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PAM 302 Root Cause Failure Analysis
INTRODUCTION
Organisations establish defences against failure such as routine maintenance, operating procedures, training, incentives, etc. to reduce the risk of failure to tolerable level. Sometimes an unanticipated event triggers a chain of conditions, actions or inactions that allows an event to breach all these defences causing undesireable outcomes. These undesireable outcomes are so small they almost go unnoticed when considered in isolation but they occur at such a high frequency that their cumulative effect can be enormous. Dealing with these chronic events poses the biggest opportunity for an organisation to improve performance. Root Cause Failure Analysis as an integral part of the FRACAS (Failure Reporting, Analysis, Corrective Action System). As part of the overall Risk and Reliability Management function, RCA closes the gap between failures that were anticipated in the RCM or FMECA process and reality. Experience hands-on in this seminar how a cross-functional team, under the guidance of a skilled facilitator, following a logical, structured approach, will uncover the physical, human and latent causes of undesireable outcomes.
TARGET LEARNERS
Learners are the team members that would participate in the development of a reliability programme/failure management programme (maintenance policies/tactics/strategy) for the physical assets of the organisation. Delegates include:
- Maintenance and reliability engineers and engineers in training
- Engineers involved in extensions, upgrades, procurement of new equipment
- OEM design, engineers, field support technicians
- Maintenance supervisors
- Master craftsmen/artisans
- Technicians
- Inspectors
- Operations supervisors
- Maintenance planners
COURSE OBJECTIVES
After completing this workshop learners will better understand:
- What the average organisation expects from its physical assets
- The precursors to asset and process improvement
- Types of analytical techniques and when to apply each technique
- Why we need to know what is expected from a physical asset
- What are undesireable states and functional failures
- The accountability of physical asset owners, operators and maintainers
- The physical causes and mechanisms of failure
- The human causes of failure
- The varieties of human error
- The effects and risks associated with failure
- How to select an appropriate failure management policy
- When is RCA ineffective and the role of technical audits
- What is FRACAS
- What is not RCA
- The difference between chronic and sporadic events
- How to codify and structure failure data to make it more useable
- How to identify the significant few in a set of data
- The four Ps of event data collection and preservation
- How to structure the 'top box' of the analysis
- How to quantify the undesireable outcome to justify the RCA
- How to establish a fact line for the analysis
- How to hypothesise causes and effects
- How to collect and use evidence to verify or disprove each hypothesis
- What actions are appropriate to deal with each root cause
- How to propose actions in the RCA report
- How to follow through the implementation of the analysis
TRAINING METHOD
Each topic is presented by means of short lectures, discussions followed by intensive practical application using real life case studies. This ensures that learners gain hands-on know-how so that they can participate effectively in root cause failure analysis projects at the workplace. Learners that gain a high level of competence in this course are candidates for further learning and could become root cause failure analysis facilitators
TRAINING TOPICS
Day One
- Introduction
Definition of RCA
'Due Process' PAM
Ten Steps to PAM
- Equipment and process expectations, failed states
System requirements and performance standards
Undesireable states
Examples of undesireable states
Accountability of users owners and maintainers
- Human error causes
Human performance problems in maintenance and operation
The fundamentals of human performance
The varieties of human error
Local error provoking factors
- Physical causes and mechanisms
Failure patterns
Normal deterioration, attrition, fatique, contamination
Abnormal mechanisms, overload
Accelerated deterioration
Practical failure mode classification
Day Two
- Options to deal with undesireable outcomes
Routine maintenance, PM, CBM, FF/FT
Modify to improve reliability
Modify to improve maintainability
Modify to reduce consequence
Change people capability
Change organisational policies, procedures
Assess residual risk to measure effectiveness
- Examples of technical audits to maintain optimal conditions
Fasteners
Lubrication
Transmissions
Pneumatics
Electrical
Trouble shooting tools and techniques
- Root cause analysis in perspective
Overview of barries and defences to failure
What is not RCA
Learing from failure
Problems and opportunities
The difference between persistent and chronic failures
- Opportunity analysis
Define system to analyse
Obtain P&IDS and other documentation
Review functions and performance standards
Define the failed state
Prepare and collect data
Summarise, encode and structure data
Calculate losses
The benefits of formal FRACAS
Identify sgnificant few
Day Three
- Prepare for the Analysis
Select team members and convene preparatory meeting
Define the functions and expectations of the system
Define the undesireable event, oucome, performance gap
Define the 'Top Box'
Establish fact line
Calculate loss and us the information to calculate RCA ROI
Define the data related to the event in terms of 4 Ps
Issue data collection assignments
- Generate Hypothesis
Review data collection assignments
Generate hypothetical causes and contributing causes
Issue verification, evidence collection assignments
- Review Hypothesis
Verify or disprove hypothesis
Identify physical root causes
Identify human root causes
Identify latent root causes
- Select and propose appropriate action
Routine maintenance options
Upgrade the physical asset or its control systems
Upgrade policies, procedures, organistion
- Upgrade human capability
Person measures
Workplace measures
- Practical Case Study
- Case study examples and templates
- Post Course Assessement
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