CONCEPT OF RCFA AND CASE STUDY

Content
Definition of Root &
Cause
Terminology
Objectives
General Analysis Techniques
RCFA Methodology
Gearbox Failure
Case Study
Q&A

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Root
Event(s), factor(s) or condition(s) which are under your control and which, if
corrected or eliminated, will prevent recurrence of the undesirable outcome

Cause
A confluence of event(s), factor(s) and condition(s) which conspire to produce
an undesirable outcome

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More Terminology
RCA (Root Cause Analysis)
- a disciplined process for focusing ideas to identify root
causes(s)
RCFA (Root Cause Failure Analysis)
- Reactive, in response to a failure
RCCA (Root Cause and Corrective Action)
- Incorporates preventive corrective action into the process
(i.e., elimination of special causes)

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Objectives
Resolve problems that affect plant performance
- not an attempt to fix blames for the incident
Prevent recurrence of an incident
- solution to a chronic problem
Responsibility
- hand-off the investigation
- liability
- blame

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General Analysis Techniques

Failure Mode and Effect
Analysis
Identify potential failure modes and determine the
effect each on system performance
Focus on prevention
Failure Mode And Effects Analysis is
- An assessment of Risk
Safety
Regulatory
Customer Satisfaction
Program

Coordinated/Documented team effort

- To determine what can go wrong

A method to determine the need and priority of

actions
Team of process expert required

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Item /
Process
Step
Function

Potential
Failure
Mode

Potential
Effect(s) of
Failure

S
e
v

C
l
a
s
s

Potential
Cause(s)/
Mechanism(s)
Of Failure

O
c
c
u
r

Current
Process
Controls
Prevent Detect

D
e
t
e
c

R
P
N

Response &
Recommended
Traget
Actions
Complete
Date

Action Results
Action
Taken

S
E
V

O
C
C

D
E
T

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R
P
N

RPN / RISK PRIORITY

NUMBER

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Cause And Effect Analysis (Fishbone

Diagram)
Can come at any point
- specific actions, or changes, and the end result or event
Helps direct activities
Brainstorming tool
Followed by data collection, verification, tests, etc.
Does not isolate the specific factors that caused the
incident
- no clear sequence of events that leads to failure

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Why Why Analysis

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Fault-Tree Analysis

A method of analyzing system reliability and safety

A detailed deductive analysis
- requires considerable information about the system
Ensures all critical aspects of a system identified and
controlled
Represents graphically the boolean logic associated
with a particular system failure (top event) & basic
failure (primary events)

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Sequence of Event Analysis

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RCFA Methodology

Reporting an Incident
- Symptoms and boundaries
- perceived cause of problem
Incident Classification
Data Gathering
- discussion with all
- collecting physical evidence
- sequence of events
Design Review
- minimum design data
- nameplate data
- procurement specification
- vendor specification
- operating & maintenance manual

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 Application/ Maintenance Review

- Installation
- operating procedures and practices
- Setup Procedures
- Transient procedures
- maintenance history
Observation & Measurements
- vibration, temperature, noise etc.
- process parameters
- visual inspection
- wear particles
Determining the Root Cause
Evaluating Potential Corrective
Actions
Cost Benefit Analysis
Report and Recommendations

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Gearbox Failure

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Case Study

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Q&A

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Thank You

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