Documente Academic
Documente Profesional
Documente Cultură
CORPORATION
Good
Morning
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SARANGANI ENERGY
CORPORATION
You Have to Know What You're Looking for If You're Going to Find It
December 4, 2014
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CORPORATION
DAY 1
Using RCFA and Making it Successful
True Causes of Plant and Equipment Failure
Risk Analysis, Reliability Growth and Failure
Elimination
Applying RCA Failure Analysis Tools and Their Use
DAY 2
The RCFA Team and The Role of the Facilitator
Introducing and using RCFA
Practice the RCFA Methods
Propagating Improvements Company-Wide
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Cross-functional
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Teams
The
Facilitator
Team Dynamics
Running RCFA Meeting
Cooperation Techniques
The Six Hats
Facilitation Techniques
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PREPARATION
Keep an Open Mind what you think happened is very unlikely to be the total story
Most problems are due to human factors and poor business processes/controls
Get/keep the evidence concerning the failure from throughout the operation hard evidence from
failed items and soft evidence from interviews
IMPLEMENTATION
Come to meetings prepared with the details that you can provide or are asked to provide
RESEARCH
Fully flow chart the process (boxes and arrows), and its interconnecting activities into other
processes, and identify the location of the problem
Provide a P&ID, drawings, operator manual, maintenance procedures, operating records, maintenance
records, etc related to the problem
ANALYSIS
Fishbone Analysis for thorough coverage and understanding from range of data collection and data
analysis tools select those that are appropriate
Develop Cause and Effect Tree of necessary cause-effect conditions, states and interactions
Test Why Tree with the 5/7 Whys start as low down Why Tree as there is certain evidence
5 Why Table with Evidence + personal beliefs, attitudes, corporate culture norms, etc. Understand
Latent issues
CORRECTION/CHANGE
Cross-functional Teams
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Facilitators Plan
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The
Powerful
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Navigator
Survivor
Victim
Powerless
Reactive
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Do you want
Reliability,
Availability,
Throughput, Safety,
Quality, Lower
Costs, and Less
Waste?
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Facilitator Ensures Solutions are
CORPORATION
Implemented
You want permanent improvement throughout the organisation, rather than
in one operation or department
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Act
Planners
Workforce
Improve the
Planning,
Procedures
and Forms
Do
Learn from
Managers
the
experience
Plan
act to
Cost
correct
Quality
Time
your
business
Check
systems
Supervisors
and
processes
so it
doesn't
Until the
new ways are
happen
again.and people are
documented,
Improve the
Job
Procedures
and Checks
Improve the
Training and
Competence
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The
Facilitators'
responsibility
may not
include
making the
changes
recommende
d by the RCA
team. It does
include
reminding
management
Continually Improve that until the
changes are
introduced
and are in
use,
the risk
Is the agreed work being completed, at the right time, with the right
resources?
remains in
the business.
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Creative: cultivates,
encourages new
ideas
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Cause to
Address
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Proposed
Solution
Solution
Objective
Risks with
Implementatio
n
Rating
for
Objective
1, 2, 3
Rate for
Option
1, 2, 3
Overall
Rating
(Obj x Opt)
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High
Do
these
first
Impact
Develop multiple
recommendations
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Gets
Management
Support
Low
Hard
High Payback
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Ease to
Implement
Easy
Easy to Do
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In preparing the report there may be some unpalatable truths but these
must be appropriately stated.
adverse events are usually the result of human errors
these errors must be accepted as system flaws, not character flaws
The report will contain all the documents produced during the
investigation and a summary Executive Report at the front. This will
enable senior, and possibly non-technical management, to read the
recommendations and appreciate the value of the RCFA procedures.
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You cannot change peoples internal values, but what you can change is
the practices they must follow so that their cognitive dissonance brings
about change in their values.
For example, if you want people to always practice creative disassembly, provide a
procedure and report sheet they must complete and hand-up at the end of every stripdown so you can encourage and train them. In this way, the organisation's practices
brings about the necessary change in the value that people put-on careful observation
and recording.
THE GROUP LEADER WILL NEED TO SUPPORT AND ENFORCE THE NEW
PERFORMANCE, ELSE PEOPLE WILL RETURN TO THEIR OLD WAYS (The really important
people are the Supervisors/Team Leaders)
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In control
and capable
In control
but not
capable
Out of control
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Number of
Events
Very Bad
Outcome
Very Bad
Outcome
Acceptable
Outcome
Value of a Critical
Parameter
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Standard to
Meet
Requirements,
Needs,
Expectations
Degree to
which
inherent
quality
characteristi
cs meet
Effect of Using a Quality
stated or
Performance
System
implied
Levelneeds.
Time
The Meaning of Quality
Quality
Improvement
Tools
Plan
Do
Measure
Improve
Measure means
to check you
have statistical
control
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Steering
Steering Committee
Committee
e.g.,
e.g., Eng,Tech,and
Eng,Tech,and Ops
Ops
Managers
Managers
Plant 1
Plant 2
Plant 3
Plant 4
Improvement Teams
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Reliability Framework
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Reliability
Reliability Management
Management
Focal
Focal Point
Point
Steering
Steering Committee
Committee
e.g.,Eng,
e.g.,Eng, Tech,
Tech, Ops
Ops
Managers
Managers
Reliability
Reliability
Improvement
Improvement
Plans
Plans
Approved
Approved
Action
Action Plans
Plans
Simplified
Simplified
RCM,
RCM, RBI,
RBI,
RCFA,
FMEA
RCFA, FMEA
Implement
Implement
Multi
Discipline
Teams
Publicity
Publicity
Feedback
Feedback
Monitor
Monitor
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FMEA
DAFT Costs
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Equipment
Criticality
Planned Preventive
Maintenance
Planned Condition
Monitoring
Planned Reliability
Improvements
Precision Maintenance skills
and equipment
Precision Breakdown Repair
Standardise best practices
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OPERATIONS
ENGINEERING
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Project
Managementc
Project
Management
Do I need to change?
