazard ConsequencesBarrier Analysis and IdentificationWhat barriers should be in place?What is the likely cause of holes in the barriers?-answer two questionsIn a well run organisation there should be many barriers against major problems.These can be physical barriers or management systems. Hole: The maintenance fitter installed the wrong valveBarrier: Independent check on critical equipment jobsWhy: Lack of training?Poor work procedures?Barrier: Skilled tradesman employed12/2/201472Sarangani Energy CorporationEach threat or escalation barrier can be represented as a piece of Swiss cheese

The holes represent weaknesses in the processes that form part of the barrier. The weakness can relate to the design of the process or its implementation.

If the holes in the threat barriers line up this forms the chain of events that lead from a hazard to an event.

If the holes in the escalation barriers line up this forms the chain of events that leads from an event into a consequence.Hazard ConsequencesHow the Swiss Cheese Slices Lined Up for the TitanicWhat barriers should be in place?What is the likely cause of holes in the barriers?Answer the two questions?Sailing at high speedMoonless, still night, no reflectionWorst iceberg season in yearsBerg seen, ship turns, but slow response from small rudderEngines stopped, reversed, rudder becomes ineffectiveExperienced Captain not on bridge12/2/201473Sarangani Energy Corporation73Each threat or escalation barrier can be represented as a piece of Swiss cheese

The holes represent weaknesses in the processes that form part of the barrier. The weakness can relate to the design of the process or its implementation.

If the holes in the threat barriers line up this forms the chain of events that lead from a hazard to an event.

If the holes in the escalation barriers line up this forms the chain of events that leads from an event into a consequence.12/2/2014

The 5/7 Whys Method to Confirm the PathThe 5/7 Whys contributes to the success of cause and effects analysis by asking you to use real evidence to prove what really happened.74Sarangani Energy CorporationScientific Causes / EffectsIncident ActionsLatent CausesBusiness System CausesUsing 5/7 Whys to Confirm Failure PathIncidentWhy 1Why 2Why 3Why 4Why 5Why 6Why 7Remember the Latency IssuesFollow the evidence.12/2/201475Sarangani Energy CorporationWhy Tree of a Failure IncidentHis late arrival at work caused an important clients deliver to be delayed and the company suffered a $25,000 penalty payment.Penalty PaymentLate DespatchManufacturing CompletedStoreman Packages ItemsStopStoreman Late to WorkCar Stopped at Side of Road Car Ran Out of FuelNo Fuel in Fuel TankThis employees after-hours behaviours caused a business process failure, which unless addressed, it will repeat again in future.12/2/201476Sarangani Energy CorporationWhy Tree of a Failure Incident - Latent CausesI Want to Be with FriendsNo Money to Buy FuelLost the Money in a Card GameI Bet All My MoneyI Often Lose at Cards No Fuel in Fuel TankMost RCA teams would stop here, thinking they had found the root causeI Live from Day to DayI Spent all I Had in My WalletI Have a Limited IncomeLatent values and attitudesEasy come easy go12/2/201477Sarangani Energy CorporationThe 5/7 Whys and 3W2H FormWhy Tree Questionnaire FormTeam Members:Date:Problem Statement: On the way to work your car stopped in the middle of the road.Estimated DAFT Cost: Taxi fare x 2 = $50, Lost 4 hours pay = $100. Contract Penalty Payment. Plus possible loss of clients.Recommended Solution: Carry a credit card to access money when needed.Latent Issues: Gambling away all the money shows a lack of personal control and responsibility of money.Why Questions3W2H Answers(with what, when, where, how, and how much)EvidenceSolution1. Why did the car stop?Because it ran out of gas in a back street on the way to workCar stopped and standing at side of road2. Why did gas run out?Because I didn't put any gas into the car on my way to work this morning.Fuel gauge showed empty3. Why didn't you buy gas this morning?Because I didn't have any money on me to buy petrol.Wallet is empty of moneyKeep a credit card in the wallet4. Why didn't you have any money?Because last night I lost it in a poker game, I played with friends at my buddys house.Poker game is held every Tuesday night Stop going to the game5. Why did you lose your money in last night's poker game?Because I am not good at bluffing when I don't have a good poker hand and the other players jack-up the bets.Have lost money in many other poker gamesBecome better at bluffing6.7.Give a complete answers full of facts12/2/201478Sarangani Energy CorporationThe 5-Whys is a simple way to try solving a stated problem without a large detailed investigation requiring many resources. Also known as a Why Tree, it is a simple form of root cause analysis. It is used whenever the real cause of a problem or situation is not clear. Most obvious explanations have yet more underlying problems. By repeatedly asking the question, Why? you peel away layers of symptoms that can lead to the root cause. The 5-Whys help to determine the relationships in a problem. It is one of the simplest investigation tools easily completed without statistical analysis. When problems involve human factors this approach is easiest because it is less stressful. Start with a statement of the situation and ask why it is happening. Then you ask Why? of the answer to the first question, and so on. The question Why? is asked five times. By refusing to be satisfied with the first explanation you increase the possibility of finding the true root cause of a situation. Although this technique is called 5 Whys, five is a rule of thumb. You may need to ask the question fewer, or more times, before you find the root of a problem (there is even school of thought that seven whys is better; that five whys is not sufficient to uncover the real truth). Some contents for this topic are from the website http://www.isixsigma.com/library

