Root Cause Analysis RCA Investigation Guide PDF

Root Cause Analysis (RCA) Investigation Guide
This resource highlights the procedures to follow when applying Root Cause Analysis (RCA)
to resolve equipment-related failures linked to oil rig downtime.
Life Cycle Engineering 2012
www.LCE.com
Root Cause Analysis (RCA) Investigation Guide

This Root Cause Analysis Investigation Guide presents the procedures to follow when applying Root Cause
Analysis (RCA) to resolve equipment-related failures linked to oil rig downtime. You will find instructions for
classifying equipment failures as minor, moderate or significant, and the appropriate investigation procedure
to use for each classification. Also included are suggested root cause and equipment failure report templates
and a visual guide to selecting appropriate root cause analysis tools.
Equipment Failure Classification:
Equipment failures are classified according to the severity of their impact. These classifications help determine
which investigation procedure to use.
General Classifications:
Classification
Minor
Severity of Impact
No impact to drilling operations
Repair costs < $5,000
Moderate
Impact shuts down drilling operations for < 2 hours

Repair costs are between $5,000 - $10,000
Significant
Impact shuts down drilling operation for > 2 hours, reportable environmental impact
and/or causes personnel injury
Repair cost > $10,000
Trigger points that indicate that an equipment failure is significant are different for rig operations and drilling
operations. These specific trigger points are documented below:
Rig Operations
Significant Failure Trigger Point
Availability Impact
> 4 hours of consecutive equipment downtime
Repair Cost Impact
Repair costs > $10,000
Maintenance Impact
Cancellation of > 10% of planned/scheduled maintenance and/or a repeatable

equipment audit discrepancy
Safety Impact
Personnel incident or injury requiring transport to medical facility
Drilling Impact
Causes drilling operation to shutdown > 2 hours
Environmental Impact
Causes a reportable environment impact
Drilling Operations
Significant Failure Trigger Point
Availability Impact
> 2 hours of consecutive equipment downtime
Repair Cost Impact
Repair costs > $10,000
Maintenance Impact
Cancellation of > API Standard planned/scheduled maintenance and/or a

repeatable equipment audit discrepancy
Safety Impact
Environmental Impact
Personnel incident or injury requiring transport to medical facility

Causes a reportable environment impact
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Investigation Procedure:
To maintain the integrity of failure history and data, and to minimize the level of effort required to prevent reoccurrence, conduct the investigation of equipment-related failures at the level consistent with the Equipment Failure
Classification. Below you will find the recommended procedure to follow and the relevant RCA team members
required for each failure classification:
Class
Minor
Investigation Level
1. Notify Rig Area Manager
2. Record equipment failure in the Failure Tracking System
(CMMS, etc.)
3. Initiate a Work Request for corrective maintenance
4. Record rig downtime in Downtime Log
Class
Moderate
Chief Engineer, Toolpusher, Safety

Representative, Senior Rig
Craftsman
Investigation Level
Investigators

(CMMS, etc.)
4. Investigate using 5 Whys RCA Problem Solving Report
5. Prioritize corrective actions
6. Initiate Work Request for corrective maintenance
7. Submit Equipment Failure Report for review/approval
Class
Significant
Investigators
OIM (Offshore Installation

Manager), Rig Supervisor, Ship/
Barge Captain, Chief Engineer,
Toolpusher
Investigation Level
Investigators

(CMMS, etc.)
4. Submit Equipment Failure Report
5. Initiate Work Request for corrective maintenance
6. Perform Root Cause Analysis
7. Prioritize corrective actions
8. Submit Root Cause Analysis Report for review/approval
OIM (Offshore Installation

Manager), Rig Supervisor, Ship/
Barge Captain, Chief Engineer,
Toolpusher
RCA Team:
Certified RCA Facilitator
Reliability Engineer
Craftsman (mechanical)
Craftsman (electrical)
Craftsman (subsea)
Craftsman (electronics)
Safety Representative
Crane Operator
Driller
On the following pages you will find:

Pg 3: A template for an Equipment Failure Report
Pg 5: A template for a 5 Whys Root Cause Analysis Problem Solving Report
Pg 6: A one page guide to selecting the appropriate root cause analysis tool
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Equipment Failure Report