Assessing
Renew & Sustain
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Roof
Fell
Foundation
Failed
Stop
Roof
Material
Failed
Stop
Column
Material
Failed
Columns
Tumble
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Scientific Event
Sequence
Stop
Column to
Ground
Connection
Fails
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Columns
Tilt
Roof Moves
Trailer Hits
Roof
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What do your
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Creative
Disassembly
Catastrophe Analysis
Team of experts in
several meetings
Escalate
High cost and time
focus on big problems
and you keep having big
problems
Identifies wider
perspectives
EFFECT OF MODERNSAFETY
SAFETYACCIDENTS
INITIATIVES
1
Serious Injuries
10
Minor Injuries
30
Property Damage
600
Incidents
EQUIPMENT FAILURES
1
Serious Failure
10 losses
Minor Failures
6500 repairs
20,000 defects
Process Losses
Procedural Incidents
Source: Winston Ledet,
Manufacturing Game
Creative Disassembly
CM
QA
Precision Reassembly
Precision Installation
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CM
PM
OPS
CM = Condition Monitoring
PM = Preventive Maintenance
QA = Quality Assurance
OPS = Operator Sensing
(Watch Keeping)
ACE = Accuracy Controlled
Enterprise
3T = Target - Tolerance - Test
Precision
Maintenanc
e
Activities
to ACE 3T
Procedures
These
techniques
deliver
Machinery
Improvement
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2nd bearing
sleeve
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What
1) HUMAN
FACTORS,
1st bearing
sleeve
1st bearing
bush
2) BUSINESS or
WORK
PROCESSES,
3) PHYSICAL
PROCESSES
AFFECTING
EQUIPMENT
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4) LATENCY
FACTORS
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Before Strip-down
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Inspection of bearings
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INSPECTION
6.
7.
8.
9.
ANALYSIS
10.
11.
12.
13.
14.
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Abnormal Patterns
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Thrusted
Double
loading
potential
cause is
Soft Foot
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Abnormal Patterns
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Overloade
d
Misalignm
ent
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Abnormal Patterns
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Unbalanc
e
Pinched
Outer Race
Bearing
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Precision
High
Quality
Frequency of Outcomes
Frequency of Outcomes
Accuracy
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Accurate
Precision
Repeatability
X X
Specification
Specification
Variability =
Range of Outcomes
Range of Outcomes =
Variability
Repeatability is low
in this process
Unwanted
Variability
= Unwanted
Outcomes
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3Ts of Failure
Prevention . Target
. Tolerance
. Test
Frequency of Outcome
et
g
r
Tarecision
P
Bands of Lesser
Quality
Quality
improvement
occurs when
variation is
reduced
(Decreasing
Accuracy)
Good, Better,
Best
Bronze, Silver,
Gold
Tolera
nce
Output
Specification
Range of Possible
Outcomes
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As GOOD as it needs to be
BEST
BETTER
As BAD as allowed
GOOD
PASS /
ACCEPT
Perfect
Result
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World Class
Target
FAIL /
REJECT
Tolerance
Limit
Certain
Failure
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Time
Time
Output
Output
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No.
Better
Best
Good
Range of Outcomes
0.9
0.9
0.9
0.9
0.99
0.99
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NOTE:
None of these task will
prevent the pump and
piping from failing.
These tasks find future
repairs and you want a
healthy, reliable pump
set...
prevention is
easier than cure
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Re
b
lia ring
bili
s
ty
Task
Step
No.
Task
Step
Owner
Task
Step
Name
(Max 3
4 words)
Record
Actual
Result
Better
Actionsif Out
ofriTolerance
ng
t b on
e
rg isi
Ta Prec
Sign-off After
Complete
Best
Toler
ance
bring
Q
uality
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Task
Step
No.
Task
Step
Owner
Task
Step
Name
(Max 3
4 words)
Tools &
Condition
Full Description of
Task
Test for
Correctness
Tolera
nc
Record
Actual
Result
Tolerance Range
Good
Better
Best
Action if
Out of
Tolerance
Sign-off
After
Complete
Targ
et
Prec
ision
Drive Improvement
Accuracy Controlled 3T Procedure Layout
Continuous improvement: Make better good, make best better and set a
new standard for best. In this way, you will drive quality improvement and
innovation in your company. Good enough never is!
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Propagation
Permanent
Improvement
Implementati
on
Corrective
Action
Be
nd
o
y
FA
C
R
Analysis
Investigation
Evidence
Failure
FA
C
R
Pr
ss
e
oc
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Many have said that RCA is more art than science. (It is if there is no RCFA process.)
Indeed, it seems to draw from a range of skills, talents, experience and
knowledge. Some investigators seem to have a special knack for it while
others toil through the process. (A diverse mix of team members makes for more success.)
Even if an RCA is unsuccessful at uncovering the root cause, the process
usually brings forth new knowledge and greater awareness of reliability risk
factors to the team. This new knowledge can then be rolled into criticality
studies, such as FMEA, leading to an overall improvement in machine
reliability. (Only if newly discovered knowledge is written into the corporate memory for all to find and
use.)
The greatest successes come when you take the learning from every RCA
across the entire business. (This is lateral development and it brings companies much success.)
Its always wise to ask, Why was this allowed to happen? What latent
thoughts, values and beliefs in the organisation and its people that let
the situation arise?
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