78Activity 4 Complete a 5-Why Table5 Why QuestionnaireTeam Members:Date:Problem Statement: On your way home from work your car stopped in the middle of the road.Estimated DAFT Cost:Recommended Solution: Carry a credit card to access money when needed.Latent Issues: Lack of personal control over money is concerning.Why Questions3W2H Answers(with what, when, where, how, how much)EvidenceSolution1. Why did the car stop?Because it ran out of gasCar stopped at side of road2. Why did gas run?Because I didn't buy any gas on my way to work.Fuel gauge showed empty3. Why didn't you buy gas this morning?Because I didn't have any money.Wallet is empty of moneyKeep a credit card in the wallet4. Why didn't you have any money?Because I lost it in a poker game last night.Poker game is held every Tuesday night Stop going to the game5. Why did you lose your money in last night's poker game?Because I'm not good at bluffing when I don't have a good hand.Have lost money in many other poker gamesBecome better at bluffing6.12/2/201479Sarangani Energy CorporationActivity 4 Complete a 5-Why TableProblem Statement: Unfinished Maintenance/Repair of feed water pump79Failure Modes and Functional Loss12/2/201480We can foretell what parts are going to cause trouble by doing experiments, conducting tests and using past failure history of similar parts. If we can predict what will go wrong, and the conditions that cause it to happen, we can design maintenance and operational loading strategies to give maximum part life.A failure is any unwanted or disappointing behaviour of a product.

A failure mode is the effect by which a failure is observed. Failure modes can be electrical (open or short circuit, stuck at high), physical (loss of speed, excessive noise), or functional (loss of power gain, communication loss, high error level).

Failure mechanism refers to the processes by which the failure modes are induced. It includes physical, mechanical, electrical, chemical, or other processes and their combinations. Knowledge of failure mechanism provides insight into the conditions that precipitate failures.

A failure site describes the physical location where the failure mechanism is observed to occur, and is often the location of the highest stresses and lowest strengths. Sarangani Energy Corporation80Failure Modes and Evidence of FailureFailureFailure ModeFailure MechanismFailure Site

Car does not startStarter Motordoes not runCorroded relaycontactsMain contact ofstarter relayToy has faded colourColour changesfrom red to pinkAccumulation of high UV doseRed plastic legHard disk failureComputer has no access to hard diskHard disk address is 11 instead of 12Line 87 in the hard disk driver softwareOnce this is known we put strategies and practices into place to; 1) Design-out the failure, 2) prevent the failure, 3) monitor the failure mode, 4) replace before failure and 5) prevent the conditions causing failure.12/2/201481Sarangani Energy Corporation81Failure Mode and Effects Analyse (FMEA) used to identify parts and equipment at risk so that sensible maintenance strategies can be selected to control the chance of failure. FMEA is both a qualitative and quantitative technique to identify how equipment can fail in order to design out a failure, or to identify and apply suitable maintenance practices to correct a developing problem before it leads to a failure. FMEA leads to a very clear and structured analysis of failure cause and consequences so problems can be addressed and mitigated in a suitable cost effective way.12/2/201482Top-Down Block Diagram Analysis