Equipment Identification
Rig
Location
System
Equipment No.
Tour/Crew
Reported By
Equipment Description
Event Description
Time
Date
Summary of Costs
Estimated Repair Cost:
Attach Equipment Failure Photos
$
-
Estimated Downtime: (hours)

Estimated Production Impact: $
Estimated HSE Impact:
Failure Description (Initial Observations)
Immediate Actions Taken
Immediate Corrective Maintenance Authorized (WO#)
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Consequences:
Address with continuous
improvement
GREEN
YELLOW
Incorporate risk
reduction measures
RED
Intolerable
Risk Assessment Matrix

Potential Consequence of the Incident
Increasing Probability
A
Rating
People
Environment
No injury
Zero
effect
Zero
damage
No impact
Slight injury
Slight
effect
Slight
damage
< US$ 10k
Slight
impact
Minor injury
Minor
effect
Minor
damage
< US$ 100k
Limited
impact
Major injury
Local
effect
Local
damage
< US$ 1MM
Considerable
impact
Single
fatality
Major
effect
Major
damage
< US$ 10MM
National
impact
Multiple
fatality
Massive
effect
Extensive
damage
> US$ 10MM
International
impact
Assets
Reputation
never
heard of in
industry
heard
of in
industry
happened
before in
Company
reported
< 3x/yr in
Company
reported
> 3x/yr in
Company
Recommended Corrective Actions to Prevent Recurrence:

Action Items
Completed By
Due By
Reviewed/Approved By
Status
Signature
Chief Engineer
Toolpusher
Ship/Barge Captain
Rig Supervisor
OIM
Reliability Engineer

www.LCE.com
5 Whys Root Cause Analysis Problem Solving Report

What Happened:
1. Why Did it Happen:
2. Why:
3. Why:
4. Why:
5. Why:
Root Cause(s) Identified
Short-term Countermeasures
Long-term Countermeasures
Report Completed By
Signature
Chief Engineer
Toolpusher
Safety Representative
Equipment Craftsman/Operator
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Product design, troubleshooting, generation

of proactive measures for prevention. Good for
complex systems with multiple failure modes.
Analysis of accidents and undesirable events

Particularly effective for incidents that have
primary and secondary events.
Where a simple, fast method for analyzing a
single chain of events or conditions. Very
effective for simple shop floor problem solving.
Identifies most probable modes

of failure, occurrence frequency
and detection for a given system,
component by component.
Describes graphically the sequence

of contributing events and existing
conditions associated with an
incident.
A simple drill-down approach Ask

Why 5 times. Each answer contains
the next why.
Situations in which a change from normal

configuration, operation or activity is likely to
contribute or lead to an undesirable condition.
Asks question: What is different now?
Compares the normal situation

to the undesirable situation and
determines changes that have
occurred.
5 Why
(ECF) Analysis
Event &
Causal Factor
(FMEA)
Failure Mode &

Effects Analysis
Change
Analysis
(FTA)
Fault Tree
Analysis
Systems wherein undesirable end events are

linked to all contributing factors - equipment
failures, design reviews. Analyzes only one failure
mode, but all causes.
Incidents where the time sequence is critical to

the evaluation of combined contributing factors.
Graphically displays the sequence of

events leading to a failure, event, or
incident .
Sequence
of Events
(Ishikawa or fishbone)
For a single failure mode (top event),

examines many cause scenarios in a
branched method.
Quality systems, product design, troubleshooting,

brainstorming where multiple interactions may
be occurring.
Plots the relationship between

various factors that contribute to
a specific event.
Cause & Effect
Applies to all problemsnot just asset related.

Non-asset problemsevaluate processes and
practices. Starting point for many RCA types.
Examines the gaps between Intent and Actual.
Compares system design to how

it is applied. Specifically, the areas
of installation, maintenance, and
operating requirements and limitations.
Design &
Application
Review
Application
Purpose
Technique
Root Cause Analysis (RCA) Tool Guide
www.LCE.com
Memory Jogger
Reliability Consulting Group

Using a proven business reengineering process, LCEs Reliability Consulting
Group (RCG) has led many clients through a total organization transformation
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processes, operational and maintenance work execution and organizational
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helps organizations determine if learning/training is the answer to a performance
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Learning Impact Maps
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When retention strategies and support beyond the classroom experience are
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800-556-9589 or education@LCE.com
To learn more about Life Cycle Engineering, contact: 843.744.7110 | info@LCE.com | www.LCE.com

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