Start at the top level & draw the process as a block diagramTake each item and draw its process block diagramOnly go to a lower level if there is too much complexity to analyse effectivelyFor the selected analysis level rate the criticality of the itemSarangani Energy CorporationExample of an expanded list of failure modes1Cracked/fractures11Fails to stop21Binding/jamming31Burned2Distorted12Fails to start22Loose32Collapsed3Undersize13Corroded23Incorrect adjustment33Overloaded4Oversize14Contaminated24Seized34Omitted5Fails to open15Intermittent operation25Worn35Incorrect assembly6Fails to close16Open circuit26Sticking36Scored7Fails open17Short circuit27Overheated37Noisy8Fails Closed18Out of tolerance (drifted)28False response38Arcing9Internal leakage19Fails to operate29Displaced39Unstable10External leakage20Operates prematurely30Delayed operation40ChafedSource Table 2 BS 5760Failure Modes: What You See/Hear When it Fails12/2/201483Sarangani Energy CorporationMounting failureImproper LubricationPhysical DamageOverloadExcessive WearLoosenessExcessive Movement of CylinderCylinder barrel failureLeaking Barrel SealPhysical DamageEnvironment heat/dirtExcessive WearCylinder seal failureImproper LubricationPhysical DamageAge/deteriorationExcessive WearExcessive Piston/rod movementPiston rod failureOver ExtensionFatigue/ageExcessive Lateral MovementPhysical DamageConnection failureLoose Hydraulic FittingsDamaged Hydraulic FittingsDamaged or Fatigued HosePiston failureExcessive WearAge/deteriorationExcessive Load/impact12/2/201484Failure Mode and Causes AnalysisSarangani Energy CorporationHidden Failures12/2/201485Failures of equipment that either dont get used regularly or only get used when something goes wrongStandby equipment eg. a standby pumpProtection equipment eg. Fire extinguisher, 2nd safety limit on a machine movement, pressure relief valvesYou typically only know these items have already failed when you really need themCarry out Failure Finding tasks. These are simple function checks e.g. changeover to standby pumpSarangani Energy CorporationFailure Mode and Effects Analysis (FMEA)Operating UnitMaintainable ItemFMEAMaintenance ActionsEngine SumpPSHeat ExchWater InWater OutTurbocharger Oil Cooling SystemTG

Turbocharger Lube Oil PumpBearing SeizesImpeller/Casing WearCoupling ShearsMech Seal LeaksTotal StoppageNo Immediate ImpactTotal StoppageNo Immediate ImpactOil Analysis, VibrationMonitor Flow RateLook for Wear & LubeLook for leaksFAILURE MODEFAILURE EFFECTOPS/MAINT ACTIONSFMPMCMWatch KeepingPMRCM12/2/201486Sarangani Energy Corporation86This is an overview of the FMEA team review process. It is a logical progression through each assembly and sub-assembly in an item of plant asking the question, What can go wrong in its operation? The team of subject matter experts identify the causes and then agree to the operating and maintenance actions to be performed to prevent a failure. These actions become maintenance and operating tasks.Failure Mode Effects Analysis (FMEA) Worksheet

12/2/201487Sarangani Energy CorporationActivity 5 FMEAOverstress failure mechanisms when a single stress excursion exceeds strengthWear-out failure mechanisms when accumulated damage exceeds enduranceMechanical Electrical Fracture Fused or shorted wires Buckling Electrostatic discharge Yielding Electrical overstress

Thermal Physical/Chemical Melting Crystal lattice attack

Mechanical Electrical Fatigue Leakage current Creep Threshold Voltage Shift Corrosion Metal migration

Thermal Physical/ChemicalElasticity degrade DepolymerisationDo FMEA and identify failure modes and functional failures in a bearing12/2/201488Sarangani Energy Corporation88In this activity you do a very basic FMEA on a piece of equipment. The aim is to realise that we can take a part and by using some key words, and the experience of a group of people in a brainstorming session, identify how it can fail and what the signs are that it is undergoing failure. From the identification of failure we can develop strategies to control it and reduce the severity of its impact.TacticUp time

% Change%

Uptime

Reactive83.5%

Planning Only+ 0.5 %

Scheduling Only+ 0.8 %

Preventive / Predictive Only- 2.4 %

All three tactics+ 5.1 %88.6 %

Plus Failure Elimination+ 14.8 %98.3%

Chart40.50.51.581.583.683.68372260.360.360.750.750.920.92372360.420.42372501.221.220.560.560.620.62372530.660.660.560.56372550.260.260.580.580.830.83332.52.51.0831.0832.112.1137287372873728737309373110.080.080.320.320.330.331.541.540.380.381.831.8337339373431.331.33373441.41.4373450.730.73373461.431.4337347373470.50.53734737348373480.670.670.780.78373500.480.483735237355373571.551.550.750.751.621.62373801.831.8337387373903739237400374031.071.0737407374200.430.432.422.4237430374303745837458374693746937469374753748037480374853752037521375233752437530375393754237555375560.80.8375613756237570375743758237583375863758737587375883758937590

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Trend Plot

Trend Plot0.50.51.581.583.683.68372260.360.360.750.750.920.92372360.420.42372501.221.220.560.560.620.62372530.660.660.560.56372550.260.260.580.580.830.83332.52.51.0831.0832.112.1137287372873728737309373110.080.080.320.320.330.331.541.540.380.381.831.8337339373431.331.33373441.41.4373450.730.73373461.431.4337347373470.50.53734737348373480.670.670.780.78373500.480.483735237355373571.551.550.750.751.621.62373801.831.8337387373903739237400374031.071.0737407374200.430.432.422.4237430374303745837458374693746937469374753748037480374853752037521375233752437530375393754237555375560.80.8375613756237570375743758237583375863758737587375883758937590

Cat1DateOutage Hours

DataDateFormatted DateHoursCategory12/1/0137226.000.510.5012/1/0137226.001.5811.5812/1/0137226.003.6813.6812/1/0137226.000.03412/3/0137228.000.3610.3612/5/0137230.000.7510.7512/5/0137230.000.9210.9212/11/0137236.000.08112/12/0137237.000.4210.4212/25/0137250.000.07112/25/0137250.001.2211.2212/26/0137251.000.5610.5612/27/0137252.000.6210.6212/28/0137253.000.6112/28/0137253.000.6610.6612/29/0137254.000.5610.5612/30/0137255.000.23112/30/0137255.000.2610.2612/31/0137256.000.5810.581/1/0237257.000.8310.831/1/0237257.00313.001/19/0237275.002.512.501/22/0237278.001.08311.081/25/0237281.002.1112.111/31/0237287.000.1211/31/0237287.000.2311/31/0237287.000.2812/22/0237309.000.5812/24/0237311.000.0813/13/0237328.000.0810.083/18/0237333.000.3210.323/18/0237333.000.3310.333/19/0237334.001.5411.543/20/0237335.000.3810.383/23/0237338.001.8311.833/24/0237339.000.4813/28/0237343.000.3813/28/0237343.001.3311.333/29/0237344.000.1813/29/0237344.001.411.403/30/0237345.000.1813/30/0237345.000.7310.733/31/0237346.000.2313/31/0237346.001.4311.434/1/0237347.000.1814/1/0237347.000.3714/1/0237347.000.510.504/1/0237347.000.8214/2/0237348.000.0514/2/0237348.000.0814/2/0237348.000.6710.674/3/0237349.000.7810.784/4/0237350.000.0514/4/0237350.000.4810.484/6/0237352.000.2214/9/0237355.000.114/11/0237357.005.9814/14/0237360.001.5511.555/2/0237378.000.7510.755/2/0237378.001.6211.625/4/0237380.000.0715/4/0237380.001.8311.835/11/0237387.000.215/14/0237390.000.315/16/0237392.000.1615/24/0237400.000.7215/27/0237403.000.1315/27/0237403.001.0711.075/31/0237407.000.4216/13/0237420.000.0316/14/0237421.000.4310.436/15/0237422.002.4212.426/23/0237430.000.0716/23/0237430.008.6217/21/0237458.000.117/21/0237458.000.1218/1/0237469.000.0218/1/0237469.000.0318/1/0237469.000.518/7/0237475.000.0318/12/0237480.000.0518/12/0237480.000.1810.188/17/0237485.000.1319/21/0237520.000.2319/22/0237521.000.2319/24/0237523.000.0719/25/0237524.000.08110/1/0237530.000.05110/10/0237539.000.33110/13/0237542.002.0712.0710/26/0237555.000.05110/27/0237556.000.17110/29/0237558.000.810.8011/1/0237561.000.07111/2/0237562.000.25111/10/0237570.000.17111/14/0237574.000.12111/22/0237582.000.28111/23/0237583.000.83111/26/0237586.000.05111/27/0237587.000.2111/27/0237587.000.13211/28/0237588.000.03111/29/0237589.002.33311/30/0237590.0012.174